Background: A nasal PAP mask assembly was shown to improve oxygenation by maintaining spontaneous respiration in sedated obese OSA patients or patients with difficult airway during awake/sleep endotracheal intubation (ETI) (Fig. 1) (1-6). We report its use in a patient with a mandibular mass during ETI.

Case Report: A 66 y/o cachectic male with A-Fib, RBBB, HTN, anemia, NIDDM, bipolar disorder, schizophrenia, lung cancer s/p RUL lobectomy, thyroid mass (2.6x4.8 cm) and necrotic mandibular sarcoma (4.4x7.4 cm) presented for resection and reconstruction. The mass extended to his lower lip. He had a Mallampati class IV airway and poor face-mask-fit. 

The patient gave his consent for using a modified nasal mask and taking photographs for educational purpose.

A modified infant mask (Fig. 2) was secured over his nose with head-straps and connected to the anaesthesia machine via a breathing circuit. The APL valve was adjusted to deliver 5-6 cm H2O CPAP with O2 (4L/min). 

Deep sedation was titrated with 100 mg lignocaine and small boluses of propofol (6x50 mg). He maintained spontaneous ventilation and 100% SpO2 with pressure-control (PC) ventilation (PIP 13 cm H2O, PEEP 5, RR 20). Video-laryngoscopy (VL) revealed a grade II laryngeal view (Fig. 3-5). 

Rocuronium (50 mg) was administrated to relax the vocal cords in order to advance FOB. However, ETT met resistance about 4 cm below the vocal cords. After inserting a rigid stylet, ETT was advanced smoothly. FOB revealed no tracheal bleeding. 

The large mandibular mass was revealed after removing the dressing (Fig. 6). He maintained 100% SpO2 during intubation and tolerated the procedure well. He was kept intubated and sedated (Fig. 7). The patient was extubated next afternoon.

Discussion: This modified nasal CPAP mask assembly provided continuous active oxygenation in a patient with a large mandibular mass and difficult airway during VL-guided FOI. 
It maintained spontaneous nasal ventilation and subsequently provided PC nasal ventilation. 

It allows calm attempts to perform VL/FOI and may improve patient safety. 

References:1. www.TSEMask.com; 2.SAMBA 28th AM, 2013; 3.SASM 3rd AM, 2013; 4.ASA AM, 2013; 5.SAM AM, 2014; 6.ASA AM, 2014 

Learning points:1. How to construct this nasal PAP mask assembly. 
2: How to provide optimum nasal CPAP to maintain spontaneous respiration. 
3: How to perform awake/sedated combined FOB/VL ETI with continuous active nasal oxygenation.

10 / A novel modified nasal PAP mask assembly maintained spontaneous ventilation and continuous active oxygenation in a cachetic patient with a large mandibular sarcoma, a large thyroid nodule and a difficult airway during video-laryngoscopy-guided oral fiberoptic intubation
