Airway Control with a Laryngeal Mask Combined with High‑Flow Oxygen During Tracheal Resection and Reconstruction for Tumor‑Induced Critical Airway Obstruction: A Case Report

The human windpipe, or trachea, is a vital tube that carries air from the throat down to the lungs. When a tumor grows inside this narrow passage, it can squeeze the airway shut, creating a life-threatening emergency. For doctors, managing such a situation is a delicate balancing act. They must put the patient to sleep for surgery while simultaneously keeping the airway open, but the very tools used to breathe—tubes and masks—can sometimes block the view or get stuck in the tumor. If the airway collapses completely during this process, the patient cannot be ventilated, and the surgeon cannot see or work. This creates a high-stakes scenario where the anesthesiologist and the surgeon share the same narrow space, and a single misstep could be fatal.

This case report from the 108 Military Central Hospital in Vietnam describes how a team successfully navigated this extreme challenge in a 76-year-old woman. She arrived with a tumor that had grown to block more than 95 percent of her windpipe, leaving her with severe difficulty breathing and coughing up blood. The tumor was fragile, meaning that trying to force a breathing tube through it could cause it to crumble or bleed, leading to a total blockage. Standard methods of securing an airway were too dangerous. Instead, the medical team employed a three-stage strategy that combined a supraglottic airway device, a tube placed deep below the tumor, and a high-flow oxygen technique that allowed the surgeons to work without any breathing tubes in the way.

The patient's condition was critical. She had been coughing up bright red blood and dark sputum for ten days, and her breathing was so strained that she made a whistling sound with every breath. Imaging showed a mass roughly the size of a small grape, measuring 18 by 18 millimeters, sitting at the top of her trachea and protruding into the tube. Because the blockage was so severe and the tissue so delicate, the team knew that trying to insert a standard breathing tube through the tumor was impossible. They also decided against using a high-pressure jet of oxygen through a tiny needle, as the tumor's fragility made that risky. Their plan began while the patient was still awake. They placed a high-flow nasal oxygen cannula in her nose, pumping 40 liters of oxygen per minute into her lungs. This pre-oxygenation boosted her oxygen reserves, buying the team precious time to act once she was asleep.

Once the patient was sedated, the team inserted a laryngeal mask airway, a device that sits above the vocal cords rather than inside the windpipe. This allowed them to ventilate her lungs without touching the tumor. With the patient breathing safely through this mask, the surgeons made an incision in her neck to expose the trachea. At this point, the team switched tactics. They removed the mask and, working together, the surgeon inserted a breathing tube directly into the lower part of the trachea, below the tumor. This distal tube took over the job of moving air in and out of the lungs, allowing the surgeons to cut out the entire 4-centimeter section of the windpipe containing the tumor.

The most delicate phase came next: reconnecting the two ends of the windpipe. To do this, the surgeons needed a completely clear view of the surgical field, free from any tubes or wires. They removed the lower breathing tube and stopped all mechanical ventilation. Instead, they directed a stream of pure oxygen at a rate of 70 liters per minute through the upper tube, which remained just above the cut. This high-flow oxygen kept the patient's blood oxygenated even though she was not breathing on her own. For 23 minutes, the patient remained in a state of apnea, or stopped breathing, while the surgeons stitched the trachea back together. During this time, her carbon dioxide levels rose slightly, a condition known as hypercapnia, but her oxygen levels remained stable and her heart rate stayed steady. The temporary rise in carbon dioxide was considered safe and acceptable given the short duration.

Once the connection was secure, the team reinserted the breathing tube, resumed normal ventilation, and reversed the muscle relaxants. The patient woke up in the operating room, breathing on her own, and was transferred to the intensive care unit for monitoring. She was discharged five days after the surgery. The authors conclude that this specific combination of techniques—using a mask to start, a tube below the tumor to remove it, and high-flow oxygen to finish the repair—offers a safe and effective way to handle these rare, critical cases. By avoiding the need for complex machines like heart-lung bypass and minimizing trauma to the fragile tumor, the team maintained a clear surgical field while keeping the patient alive and oxygenated throughout the entire procedure.