Awake percutaneous tracheostomy as an alternative to open emergency tracheostomy in a threatened airway

Abstract

Background: This case report details the management of a patient with a threatened airway booked for an emergency awake tracheostomy but successfully managed with a percutaneous tracheostomy technique. The case illustrates the challenges of managing a severely compromised airway and presents an alternative technique for consideration that may obviate the requirement for a challenging surgical attempt to secure the airway.
Methods: A 42-year-old male presented with a threatened airway as a consequence of complicated dental sepsis extending into the neck. Extensive head and neck swelling was assessed as severe enough to make bag-mask ventilation, direct laryngoscopy and rescue with a supraglottic airway (SGA) impossible. Critical narrowing of the pharynx, identified on CT scan, made fibre-optic intubation risky in terms of completely obstructing the airway during the attempt. The airway was secured by a percutaneous tracheostomy technique with local anaesthetic under ultrasound guidance with the patient awake and spontaneously breathing in the upright position.
Results and conclusions: Tracheostomy is a potentially hazardous procedure. The distortion of anatomy as occurs in severe forms of sepsis may complicate surgical approaches, increasing time to securing the airway and increasing the time under stress for the patient (and the anaesthetist). This case report demonstrates the utility of the percutaneous tracheostomy technique under ultrasound guidance for securing the airway in such cases.