Awake Nasal Tracheal Intubation Before Emergency Tracheostomy in Malignant Airway Obstruction
9th European Airway Management Congress · , İstanbul, Türkiye, 14 - 17 Ekim 2026, (Yayınlanmadı)
- Yayın Türü: Bildiri / Yayınlanmadı
- Basıldığı Şehir: İstanbul
- Basıldığı Ülke: Türkiye
- Dokuz Eylül Üniversitesi Adresli: Evet
Özet
Background: Malignant
upper-airway obstruction may lead to complete airway loss following induction
of general anaesthesia. Awake tracheal intubation (ATI) allows preservation of
spontaneous ventilation while securing the airway in selected patients with an
anticipated difficult airway.
Case Presentation: A 50-year-old woman with
metastatic non-small-cell lung cancer and brain metastases developed progressive
respiratory compromise associated with a malignant oral cavity mass, complicated
by recurrent tumour bleeding requiring blood transfusion. The oral cavity was
completely obstructed, making oral intubation impossible, and dyspnoea worsened
in the supine position. Despite marked anatomical compromise, SpO₂ was 95% with
6 L/min oxygen via nasal cannula (Figure 1). Because induction of general
anaesthesia and neuromuscular blockade posed a high risk of total airway loss, awake
nasal tracheal intubation using a flexible bronchoscope was selected. Following
topical airway anaesthesia with lidocaine spray, a 6.0-mm endotracheal tube was
advanced over the flexible bronchoscope into the trachea on the first attempt
while the patient remained awake and spontaneous ventilation was preserved
(Figure 2). After confirming correct tube placement, general anaesthesia was
induced with fentanyl, propofol and neuromuscular blockade was achieved with
rocuronium. The otorhinolaryngology team subsequently performed surgical
tracheostomy, inserting a 7.5-mm cuffed tracheostomy cannula.
Conclusion: This
case highlights the importance of anticipating not only difficult intubation
but also potential airway loss following induction in malignant airway
obstruction. When oral access is blocked, awake nasal flexible bronchoscopic
intubation provides a safe, controlled bridge to definitive surgical
tracheostomy, successfully delaying induction and neuromuscular blockade until
the airway is fully secured.