Avalon iconHow’s this for thinking outside the box in the approach to the difficult airway!? Difficult airway algorithms and advanced management options for difficult airways mostly concentrate on getting into the trachea. But what happens if getting into the trachea is the easy bit? What happens if that’s where you run into a dead end? How do you manage the crashing airway where the problem lies just after the end of your tube? I stumbled across this case report published in the Annals of Thoracic Surgery this year which provides an elegant solution to managing a near total tracheal occlusion.

The Case
The case report describes a 36 year old woman with a known bulky tracheal tumour who presents as an emergency with an acute respiratory decompensation. She’s taken to theatre for an emergency bronchoscopy but deteriorates further and has a respiratory arrest on the table. After intubating and taking a look with a flexible scope the team find that the tumour now totally occludes the left main bronchus and most of the right. She’s only saturating 75% on 100% oxygen (contributed to by subsequently diagnosed PEs) and they’re unable to continue with resecting the tumour. Your standard end of algorithm FONA (Front Of Neck Access) is not going to solve this.

If the airway’s a problem you can’t solve, just bypass the problem! They did SONA and put her on veno-venous (VV) ECMO. We’ve previously discussed the use of VV-ECMO in the management of complex airways in the elective setting here. What makes this case so interesting is both that it was used in an emergency and they used a single ECMO cannula.

The authors insert an Avalon catheter, a double lumen ECMO catheter, into the right IJ. The oxygenation and ventilation are solved and they are able to extubate her and carry on with resecting the tumour and stenting the trachea without the inconvenience of having a tube in the way. Fully oxygenated and normocarbic on ECMO. They then reintubate after a successful procedure are able to wean her off ECMO. After delayed extubation in the ICU she was discharged home 3 days later! Nice job, ECMO!

Avalon – single catheter VV-ECMO
The use of a single, double lumen catheter for VV-ECMO is less common than separate femoro-juglar cannulation. It allows full VV-ECMO to be initiated with just a single venous access. It has drainage ports in the inferior and superior vena cava and a return port that must be aligned with the right atrium.

vv vs avalon ecmo
A: Standard two cannula VV ECMO.
B: Avalon single catheter (with double lumen) VV ECMO

Final thoughts
This is a brilliant – if high tech – solution to a crashing airway and is a great example of thinking outside the box to solve the unique problem you have in front of you. I’m pretty sure this isn’t in any difficult airway algorithm I’ve every read! It just goes to show that the ‘difficult airway’, is not a single entity. Anatomical and pathological processes at different levels provide their own unique set of challenges and need their own unique solutions.

This case shows that there’s more to airway management than just getting past the cords. If you have reason to believe that the end of the airway algorithm isn’t going to get the job done, maybe ‘side of neck access’, is really what’s needed.

Use of single-cannula venous-venous extracorporeal life support in the management of life-threatening airway obstruction, Ann Thorac Surg, 2015.

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