Clinical Dilemma

A 30-year-old, 27-week pregnant woman with obesity (BMI over 34 at the booking of her pregnancy) presents with an increasingly quiet voice, increasing shortness of breath on exertion and worsening stridor. For the past few days she has had significant orthopnoea.

She has a history of juvenile-insert laryngeal papillomatosis and on fibreoptic nasal endoscopy is found to have a very large papilloma arising from the vocal cords.

She requires urgent laser treatment for the papilloma. She is extremely anxious about the impact this may have on her baby.

What is your plan?

What Would You Do?

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WHATWOULDYOUDO?

DAS Expert Corner

Airway Expert 1:

This patient can’t be delayed because of the increasing orthopnoea.

Plan with ENT team - laser or diathermy, laser ETT or a tubeless technique. In my practice we do the latter. Need to balance the risk of regurgitation against that of good surgical access and therefore a quicker procedure, better for the patient.

Plan with Obstetric team: key questions, is this a normal or high-risk pregnancy and what is the risk of an emergency delivery? If it’s a low risk pregnancy our Obs team would do a CTG immediately pre-op and then in recovery. The midwife would stay in theatre during the procedure.

Anaesthetic plan: For high-pressure source ventilation (Monsoon/TwinStream jet ventilator) and TIVA

Pre-op:

✦ Premed with Na citrate/omeprazole / metoclopramide

In theatre induction:

✦ Pre-O2 with HFNO, slight L lateral tilt of abdomen only with a wedge (head & chest need to be flat for placement of suspension laryngoscope) but head -up for any regurgitation.

✦ IV induction : TCI prop/remi and rocuronium (not an RSI but have surgeons ready to place laryngoscope)

Maintenance and surgery:

✦ TIVA

✦ Placement of suspension laryngoscope and jet needle and supraglottic HFJV (remove Optiflow prongs from patient)

✦ Laser or diathermy of lesions - remember to reduce FiO2 if any packs or patties in airway (fire triad of

O2, source and fuel).

Recovery:

✦ After removal of suspension laryngoscope, put the Optiflow back and place an SAD to check EtCO2. If not high then reverse with sugammadex and stop TIVA.

✦ Provide more left lat tilt and slightly head up.

✦ Wake and CTG check in recovery and consider low flow Optiflow there.

Sometimes pregnancy can accelerate development of recurrent respiratory papillomatosis (RRP) so expect the patient to return

Airway Expert 2:

This is a complex case with a patient with potentially progressive airway obstruction due to papillomata. Throughout pregnancy, airway oedema will further increase this risk. Thus treatment is warranted.

My plan with this patient is to begin by reassuring her that the procedure is necessary for the safety of both mother and baby. I will explain the plan and what we wish to do in order to mitigate complications. I would have a discussion with the patient’s obstetric team and gain any further advice or insights regarding the safety of the pregnancy.

I would manage this patient with awake tracheal intubation in the operating theatre with the surgeon present and the team ready for a tracheostomy if needed. I would use HFNO, remifentanil for sedation, 10% lidocaine for topicalisation and a micro laryngeal tube via the oral route. Once tracheal intubation has been confirmed with a two-point check, I would induce anaesthesia with propofol and remifentanil. We could then safely position (whilst administering 100% oxygen) then when we are ready to perform suspension laryngoscopy, remove the tracheal tube and commence ventilation using the TwinStream for high-frequency jet ventilation via the suspension laryngoscope.

I would ensure PEEP is delivered, and 100% oxygen until laser is to commence, when I would reduce the fractional inspired concentration of oxygen to 28% for 30 s before lasering. Once lasering is complete, I would insert a second-generation supraglottic airway device and wake the patient up. If the patient desaturates during the procedure and I am unable to bring the saturations up with the TwinStream, I would insert a microlaryngeal tube and commence traditional positive pressure ventilation.

Airway Expert 3:

Issues:

1. Glottic compromise in need of urgent treatment under GA 2. Early 3rd trimester – not suitable for delivery at 27 weeks but low risk of preterm labour 3. Gas exchange compromise – airway, pregnancy and obesity 4. Aspiration risk.

MDT:

✦ Anaesthesia (Airway + Abs), ENT, Obstetrics and Neonatology - involve clinicians who will deliver the care. ✦ Discuss all relevant issues ✦ Airway assessment and prediction of success/failure of proposed techniques ✦ Tubeless field is far from ideal - I would essentially be ruling this out. ✦ Steroids? NSAIDs? [d/w neonatology] ✦ Post-op care

Then with patient: ✦ Discuss risks + benefits of approaches. ✦ Shared decision making. ✦ Establish informed consent for strategy.

Airway:

Manage as experts see fit. With FNE findings, it does not sound as if ATI is necessary as ventilation should be expected to be possible and glottis should be accessible… but already has moderate glottic narrowing so ATI may be preferred option.

If team are happy for GA intubation, I would recommend: ✦ GA. ✦ Aspiration protective strategies. ✦ “Best” team delivering care and prepared for all airway eventualities ✦ HFNO, VL, TIVA, pEEG, quantitive TOF. ✦ GA with TIVA propofol + remifentanil; Rocuronium. ✦ Monitor foetus. ✦ Mac VL (if access to glottis expected to be straightforward following airway assessment) ✦ Small Laserflex ETT (start with stylet to maximise 1st pass success). ✦ Probably avoid LA to glottis. ✦ Optimise gas exchange and CVS stability (FiO2 with cuffed ETT does not have to be limited with laser). ✦ Dexamethasone.

Extubation:

✦ Safe, optimised extubation – minimising risk of desaturation, aspiration or excessive coughing. ✦ Probably my preferred technique would be awake with Remi obtunding cough.

Airway Expert 4:

Issues that need to be addressed:

1. Timing of surgery with respect to gestational age of baby vs how symptomatic the patient is

2. Intraoperative and post operative obstetric MDT care

3. Airway management technique for laser surgery

Ideally this case needs to be delayed until after the patient gives birth, but as the symptoms are getting worse so she needs urgent surgery. In which case the risks of having a GA to the baby need to be discussed

This case will require MDT input from midwives, obstetricians, obstetric anaesthetists as well as the ENT surgeon and airway anaesthetist. An MDT meeting should be arranged prior to doing the case so a perioperative plan is discussed and all eventualities are covered. This should include location, personnel that need to be present on the day, continuous foetal monitoring, ability to perform a CSection if required and post operative care of both mother and foetus.

Airway management for me would be as follows:

✦ ATI with a MLT to navigate around the polyp then intubation once trachea has been identified then induce anaesthesia

✦ Once asleep, position the patient (bearing in mind that she is 27 weeks gestation), suspend with the surgical laryngoscope and if there is a good view of the lesion and ventilation is adequate then the cuff can be deflated and MLT removed so surgeon has good access to the lesion and HFJV can be commenced

✦ We have the TwinStream at my hospital so I would use that as my choice of HFJV, via the suspension laryngoscope

✦ If I didn’t have the TwinStream, then I would use another device that allows HFJV, like the Monsoon

✦ Whilst all this is happening, foetal CTG monitoring must be on

✦ During any laser surgery all standard Laser precautions should be undertaken and laser safe devices used

✦ Always reduce the FiO2 when laser is in use, this is achievable with the TwinStream

✦ Never use THRIVE when undertaking laser surgery, unless the FiO2 can be reduced to 30%

✦ Surgery should be as quick as possible and undertaken by an experienced surgeon, this case should only take 15-20 minutes

✦ Backup for desaturation or inadequate ventilation or failed intonation, would be a surgical tracheostomy

✦ Once done I would be happy to extubate but patient should go to an HDU post op with continuous

CTG monitoring

Airway Expert 5:

1. A history of juvenile papillomatosis is likely to mean that she has had previous/even recent anaesthetics 2. This is best treated electively prior to the peripartum period so that it does not complicate any emergency interventions around labour and delivery 3. A multidisciplinary approach is required- ENT surgeon, obstetrician. obstetric anaesthetist, head and neck anaesthetist 4. A flexible nasoendoscopy is essential (ideally on video so that all team members can view)

Making the assumption that doing nothing is not an option: ✦ All ramping and antacid precautions should be taken, appropriate foetal monitoring given the gestational age of 27+ is also important ✦ The patient should be done in daylight hours with plenty of time on the list

There is no perfect technique: ✦ Using an endotracheal tube (MLT) risks making access to the lesion difficult and sheering of a fragment of tissue could occlude the end of the ET tube unless it is placed with a bougie ✦ THRIVE is an option but its use with a LASER must be restricted to a highly specialist centres where a thorough risk assessment has been undertaken by the LASER safety officer and the entire theatre team are trained, skilled and drilled in safe practice ✦ [Fact- there are very few hospitals where this will have been done and the published literature is limited to a very few specialist centres] ✦ Assumption- the hospital in question is unlike to be one of those highly specialist centres] ✦ Jet Ventilation- again jet ventilation is not without risk and whilst HFJV is safer, LFJV is more common- again Specialist expertise is vital to avoid harm ✦ This is especially true if the papilloma close the glottis when the patient is lying flat and there is no room for gas egress ✦ Options like the ventrain or tritube could be considered – but given the limited clinical experience with these devices this would be for an academic discussion only

Personally: 1. Ramp the patient 30 degrees head up, with lateral ramping also 2. Optiflow Switch at induction to facilitate per laryngoscopy oxygenation 3. TIVA 4. Test bag 5. Initial inspection under THRIVE (team set to intervene at SpO2<95%) 6. Is there a large part of the lesion that can be excised to create an airway? 7. Transfer to jetting to facilitate laser resection (HFJV preferred given alarms etc) - Ensure expiration by hand on chest 8. Supraglottic device at end of case 9. Consider elective cannula cric to facilitate emergency oxygenation if airway difficult- but again consider the risks of the cannula kinking and of barotrauma if expiration does not occur

***This is not a simple case and should only be performed at a specialist centre where teams are experienced in all of these techniques- that may mean moving an obstetric team to an ENT setting but that is the best option as delivery is the most unlikely outcome***

EXPERT INPUT is essential and the management of this case could be discussed in several thousand words.

THOUGHTS FROM OUR CASE SETTER

| Natalie Silvey |

This case has promoted some incredibly interesting responses from our airway experts and it is clear why. Not only do we have a patient with a rapidly progressing pathology requiring urgent intervention but this patient also is living with obesity and is pregnant. There is a huge amount to consider that is entirely separate to the airway pathology that the patient is presenting with, which is already a challenge in itself.

Juvenile-insert laryngeal papillomatosis is characterised by the development of papillomas in the respiratory tract caused by human papilloma virus (usually types 6 and 11). Transmission is believed to occur during birth as the foetus passes through an infected genital tract. The larynx is the most common site of involvement but the trachea, oropharynx, nasopharynx, nose and oral cavity can all be involved. Patients require repeated procedures to remove the papillomas. The condition accelerates in the presence of increased oestrogen concentrations and therefore pregnant women with the condition, as in this case, should be warned of the possibility of worsening of the disease in pregnancy.

So our patient has an airway disease requiring urgent intervention, but with some major additional complicating factors - both her pregnancy and the fact she is living with obesity.

The Society for Obesity and Bariatric Anaesthesia provides an excellent one page guidance sheet on anaesthesia for patients living with obesity and this has become a stalwart for all of us when providing anaesthesia to this cohort of patients.

Our patient is also pregnant which adds additional complexity due to the presence of a gravid uterus, foetal considerations and the significant physiological changes pregnant women experience. This may not be an entirely comfortable scenario for some head and neck anaesthetists and it is a situation when calling a colleague and carefully planning would be at the forefront of my mind.

As stated in the responses, this is a case which exemplifies the importance of MDT working. Airway management is a team sport, as is the management of complex cases. This isn’t just anaesthetists but obstetricians, midwives and the entire theatre team in this case.

So how would you approach this case? We would love to hear your thoughts. Contact us on twitter @dastrainees or email ezine@das.uk.com.