You are asked to review a 46-year-old female on the surgical ward who has stridor 4 hours after a total thyroidectomy.
a) List six possible causes for this. (30% marks)
b) You determine intubation is necessary. Outline your approach to securing her airway and justify it.
Immediate oxygenation measures:
Administer High flow Oxygen / Hudson mask with rebreath bag at 15L. Sitting up position better tolerated than lying flat
Can try Heliox – though to be effective will need 79% Helium, 21% Oxygen mix which may be inadequate if patient has poor gas exchange / pulmonary oedema
Declare Airway emergency – get help: Surgeon, Anaesthetist, Nursing staff
Decide on location for intubation: In ward, theatre or ICU – depending on distance to be moved and patient stability
Decide on and communicate plan of airway intervention including plan for failure: Plans A,B,C highlighting each approach
Ensure Team members are aware of roles & sequence of events and emergency responses
Check Equipment for familiarity and correct function
Be clear about pros and cons of approaches for airway management (Must justify one)
Outline plan for failure: then front of neck access:
Possible causes of stridor in a patient returning from thyroidectomy are more than likely going to be related to the thyroidectomy, or less likely to the drugs which have been given around the time of the thyroidectomy. In any case, it is still probably worthwhile reasoning through this as if it were an exercise in generating differentials:
To throw a coat of peer-review varnish over this unprofessional gibberish, one could point to an excellent article by Ayandipo et al (2016), which discusses a case series of airway complications from a high-volume ENT service in Nigeria. The most common reason for the reintubation was tracheomalacia, which was observed in something like 5% of the total cases.
Approach to securing the airway is an exercise in demonstrating a level of caution and anxiety to the examiners, so as to give the appearance of a safe practitioner. Specific noises which one needs to make to generate this impression are:
So, the ideal approach here would be:
However, the college asked for "your approach to securing her airway", not "your approach to avoiding having to handle her airway". Frequently, this scenario plays out after-hours. Consider that a complex total thyroidectomy may take all day, finish at 8pm, and then stridor comes at midnight. One might be working with a skeleton staff and with no theatre available, plus the surgeon is now on his private island and is not inclined to return to the hospital. In short, you're it.
Preparation of the staff
Preparation of the equipment
Preparation of the patient
Scanlon, Edward F., Stephen F. Sener, and E. Dennis Murphy. "Early onset of tetany following thyroidectomy: report of two cases." Journal of surgical oncology 29.4 (1985): 222-223.
Jeong, Jee Yeon, et al. "Respiratory difficulty at a postanesthesia care unit after total thyroidectomy: a case report." Korean J Anesthesiol 45.4 (2003): 540.
Ayandipo, O. O., T. A. Adigun, and O. O. Afuwape. "Airway Complications and Outcome after Thyroidectomy in Ibadan: A 15 year review." Arch Med 8 (2016): 4.
Law, J. Adam, et al. "The difficult airway with recommendations for management–part 2–the anticipated difficult airway." Canadian Journal of Anesthesia/Journal canadien d'anesthésie 60.11 (2013): 1119-1138.