Structured multidisciplinary airway management for critical tracheal obstruction: A case report

Critical tracheal obstruction caused by anterior mediastinal masses constitutes one of the most life-threatening emergencies in airway management. The potential for complete airway collapse upon induction of anesthesia, coupled with the lack of a reliable rescue mechanism, should conventional intubation prove unsuccessful, necessitates meticulous pre-procedural planning. The Fourth National Audit Project (NAP4) identified human factors, namely communication failures, inadequate leadership, and poor team coordination, as contributors to 40% of major airway complications. An additional critical consideration concerns conceptual clarity regarding extracorporeal membrane oxygenation (ECMO): a prospectively planned standby ECMO, with personnel, a primed circuit, and vascular access pre-established, represents a viable contingency for anticipated difficult airways. Conversely, unplanned rescue ECMO during a can-not-intubate, can-not‑oxygenate (CICO) crisis is unrealistic; even experienced centers require a minimum of fifteen to twenty minutes for cannulation, thus far exceeding the window before irreversible hypoxic brain injury. A 43-year-old male patient presented with severe dyspnea and 80–90% tracheal obstruction resulting from an undiagnosed mediastinal T-cell lymphoblastic leukemia. The multidisciplinary team employed structured pre-briefing in accordance with crisis resource management (CRM) principles, with explicit role assignments, standardized critical language, safe patient transport facilitated by high-flow nasal oxygenation (HFNO), prophylactic femoral vascular access for standby ECMO, and awake fiberoptic intubation, achieving first-pass airway success. Following thirty-five days of mechanical ventilation during chemotherapy, the patient was successfully extubated and discharged on the forty-ninth hospital day. Awake tracheal intubation with standby ECMO, combined with structured team coordination and a standardized critical language, exemplifies the optimal systems-based model for anticipated difficult airway emergencies.