Case Report: Awake lateral decubitus intubation for a patient with critical tracheal stenosis secondary to retrosternal goiter: salvaging a 2 mm airway without ECMO support

Background: Tracheal compression frequently occurs in patients with retrosternal goiter, potentially leading to critical tracheal stenosis. The lateral position has been shown to increase the cross-sectional area of the upper airway and improve the oxygenation in sedated patients compared to the supine position. However, it is unclear whether it can be successfully applied to airway management in patients with critical tracheal stenosis. Case presentation: We report the case of a 71-year-old female patient undergoing total thyroidectomy for a massive retrosternal goiter extending to the descending aorta. Chest computed tomography (CT) showed a tracheal lumen with a minimum diameter of 2.0 mm when the patient was in the supine position. Consequently, our anesthesiology team adopted a 30° head-up left lateral positioning strategy, integrating video laryngoscopy and fiberoptic bronchoscopy (FOB) for awake intubation as the primary airway management protocol. Extracorporeal membrane oxygenation (ECMO) was prepared as a backup for airway rescue. Ultimately, the patient successfully established an artificial airway via awake intubation in the lateral decubitus position, followed by the smooth completion of a thyroidectomy. Conclusion: Employing the lateral decubitus position, a dual-guidance technique combining video laryngoscopy with FOB for awake endotracheal intubation, represents a feasible airway management strategy for patients presenting with critical tracheal stenosis.