Background: Perioperative anesthetic management of thyroid mass causing severe tracheal obstruction with positional symptom is critical in regard that it can lead to difficulty in either ventilation or intubation and result in acute respiratory decompensation at every stage of anesthesia.
Case Report: A 67-year-old male patient with huge intrathoracic goiter causing severe tracheal obstruction, presenting progressive dyspnea aggravated by supine position was scheduled for total thyroidectomy. The preoperative CT scan showed large multinodular goiter extended to thoracic cavity with diffuse 6cm segmental tracheal narrowing, 4.29 mm in diameter at the narrowest portion of the trachea (Figure1).
Prior to induction of general anesthesia, we applied veno-venous extracorporeal membrane oxygenation(ECMO) under sedation with dexmedetomidine in preparation for potential difficulty in securing the airway during general anesthesia, and then anesthesia induction and maintenance progressed uneventfully. After the surgical procedure, resolution of the tracheal narrowing was revealed in fiberoptic  bronchoscope and chest radiograph postoperatively. ECMO was weaned 2 hours after the surgery and extubation was performed on the first postoperative day. The patient was discharged without any complication.
Discussion: Although the literatures on using extracorporeal circulation before induction of anesthesia for prevention of airway and hemodynamic complication is limited to few case reports, the establishment of femorofemoral bypass under local analgesia prior to induction of anesthesia in elective manner and not as a rescue has been safely performed in adult patients.

03 / Applying extracorporeal membrane oxygenation as anesthetic consideration for huge intra-thoracic goiter causing severe tracheal obstruction with positional symptoms