A Compromised Airway in the Setting of Failed Extracorporeal Membrane Oxygenation Cannulation

We report a case involving failed extracorporeal membrane oxygenation (ECMO) cannulation in the setting of critical airway stenosis secondary to a large anterior mediastinal mass. The most invasive management option, ECMO, was initially pursued solely to avoid manipulation of a critical airway in case of intubation failure or life-threatening airway bleeding. However, after unexpectedly failing cannulation in two separate cannulation sites with an impending respiratory collapse, awake fiberoptic or emergent rigid bronchoscopy was the remaining viable option. The patient was ultimately intubated via awake fiberoptic intubation even though this modality carried a high complication risk and potential mortality if failed. This case report illustrates both the potential role of ECMO within the airway management hierarchy and the persistent need for contingency planning should ECMO cannulation fail. With the recent enthusiasm for ECMO incorporation into difficult airway management, our report serves to highlight the very serious issue of cannulation failure. There is a limited amount of case reports describing ECMO failure in a critical airway, and little has been described about rescue methods when ECMO fails. Our goal is to remind readers that although ECMO can be an excellent rescue option for a critically ill patient, it cannot be viewed as a last line of therapy. If one is able to rapidly recognize impending ECMO cannulation failure and is prepared for cannulation failure, they can save invaluable time in a decompensating patient.