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LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 168-169

Airway ultrasound as a real-time, dynamic assessor for intraoperative tracheal collapsibility


1 Department of Anaesthesiology, Critical Care and Pain, Homi Bhabha Cancer Hospital and Research Centre, Visakhapatnam, Andhra Pradesh, India
2 Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India

Date of Submission13-Aug-2020
Date of Acceptance25-Nov-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
Dr. Mritunjay Kumar
Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/arwy.arwy_32_20

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How to cite this article:
Ramkiran S, Kumar M. Airway ultrasound as a real-time, dynamic assessor for intraoperative tracheal collapsibility. Airway 2020;3:168-9

How to cite this URL:
Ramkiran S, Kumar M. Airway ultrasound as a real-time, dynamic assessor for intraoperative tracheal collapsibility. Airway [serial online] 2020 [cited 2021 Jan 21];3:168-9. Available from: https://www.arwy.org/text.asp?2020/3/3/168/304843



Thyroid cancers infiltrating the trachea can pose a serious challenge in airway management.[1] Point-of-care ultrasound can be more useful than static imaging modalities such as X-ray and computed tomography (CT) scan as it can be used as a real-time dynamic airway assessment tool preoperatively and intraoperatively, helping to make crucial decisions.[2],[3],[4]

A 48-year-old male patient diagnosed with papillary carcinoma thyroid presented with cough and haemoptysis requiring hospitalisation. The patient was scheduled to undergo elective total thyroidectomy with tracheal ring resection and primary endoluminal closure. CT scan neck and chest showed a 7 cm × 10 cm thyroid mass with involvement of the isthmus but no retrosternal extension. There was evidence of metastasis to deep cervical lymph nodes. In addition, there was a partial luminal compromise and leftward deviation of the trachea till the level of the second thoracic vertebra. An awake fibreoptic bronchoscopy under local anaesthesia revealed the involvement up to the upper four tracheal rings. After performing a complete clinical examination, airway ultrasound was planned to measure the tongue thickness (3.06 cm), skin-to-epiglottis distance (1.31 cm), hyomental distance (1.6 cm) and tracheal diameter at the subglottic level (2.11 cm).

The difficult airway cart and emergency tracheostomy equipment were kept ready in view of an anticipated difficult airway. Preoxygenation with high flow oxygen was followed by paraoxygenation using high flow oxygen through a nasal cannula.

A continuous, real-time dynamic assessment of the airway using ultrasound at cricothyroid/subglottic and suprasternal notch levels was undertaken during and after anaesthetic induction using the 7.5 MHz linear transducer (7L4P) of Mindray Z6 diagnostic ultrasound system (Shenzen Mindray Bio-Medical Electronic Co. Ltd., Nanshen, Shenzen, China). This assessment did not reveal any collapse of the tracheal lumen both at the level of invasion and distally till the lower tracheal rings accessible to ultrasound until the sternum [Figure 1]. Confirmation of non-collapsibility of the tracheal lumen after induction of anaesthesia paved the way for the administration of a muscle relaxant (succinylcholine). Tracheal intubation was successfully performed using an 8.0 mm ID wire-reinforced endotracheal tube. Airway ultrasound was repeated at the end of surgery to rule out any luminal compromise after resection of the tracheal rings. Extubation was performed over an airway exchange catheter in the intensive care unit, and further postoperative course was uneventful.
Figure 1: Dynamic assessment of airway collapsibility during anaesthetic induction

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Airway collapsibility and loss of a definitive airway upon anaesthetic induction are inherent risks associated with invasive thyroid malignancy. Administration of a muscle relaxant in such scenarios may further worsen the airway management strategy, leading to serious airway catastrophe.

Ultrasound can be of immense help in such scenarios.[2],[3] Ultrasound is already being used for predicting an anticipated difficult airway, predicting difficult supraglottic airway placement, anticipating obstructive sleep apnoea, detecting upper airway pathologies, assessing the size of trachea till the main stem bronchus, confirming proper endotracheal tube position with insertion depth, assessing the performance of ultrasound-guided airway nerve blocks, assisting invasive procedures such as cricothyrotomy or percutaneous dilatational tracheostomy and predicting post-extubation stridor.[2],[5] Its potential use for real-time visualisation of collapsibility and other dynamic changes in the airway in response to positioning, anaesthetic induction and administration of sedative agents and muscle relaxants, especially in patients at risk such as those with malignancies in the neck invading the trachea, tracheomalacia or external tracheal compression due to any other causes, opens a new frontier for intraoperative airway assessment and deserves to be explored further.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hobai IA, Chhangani SV, Alfille PH. Anesthesia for tracheal resection and reconstruction. Anesthesiol Clin 2012;30:709-30.  Back to cited text no. 1
    
2.
Garg R, Gupta A. Ultrasound: A promising tool for contemporary airway management. World J Clin Cases 2015;3:926-9.  Back to cited text no. 2
    
3.
Sivakumar RK, Mohan VK, Venkatachalapathy R, Kundra P. Ultrasonography as a novel airway assessment tool for preoperative dynamic airway evaluation in an anticipated difficult airway. Indian J Anaesth 2017;61:1023-5.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Gottlieb M, Nakitende D, Sundaram T, Serici A, Shah S, Bailitz J. Comparison of Static versus Dynamic Ultrasound for the Detection of Endotracheal Intubation. West J Emerg Med 2018;19:412-6.  Back to cited text no. 4
    
5.
You-Ten KE, Siddiqui N, Teoh WH, Kristensen MS. Point-of-care ultrasound (POCUS) of the upper airway. Can J Anaesth 2018;65:473-84.  Back to cited text no. 5
    


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