Clinics in Medicine 2020 | Volume 2 | Article 1019 09 © 2020 - Medtext Publications. All Rights Reserved. ISSN: 2688-6731 Awake Fibreoptic Intubation in Sitting Position can be Life-Saving in an Emergency Case Report Shiv Lal Soni, Ajay Singh * , Parul Gupta and Narender Kaloria Department of Anaesthesia and Intensive Care, Nehru Hospital, India Citation: Soni SL, Singh A, Gupta P, Narender K. Awake Fibreoptic Intubation in Sitting Position can be Life-Saving in an Emergency. Clin Med. 2020; 2(1): 1019. Copyright: © 2020 Shiv Lal Soni Publisher Name: Medtext Publications LLC Manuscript compiled: Apr 30 th , 2020 *Corresponding author: Ajay Singh, Department of Anaesthesia and Intensive Care, Nehru Hospital, PGIMER, Chandigarh, 160012, India, Tel: +919999276845; E-mail: ajay.ydv2509@gmail.com Abstract Patients with large thyroid mass may present in stridor requiring emergency tracheostomy. Securing the airway frst with endotracheal tube before surgical tracheostomy is the preferred modality in these patients which may be challenging, especially in an emergency. We report the airway management of a 74-year-old female with thyroid malignancy presented with stridor and was unable to lie supine. Keywords: Stridor; Sitting position; Fibre optic intubation Introduction Airway management of the patients who present with huge thyroid mass with stridor is challenging for anesthesiologist because of a potential difcult airway [1]. Prolonged compression over the trachea can lead to the sudden loss of airway under any kind of anaesthesia [2]. Awake fbre optic nasal intubation has been reported successful in patients with enlarged thyroids in a difcult airway situation [3]. However, this can be more challenging when the patient is unable to lie supine. We present a case of successful awake FOB guided nasal intubation in sitting position who presented in stridor with a large thyroid mass with retrosternal extension for emergency tracheostomy. Case Presentation A 74-year-old, 45 kg female presented in stridor with a large swelling predominantly on the right side and front of the neck for the past 30 years. Tere was a progressive increase in the size of swelling since last 3 months with difculty in breathing. Tere was no history suggestive of hypothyroidism or hyperthyroidism and thyroid function tests were within normal limits. She had a history of change in voice, stridor and difculty in breathing which aggravated on lying down for last one and half months. On examination, the swelling was a multilobulated frm nodular mass on the anterior and right side of the neck measuring 15 cm × 8 cm in size. Mass was immobile and extending from the lower jaw to the sternal notch (Figure 1). Te lower limit of the swelling was neither visualized nor palpable. Tere were engorged veins visible on the chest and neck. On airway examination mouth opening was more than two fngers, Mallampati grade 2 with limited neck extension and severely restricted neck fexion. Te trachea was deviated to the lef side. Indirect laryngoscopy revealed restricted mobility of lef vocal cord. USG neck showed a large multilobulated, heterogeneous, hypoechoic lesion in the thyroid region with a heterogeneous hypoechoic lesion at level 1b on the right side and level 2 supraclavicular location. CT scan chest and neck showed grossly enlarged thyroid gland with retrosternal extension and marked compression of the trachea (Figure 2). FNAC showed anaplastic carcinoma thyroid. Te patient was in active stridor and because of huge size and long history of the thyroid mass, we anticipated difculty in mask ventilation, laryngoscopy and intubation. Terefore, awake fbreoptic intubation was planned. Tere was an increase in respiratory distress in the supine position, hence we planned the intubation in sitting position only. Difcult airway cart was kept ready. Te procedure was explained to the patient and written informed consent was taken. Te patient was shifed to the operation theatre and ASA standard monitors were attached, baseline vitals included HR 120/min and NIBP 160/90 mmHg and ECG showed sinus tachycardia. Injection glycopyrrolate 0.2 mg IV was administered to minimize the secretions. Xylometazoline drops were instilled in both the nostrils for nasal decongestion to facilitate the smooth passage of FOB without mucosal injury. Te patient's airway was anaesthetized with 4% lignocaine nebulization and 10% lignocaine spray. Oxygen was administered via nasopharyngeal airway in the other nostril at a rate of 2 L/min. Te fbreoptic bronchoscope was loaded with a 6.5 mm cufed fexo metallic endotracheal tube and the patient was made to sit on the operation table. Te anaesthesiologist was standing on the lef side of the patient-facing the FOB monitor. Te FOB was inserted nasally and advanced towards the laryngeal inlet. Te patient was asked to inhale deep and the laryngeal opening was visualized with great difculty due to distortion of the airway and 2 ml 2% lignocaine was sprayed using the spray as u go technique to block the superior laryngeal nerve. Te FOB was then advanced and positioned just above the carina and endotracheal tube was threaded down the bronchoscope under the vision and the FOB was removed. Te anaesthesia breathing circuit was attached and the tube placement was confrmed with capnography. Te patient was made to lie in the supine position and induction of anaesthesia was done with fentanyl, propofol and atracurium. Afer securing the airway, ETT was withdrawn slightly under visual guidance just below the level of vocal cords and tracheostomy tube was placed. Afer confrmation of the position of tracheostomy tube through capnography, ETT was withdrawn out completely. Te tracheostomy tube was frmly