Total airway obstruction during local anesthesia in a non-sedated patient with a compromised airway.
OBJECTIVE
To report a case of complete upper airway obstruction after topicalization with lidocaine in a completely conscious patient with partial upper airway obstruction.


METHODS
A 69-yr-old man with a history of neck cancer and radiation presented for resection of recurrent neck tumour. No preoperative sedation was given. He had inspiratory and expiratory stridor but had no history of aspiration or swallowing problem. Phonation was distorted but effective. The surgeon was reluctant to perform an awake tracheostomy under local anesthesia. In preparation for a fibrescope-assisted orotracheal intubation, the non-sedated patient was given topical upper airway lidocaine during which he developed total airway obstruction and hypoxemia. He was immediately intubated with a fibrescope. His vocal cords were not edematous although the supraglottic structures appeared to be. The vocal cords were abducted and their movement was limited and not paradoxical. Tumour resection was uneventful upon successful tracheal intubation and general anesthesia. Tracheostomy at the end of the case was difficult, as expected. The patient tolerated the procedures and regained consciousness with no neurologic sequelae.


CONCLUSIONS
Dynamic airflow limitation associated with local anesthesia of the upper airway may lead to complete upper airway obstruction in a compromised airway. The main cause may be the loss of upper airway muscle tone, exacerbated by deep inspiration during panic.
Ho
Anthony M H
AM
Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR, PRC. hoamh@cuhk.edu.hk
Chung
David C
DC
To
Edward W H
EW
Karmakar
Manoj K
MK
D000368:Aged; D000402:Airway Obstruction / Q000139:chemically induced* / Q000150:complications; D000768:Anesthesia, General / Q000379:methods; D000772:Anesthesia, Local / Q000009:adverse effects* / Q000379:methods; D000779:Anesthetics, Local / Q000009:adverse effects; D001285:Atropine / Q000008:administration & dosage; D001993:Bronchodilator Agents / Q000008:administration & dosage; D002294:Carcinoma, Squamous Cell / Q000601:surgery*; D003243:Consciousness / Q000502:physiology*; D005336:Fiber Optic Technology / Q000379:methods; D006258:Head and Neck Neoplasms / Q000601:surgery*; D006801:Humans; D000860:Hypoxia / Q000139:chemically induced / Q000150:complications; D007442:Intubation, Intratracheal / Q000379:methods; D008012:Lidocaine / Q000009:adverse effects*; D008297:Male; D010100:Oxygen / Q000008:administration & dosage; D012121:Respiration, Artificial / Q000379:methods; D012135:Respiratory Sounds / Q000503:physiopathology; D014139:Tracheostomy / Q000379:methods
D000779:Anesthetics, Local; D001993:Bronchodilator Agents; D001285:Atropine; D008012:Lidocaine; D010100:Oxygen