Stridor at Rest with a Fixed Subglottic Recurrence

Proposed plan: an awake, spontaneously ventilating technique, with a low threshold for awake tracheostomy under local anaesthetic as the primary rather than rescue option.

The core danger here is not failure to intubate but loss of the patient's own airway. Fixed stridor at rest with subglottic extension means positive pressure and loss of muscle tone can convert partial obstruction into complete obstruction, and a supraglottic rescue device cannot bypass a subglottic lesion.

• Awake fibreoptic intubation preserves tone and spontaneous ventilation, but topicalisation can trigger coughing, bleeding and total obstruction, and the scope must pass a narrowed, irradiated subglottis. A 5.2 mm scope and a 6.0 mm reinforced tube are reasonable only if CT shows a lumen comfortably larger than the tube.
• Inhalational induction with sevoflurane maintaining spontaneous ventilation is a recognised alternative and is often preferred in children, but in a fixed, irradiated adult airway, deepening anaesthesia may abolish the last residual tone abruptly, and the patient cannot be ventilated if obstruction occurs.
• Awake tracheostomy under local creates a definitive airway below the obstruction without instrumenting the tumour, in a sitting patient, in a neck distorted by fibrosis. Given ENT is scrubbed and no bypass is available, this is arguably the safest first step and should be discussed explicitly with the surgeon.

I would agree the sequence with ENT before starting: awake nasal fibreoptic with immediate conversion to surgical airway if luminal narrowing is critical, tracheostomy set open, muscle relaxation withheld until the tube is confirmed in the trachea and the surgeon is ready.

Preparation is where this case is won or lost; every drug must be chosen so as not to obtund airway tone or cause apnoea.

Sequence:

1. Antisialagogue first: glycopyrrolate 0.2 mg IV (or 0.4 mg IM) 20–30 minutes ahead, to dry secretions and improve topical anaesthetic spread. Avoid heavy sedation; small midazolam (1–2 mg) only if the patient is very distressed, accepting the risk of respiratory depression.
2. Positioning and oxygen: sit the patient up, apply high-flow humidified nasal oxygen at 40–60 L/min, ECG, SpO2 with a good waveform, capnography via a nasal sampling line, and non-invasive blood pressure cycling every 2–3 minutes.
3. Nasal preparation: xylometazoline 0.1% spray to decongest and reduce bleeding; then nebulised 4% lidocaine 4 mL over 10 minutes, followed by careful oropharyngeal and nasal topicalisation.
4. Dose limit: calculate lidocaine against adjusted (not actual) body weight, keeping the total below about 4.5 mg/kg without adrenaline; in a 118 kg patient that is a real constraint, so use small aliquots of 2% and document the total.

Staffing and kit: two anaesthetists (one for the airway, one for drugs and monitoring), ENT scrubbed and gowned, difficult airway trolley, rigid bronchoscope, video laryngoscope, surgical cricothyroidotomy kit, and a clear verbalised plan for who performs the surgical airway. A second dose of vasoconstrictor and a vasopressor drawn up, since hypotension after topicalisation is common.

This is a 'cannot intubate, cannot oxygenate' emergency superimposed on a fixed upper airway obstruction. Do not paralyse, do not instrument the larynx.

First 60 seconds:

1. Call for help loudly and name the plan: 'total obstruction, ENT to the neck now'. Everyone should know the surgical airway is starting.
2. Sit him upright, 100% oxygen by tight-fitting face mask with a two-person technique, gentle jaw thrust and chin lift; add CPAP 10–15 cmH2O, which can splint open a collapsing supraglottic segment.
3. Try a lubricated nasopharyngeal airway (6.0–7.0) if the nasal passage is patent - he has had nasal surgery? No, but bleeding risk from the tumour remains, so one gentle attempt only.
4. Small aliquots of propofol 10–20 mg or sevoflurane 8% in 100% oxygen can occasionally deepen the patient enough to relieve laryngospasm, but if there is a fixed subglottic component this will not help and may hasten collapse - one attempt, no more.
5. Simultaneously, ENT performs an awake or immediate surgical tracheostomy under local anaesthetic; the neck is already prepared and the set is open. If the trachea cannot be reached, perform a scalpel–bougie cricothyroidotomy. Needle cricothyroidotomy and jet insufflation are a poor fallback in a partially obstructed upper airway because exhalation is impossible and barotrauma is likely.
6. Muscle relaxants and direct laryngoscopy are contraindicated here; they abolish the only remaining muscle tone and will not bypass a subglottic lesion.

Debrief afterwards, and document the pre-agreed plan, the failed topicalisation, and the decision analysis.