Airway Management Using Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for Critical Distal Tracheal...

Critical distal tracheal stenosis caused by a massive goiter poses a major airway challenge in which tracheal intubation and positive-pressure ventilation may fail, potentially leading to severe hypoxia during induction. We report the case of an 88-year-old woman with dementia who underwent thyroidectomy for severe distal tracheal compression caused by a large goiter. Preoperative imaging demonstrated near-critical tracheal narrowing measuring 4 × 9 mm over a 5-cm segment. Awake fiberoptic intubation was not feasible due to severe cognitive impairment and recurrent episodes of acute respiratory distress, making an awake technique dependent on spontaneous ventilation unreliable. A structured multidisciplinary airway strategy was developed, including anesthesiologists, surgeons, and clinical engineers, with a cardiovascular surgeon present in the operating room and extracorporeal life support (ECLS) prepared with immediate availability and readiness for rapid deployment as a rescue option. Within this strategy, transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) was used as an oxygenation technique during apnea. Despite ineffective mask ventilation with high airway pressures, THRIVE at 70 L/min maintained oxygen saturation at 100% throughout a 12-minute apneic period and facilitated successful bronchoscopic placement of a 4.5 mm endotracheal tube beyond the stenosis. This case demonstrates that THRIVE, when used as part of a structured airway management strategy, may help maintain oxygenation in a high-risk, difficult airway where conventional ventilation techniques fail.