(P30) I Thought It Was COPD: A Case of Unanticipated Difficult Airway

Chief Complaint : Shortness of breath/COPD exacerbation

History of Present Illness : A 77-year-old female with a past medical history of hypertension, chronic back pain, and questionable chronic obstructive pulmonary disease (COPD) was brought in by EMS from home for respiratory distress. Per EMS, the family stated that the patient had a history of COPD, so she was given nebulized albuterol and ipratropium along with dexamethasone en route to the hospital. On arrival to the ED, the patient was receiving a nebulized treatment, had significant respiratory distress with tachypnea, suprasternal and subcostal retractions, and most notably had a muffled voice with audible stridor. She was unable to contribute to history. Per chart review, she is an active tobacco smoker with 51 pack year history.

Pertinent Physical Exam: General: Elderly obese female, anxious appearing, in acute respiratory distress.
HEENT: Normocephalic and atraumatic. Mass at the posterior oropharynx with an area of questionable necrosis with almost complete airway occlusion. Patient with muffled voice and stridor.
Cardiovascular: Tachycardia, regular rhythm with normal S1 and S2. No murmurs, rubs, or gallops. Distal pulses 2+ and symmetric on upper and lower extremities.
Pulmonary: Tachypnea, subcostal and suprasternal retractions, diffusely decreased breath sounds without wheezes, rales, or rhonchi.
Extremities: Warm, well-perfused, no pitting edema.

Pertinent Laboratory Data: VBG: pH 7.23, CO2 76.3, O2 107, lactate 1.0
BNP 103
Troponin 0.01
CBC: WBCs 14.7, H&H 13.6/42.1, PLTs 342

Case Discussion: Upon arrival to the ED, the patient was triaged as a COPD exacerbation and was initially treated with nebulized albuterol and ipratropium. The patient was primarily Spanish-speaking and was wearing a nebulizer mask making it difficult to understand her. The provider auscultated her chest and noticed decreased breath sounds without obvious wheezing and removed the patient’s mask to reveal a muffled voice and audible inspiratory stridor. On inspection, the patient had a soft tissue mass with darkened central area in the posterior oropharynx with uvular effacement prompting concern for airway obstruction. The patient was given an additional round of nebulized albuterol and ipratropium, nebulized racemic epinephrine, Toradol, intravenous fluids, and broad-spectrum antibiotics for concern over possible infectious etiology. Shortly after, the patient was noted to be hypoxic and with increasing respiratory distress, so she was placed on high-flow nasal cannula and non-rebreather mask and had an oxygen saturation of 89%.
ENT emergently scope the patient, which revealed pooling of secretions in the nasopharynx and a right-sided bulging mass that was partially obstructing the oropharyngeal passage. She required emergent airway management and had a difficult bedside intubation. A soft tissue neck CT obtained shortly after showed a large enhancing soft tissue mass involving the right palatine tonsil that was completely effacing the oropharyngeal airway. The mass abutted the right medial pterygoid muscle, soft palate, tongue base and longus coli and capitis muscles with encroachment on the right retromolar trigone. CT also demonstrated bilateral metastatic adenopathy.

References and Acknowledgements (Optional): N/a