AIRWAY MANAGEMENT IN TOTAL THYROIDECTOMY IN MORBIDLY OBESE PATIENT:
A CASE REPORT
Tesha I. Monika1, Jonathan Anthonius1, Nabila Jasmine1, Michael Sukmapradipta1, Maria E. Sulistio1
1 Metropolitan Medical Centre Hospital, Jakarta, Indonesia
INTRODUCTION
• Difficult airway is when difficulty or failure in
airway procedures is encountered, with
various adverse outcomes. 1
• This case report describes expected airway
difficulties in 47-year-old female, whom we
performed anesthetic and airway procedures
referring to Difficult Airway Society (DAS)
Difficult Intubation Guidelines 2015.2
CASE PRESENTATION
• A 47 year-old female with Non-Toxic Nodular
Goiter (clinically euthyroid) undergoing total
thyroidectomy with narrowing of the trachea
to the right due to the compression of the
large mass on both sides of the neck, morbid
obesity (weight = 107 kg, neck circumference
= 48 cm), Mallampati Class IV.
• Procedures: Referring to the DAS Difficult
Intubation Guidelines 2015.2
• Outcomes: The patient was stable in the
intra- and post-operative stages.
DISCUSSION
Procedures – Referring to DAS Guidelines:
- ‘Ramped’ position: Recommended for
morbidly obese patients as functional
residual capacity (FRC) detoriates in supine
position.3
- Preoxygenation: Increases O2 reserve, delays
hypoxia, and allows more time for airway
procedures (DAS, 2015).2
- Induction done while maintaining
spontaneous breathing on Fentanyl 150 mcg
and Propofol 150 mg: Decreases risk of side
effects and allows rapid reversal of
neuromuscular blockade in difficult
intubation ; Propofol provides better
3 should optimize first-attempt success of airway
conditions for airway management.2
- Prepared non-kinking endotracheal tubes
(ETT) and laryngeal mask airway: Non-kinking
TTs is valuable in some head and neck
surgery3; Maintaining oxygenation and
inserting supra-glottic airway device is
recommended in case of failed intubation.2
- Video laryngoscope: Improves visualization.3
Fig 1. Mallampati IV (a) Neck circumference (b) Trachea deviation (c)
Fig 2. Pre-oxygenation, ramped position (a) Video laryngoscope (b)
Thyroid mass (c)
SUMMARY
Airway difficulties can be found in ER or ward
setting. Management of difficult airways
management, improve patient safety, and
minimize / avoid adverse effects.
REFERENCE
1. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American
Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.
Anesthesiology. 2022 Jan;136(1):31–81. https://doi.org/10.1097/aln.0000000000004002.
2. Frerk C, Mitchell VS, McNarry AF, Mendonca C,Bhagrath R, Patel A, O’Sullivan EP, et al. Difficult
Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults.
BJA: British Journal of Anaesthesia. 2015 Dec;115(6):827–48. https://doi.org/10.1093/bja/aev371
3. Morgan GE, Mikhail MS, Murray MJ. Clinical anesthesiology. New York Lange Medical
Books/Mcgraw-Hill; 2013.