A Case Series Reflecting Airway Difficulty Challenges: Insights into Intubation and Extubation for Large Retrosternal Goitres
UR01-UR04
Correspondence
Dr. Runjhun Jain,
Resident, Department of Anaesthesiology, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune-411018, Maharashtra, India.
E-mail: jainrunjhun@yahoo.com
Retrosternal goitres, often due to longstanding thyroid enlargement, can compress critical structures like the trachea and oesophagus, necessitating thyroidectomy. Managing the airway while ensuring patient safety presents a significant challenge for anaesthesiologists. This case series explores the complex airway management in three patients with large retrosternal goitres undergoing total thyroidectomy. The patients, aged 50, 60, and 73, presented with long-standing neck swelling, tracheal deviation and symptoms including breathlessness, dysphagia and hoarseness of voice. The goitres had progressively enlarged over many years, leading to significant tracheal compression and deviation, which posed a high-risk for airway obstruction during surgery. Given these challenges, Awake Fiberoptic Intubation (AFOI) was chosen to secure the airway while minimising the risk of airway loss. AFOI was performed under conscious sedation with dexmedetomidine and local anaesthesia, providing effective intubation with minimal discomfort and stable haemodynamics. This approach was critical in managing the anticipated difficult airway due to the retrosternal extension of the goitres and their impact on surrounding structures. Postoperatively, the patients were kept intubated to prevent tracheomalacia, a potential complication arising from prolonged tracheal compression. Tracheomalacia, characterised by the weakening of tracheal walls, can lead to airway collapse after extubation. To ensure airway stability, extubation was delayed until a satisfactory cuff-leak test was performed 24-36 hours after surgery. This case series emphasises the importance of careful preoperative planning and the use of AFOI in managing patients with large retrosternal goitres to avoid a ‘can’t intubate, can’t ventilate’ situation. The successful management of these cases highlights the effectiveness of AFOI in reducing perioperative risks and ensuring patient safety, particularly in scenarios where difficult airway management is anticipated. By implementing appropriate postoperative protocols, the risk of complications such as tracheomalacia can be significantly reduced, leading to improved surgical outcomes.