24: A Novel Approach Using Veno-Arterial Extra Corporeal Membrane Oxygenation (VA ECMO) for Massive Retrosternal Goiter with Stridor

Introduction: Retrosternal goiter with mass effect with stridor is an acute airway emergency. This case explored the possibility of VA ECMO use for central airway obstruction using a multidisciplinary approach. Case Report: 52-year-old female presented to the ER with complaints of cough for 1 week and breathlessness for 2 days which worsened overnight. On presentation, she was conscious, oriented and hemodynamically stable, RR of 22 cycles/min, SpO2 of 95% on room air with stridor. On examination, she had left-sided neck swelling with tracheal shift to the right, moving with deglutition and the lower border non-palpable. She had dilated blood vessels over the right side of her neck and chest. CECT neck obtained showed a well-defined heterogeneously enhancing mass lesion possible retrosternal goiter, with significant mass effect with displacement, distortion and narrowing of the trachea. After a multidisciplinary meeting involving the ENT, CTVS, and Anesthesiology, she was planned for left hemithyroidectomy with VA ECMO. Due to stridor, direct laryngoscopy was not feasible. Awake sitting VA ECMO cannulation was done under local anesthesia and anesthesia induced. Bronchoscopy was done and patency of airway confirmed. ET size 7 armored was railroaded and cuff inflated. Left hemi-thyroidectomy was done. VA ECMO flow of 2.5 L/min was maintained throughout, and anesthesia maintained on total intravenous anesthesia (TIVA). Post surgery, VA ECMO was weaned and decannulation was done. Prior to extubation, bronchoscopy was done for ET repositioning and to rule out tracheomalacia. She was extubated on day 1 and discharged on day 4. Conclusion: Multidisciplinary approach for an airway emergency involving retrosternal goiter with mass effect was effectively managed by instituting VA ECMO and relieving the airway obstruction surgically. Post surgery, VA ECMO could be effectively weaned off and patient safely extubated. Acute central airway emergencies can be dealt with through multidisciplinary approaches.