In Response to Oropharyngeal Swelling and Airway Obstruction from Environmental Cold Exposure: A Case Report

To the Editor:

We read the article authored by Cowtan et al, recently published in your esteemed journal, with great interest. ¹ The authors have done a commendable job managing such a challenging case. While going through the manuscript, we came across some points of concern and would like to highlight them.

In this case report, the authors have highlighted the challenges encountered and their subsequent management in the case of a young patient presenting with oropharyngeal swelling and airway obstruction following exposure to extreme cold. While reading the article, we found no mention of the vitals like heart rate, blood pressure, or temperature at any point in time, starting from admission until discharge. ¹ The readers would like to know if there were any features of hypothermia like bradycardia or arrhythmia in electrocardiography (ECG) findings, including body temperature. ² These findings would have helped the authors reach a definitive diagnosis rather than rely upon the exclusion criteria of the other differential diagnosis. ¹ Having said that, we appreciate the efforts put in by the authors to exclude other possible causes of airway edema.

Furthermore, as evident from the degree of facial edema, airway topicalization and awake fiberoptic would not have been easy, especially since the patient was in respiratory distress and had stridor due to airway edema. So, a detailed mention of airway preparation and topicalization before proceeding with awake fiberoptic intubation would have made the report more interesting and informative for the readers. ³ The readers would be interested to know if the authors had any backup plan for a failed tracheostomy. It is also unclear if the authors considered other airway securing options, like cricothyroidotomy with jet ventilation, as backup plans. ⁴ Further, it would have been desirable to provide preoxygenation using a high-flow nasal cannula (HFNC) to improve apnea time in a patient with severe respiratory distress. It is also surprising to know that multiple failed attempts of awake fiberoptic intubation were carried out inside the operation room by the anesthesia team despite knowing that the airway and oropharyngeal swelling can obscure the fiberoptic view. Tracheal intubation using rapid sequence intubation under video laryngoscopy (VL) would have been a preferred option in such an emergency. ⁵ Why VL was not considered in this case is not clear. Video laryngoscope has better resolution than fiberoptic bronchoscopy and would provide a magnified view, which would have been helpful in this case of airway swelling, making bronchoscopy conditions much more difficult. ⁵ The authors have mentioned that the patient had a hypoxic episode before reaching the hospital; the readers would be interested to know if there was any episode of loss of consciousness or drowsiness, as this had implications for airway management. Because airway edema usually presents with respiratory distress, which can lead to cerebral hypoxia and loss of consciousness, information on this important issue wasn’t mentioned.^1,6 The authors mentioned a concern for airway compromise as he could not manage his secretions. ¹ The airway should have been secured at that time as it was an imminent sign of airway obstruction, and the success of securing the airway was likely higher. In burns-related inhalation injuries, it is also recommended to secure the airway at the earliest sign of respiratory distress. ⁷

Further, when there is airway edema and narrowed airway caliber, fiberoptic bronchoscopy can lead to a tube-with-tube situation and complete airway obstruction. ⁸ The same situation probably happened in this case, as mentioned by the authors, that the airway became completely obstructed during fiberoptic attempts. ¹ Complete obstruction can cause hypoxia, probably leading to cardiac arrest. In such cases, directly going in front of the neck opening to secure the airway would have been a more logical option. The authors haven’t commented upon whether the patient was managed in the intensive care unit (ICU) or the ward, required ventilatory backup (for how many days), or was managed in a T-piece with spontaneous respiration. ¹ There is also no information on the number of days in the ICU, tracheostomy days, day of decannulation of the trachea, and total hospital length of stay.

To conclude, we hope that the points mentioned earlier will be informative for the readers.