Craen, Alexandra M

Czysz, Aaron J, MD

MacKenzie, Richard S., MD

Misselbeck, Tim S, MD

Niehaus, Matthew, DO

Weil, Daniel, MD

Wu, James K., MD

Misselbeck, Timothy S

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works Department of Emergency Medicine Case report: Triple setup airway-simultaneous oropharyngeal, surgical, and ECMO preparation. Richard S. MacKenzie MD Lehigh Valley Health Network, Richard.MacKenzie@lvhn.org Alexandra M. Craen Lehigh Valley Health Network, alexandra.craen@lvhn.org Matthew Niehaus DO Lehigh Valley, Matthew.Niehaus@lvhn.org Aaron J. Czysz MD Lehigh Valley Health Network, aaron_j.czysz@lvhn.org Timothy S. Misselbeck Lehigh Valley Health Network, Timothy.Misselbeck@lvhn.org See next page for additional authors Follow this and additional works at: https://scholarlyworks.lvhn.org/emergency-medicine  Part of the Emergency Medicine Commons Published In/Presented At Mackenzie, R. S., Craen, A. M., Niehaus, M. T., Czysz, A. J., Misselbeck, T. S., Weil, D. P., & Wu, J. K. (2016). Case report: Triple setup airway-simultaneous oropharyngeal, surgical, and ECMO preparation. The American Journal Of Emergency Medicine, 34(12), 2468.e5-2468.e7. doi:10.1016/j.ajem.2016.06.057. This Article is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. Authors Richard S. MacKenzie MD, Alexandra M. Craen, Matthew Niehaus DO, Aaron J. Czysz MD, Timothy S. Misselbeck, Daniel Weil MD, and James K. Wu MD This article is available at LVHN Scholarly Works: https://scholarlyworks.lvhn.org/emergency-medicine/389 Case ReportTriple setup airway—simultaneous oropharyngeal, surgical, andECMO preparation☆AbstractExtracorporeal membrane oxygenation is increasingly used in theintensive care unit for refractory cardiopulmonary diseases [1]. Therehas been little application at this time of its use in the emergency de-partment (ED) and none for its use in high-risk airways. We present acase of a patient with supraglottitis and large parapharyngeal abscessescausing an unstable airway that would be difficult to manage with tra-ditional “double setup” (oropharyngeal and surgical) methodology.We highlight the potential use of extracorporeal membrane oxygena-tion in the management of her airway.Extracorporeal membrane oxygenation (ECMO) is used in intensivecare medicine for treating refractory cardiopulmonary diseases. Whiletraditionally, ECMO has been used to support patients suffering fromARDS, there has been increased interest in exploring the use of EMOfor various diseases [1,2]. For instance, the use of ECMO as a bridge totreatment and recovery in cardiac arrest has been studied [1,3,4]. Addi-tionally, reports have appeared in the literature concerning the use ofECMO in severe accidental hypothermia [5,6]. There are few document-ed reports of ECMObeing used for difficult airways and none specificallyin the ED [7–9]. We report a case of ECMO as a management option inthe ED for a woman with extensive parapharyngeal abscesses.A 58-year-old woman with a history of GERD presented to the EDcomplaining of throat pain. She had previously been seen at an urgentcare facility three days prior, and diagnosed with viral pharyngitis. Hersymptoms worsened, which prompted her ED visit.On arrival, she complained of fevers, chest tightness, neck swellingand dysphagia. Initial vitals included blood pressure, 106/58 mmHg;pulse, 77 beats/minute; temperature, 96.7°F; respirations, 14; and oxy-gen saturation, 100%. The patient was awake and alert. She had mildpharyngeal erythema, a midline uvula and no obvious peritonsillarswelling or abscess. Remarkable blood chemistries measured: WBCs,19.2 (4-10.0 thou/cmm) with left shift; and creatinine, 1.32 (0.53-1.20mg/dL). A CT of the patient's neck with contrast showed extensivesupraglottic edema with narrowing of the airway at the level of thefalse vocal cords (Figs. 1,2). In addition, there were multiple abscessesin the neck with extension into the retropharynx and mediastinum.She was treated with broad-spectrum antibiotics and steroids. Defini-tive surgical care was anticipated to be difficult. While the patient wasnot in acute airway obstruction at that time, the rapid progression ofthis disease raised the possibility of an imminent airway collapse.The on-call physicians for anesthesia, trauma surgery, intensive care,and cardiothoracic surgery conferred with the ED physicians about thebest approach. This patient traditionally would require a “doubleprep” in theORwhere anesthesiawould attempt the oropharyngeal air-way and surgery would prepare for an immediate surgical airway incase that failed. However, there was even a high risk of failure for thesurgical airway given extensive infection overlying her trachea. As athird failsafe, ECMO was considered. The risk of preparation was mini-mal for ECMO. Therein, 5 French venous and arterial sheaths wereplaced by cardiothoracic surgery staff prior to the airway attempts.The cardiothoracic team also went to the OR; if the definitive airway at-tempts failed, dilation of the vessels and placement of the catheters,could be done in minutes. Once achieved, the ECMO machine wouldserve as intended, to be a bridge for oxygenation.In our case, this “triple setup” occurred in the OR. The patient wasultimately intubated by anesthesia by direct laryngoscopy, the sheathswere removed, and the patient was stabilized. The abscesses thatextended into the mediastinum were surgically attended to and thepatient recovered uneventfully.Maintaining systemic oxygenation is an essential responsibility of anemergency physician. In this case, extensive parapharyngeal abscessesmade both endotracheal intubation and tracheostomy dangerous optionsfor airway management. Traditionally, the ED physician approaches thedifficult airway with a variety of options and techniques that include anemergent surgical airway. In select patients, obstacles to both endotrache-al and surgical approaches occur, such as stenosis from prior proceduresor radiation, tumors, foreign bodies, or, as in this case, abscesses.In these cases, ECMO is a reasonable therapy to consider. While ourcurrent approach to airway control does work for most patients, somewill succumb to their airway disease [10]. ECMO can be a bridge forany kind of lung or airway malfunction until recovery can occur. Therisk of this approach is similar to any central line risk. The benefit isthat patientswith tenuous airways can recover from their airway insult.Although it has been reported in critical care literature [11] there areno cases in the emergency medicine literature of ECMO being used forthe difficult airway (specifically not in the ED). Previously, ECMO hasbeen used for respiratory support in patients with massive hemoptysisor those undergoing tracheal surgerywheremechanical ventilationwasnot feasible [12]. In the pediatric literature, it has been used to facilitateoxygenation during the removal of bronchial foreign bodies [13,14]. Ad-ditionally, non-intubated patients have been supported solely on ECMOas a bridge to lung transplantation, aswell as an alternative to tradition-al mechanical ventilation in COPD and ARDS patients [15–19].As ECMO technology improves, the discussion about how to ap-proach the anticipated difficult airway must change. In this case, weAmerican Journal of Emergency Medicine 34 (2016) 2468.e5–2468.e7☆ The authors have no outside support information, conflicts or financial interest todisclose.0735-6757/© 2016 Elsevier Inc. All rights reserved.Contents lists available at ScienceDirectAmerican Journal of Emergency Medicinej ourna l homepage: www.e lsev ie r .com/ locate /a jemDownloaded for library services (libraryservices@lvhn.org) at Lehigh Valley Health Network from ClinicalKey.com by Elsevier on August 24, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.utilized a multidisciplinary team to determine the best course of treat-ment for a critically ill patient with a tenuous airway.AcknowledgementsThe authors would like to thank other members of the team thatmanaged this critically ill patient, Marianne L. Smalley MD, Reza S.Armaghan RN, Jonathan T Davenport RN, and Jayme Lieberman MD.Richard S. Mackenzie, MDAlexandra M. Craen, BA*Matthew T. Niehaus, DODepartment of Emergency Medicine, Lehigh Valley Hospital and HealthNetwork/USF MCOM, CC & I-78, Allentown, PA, 18103⁎Corresponding author: Department of Emergency Medicine2545 Schoenersville Rd, Muhlenberg Campus LVH, 5th floor EMResidency Suite. Tel.: +1 484 884 7514; fax: +1 484 884 7510E-mail address: Alexandra.Craen@lvhn.orgAaron J. Czysz, MDDepartment of Medicine/Critical Care, Lehigh Valley Hospital and HealthNetwork/USF MCOM, CC & I-78, Allentown, PA, 18103Timothy S. Misselbeck, MDDepartment of Surgery, Lehigh Valley Hospital and Health Network/USFMCOM, CC & I-78, Allentown, PA, 18103Daniel P. Weil, MDDepartment of Anesthesiology, Lehigh Valley Hospital and HealthNetwork/USF MCOM, CC & I-78, Allentown, PA, 18103James K. Wu, MDDepartment of Surgery, Lehigh Valley Hospital and HealthNetwork/USF MCOM, CC & I-78, Allentown, PA, 18103http://dx.doi.org/10.1016/j.ajem.2016.06.057References[1] Mosier JM, Kelsey M, Raz Y, Gunnerson KJ, Meyer R, Hypes CD, et al. Extracorpo-real membrane oxygenation (ECMO) for critically ill adults in the emergencydepartment: history, current applications, and future directions. Crit Care2015;19(1):431.[2] Peek Giles J, Clemens F, Elbourne D, Firmin R, Hardy P, Hibbert C, et al. CESAR:conventional ventilator support vs extracorporeal membrane oxygenation forsevere adult respiratory failure. BMC Health Serv Res 2006;6:163.Fig. 1. CT of patient's neck with narrowing of the airway.Fig. 2. CT of patient's neck with extensive subglottic edema.2468.e6 R.S. Mackenzie et al. / American Journal of Emergency Medicine 34 (2016) 2468.e5–2468.e7Downloaded for library services (libraryservices@lvhn.org) at Lehigh Valley Health Network from ClinicalKey.com by Elsevier on August 24, 2022. For personal use only. No other uses without permission. Copyright ©2022. Elsevier Inc. All rights reserved.[3] Chen YS, Lin JW, Yu HY, Ko WJ, Jerng JS, Chang WT, et al. Cardiopulmonary resusci-tation with assisted extracorporeal life support versus conventional cardiopulmo-nary resuscitation in adults with in-hospital cardiac arrest: An observational studyand propensity analysis. Lancet 2008;372L:554–61.[4] Stub D, Bernard S, Pellegrino V, Smith K, Walker T, Sheldrake J, et al. Refractory car-diac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion(the CHEER trial). Resuscitation 2015;86:88–94.[5] Sawamoto K, Bird SB, Katayama Y, Maekawa K, Uemura S, Tanno K, et al. Outcomefrom severe accidental hypothermia with cardiac arrest resuscitated with extracor-poreal cardiopulmonary resuscitation. Am J Emerg Med 2014;32(4):320–4.[6] Ginty C, Srivastara A, RosenblumM, Fowler S, Filippone L. Extracorporeal membraneoxygenation rewarming in the ED: an opportunity for success. Am J Emerg Med2015;33(6):857 [e1-2].[7] Willms DC, Mendez R, Norman V, Chammas J. Emergency Bedside ExtracorporealMembrane Oxygenation for Rescue of Acute Tracheal Obstruction. Respir Care2012;57(4):646–9 [Available at http://rc.rcjournal.com/content/57/4/646.full.pdfAccessed 03/25/2016].[8] Hong Y, Jo KW, Lyu J, Huh JW, Hong SB, Jung SH, et al. Use of venovenousextracoroporeal membrane oxygenation in central airway obstruction to facilitateinterventions leading to definitive airway security. J Crit Care 2013;28(5):669–74.http://dx.doi.org/10.1016/j.jcrc.2013.05.020 [Epub 2013 Jul 8].[9] Ko M, dos Santos PR, Machuca TN, Marseau K, Waddell TK, Keshavjee S, et al. Use ofsingle-cannula venous-venous extracorporeal life support in the management oflife-threatening airway obstruction. Ann Thorac Surg 2015;99(3):e63–5.[10] Dulguerov P, Gysinc C, Perneyer TV, Chevrolet JC. Percutaneous or surgical tracheos-tomy: a meta-analysis. Crit Care Med 1999;27(8):1617–25.[11] Holliday T, Jackson A. 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Artificial lung as analternative to mechanical ventilation in COPD exacerbation. Eur Respir J 2012;39(1):212–4.[17] Reeb J, Falcoz PE, Santelmo N, Massard G. Double lumen bi-cava canula for veno-ve-nous extracorporeal membrane oxygenation as bridge to lung transplantation innon-intubated patient. Interact Cardiovasc Thorac Surg 2012;14:125–7.[18] Lindskov C, Jensen RH, Sprogoe P, Klaaborg KE, Kirkegaard H, Severinsen IK, et al. Ex-tracorporeal membrane oxygenation in adult patients with severe acute respiratoryfailure. Acta Anaesthesiol Scand 2013;57(3):303–11.[19] Mosier JM, Hypes C, Joshi R, Whitmore S, Parthasarathy S, Cairns CB. Ven-tilator Strategies and Rescue Therapies for Management of Acute Respira-tory Failure in the Emergency Department. Ann Emerg Med 2015;66(5):529–41.2468.e7R.S. 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Case report: Triple setup airway-simultaneous oropharyngeal, surgical, and ECMO preparation.

Case report: Triple setup airway-simultaneous oropharyngeal, surgical, and ECMO preparation.

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