High-flow Nasal Oxygen in a Physiologically Difficult Airway for Awake Craniotomy: Optimising the Highs and Lows

Respiratory failure is a major risk factor for perioperative pulmonary complications, requiring mechanical ventilation following general anaesthesia. Awake craniotomy avoids physiological derangements related to general anaesthesia, while facilitating continuous neurological monitoring of eloquent areas. High-flow nasal oxygen (HFNO) provides effective oxygenation with CPAP of 3–4 cmH2O, along with providing a favourable interface for communication. We present a 53-year-old female with carcinoma breast having brain and lung metastases with malignant pleural effusion and superimposed pulmonary infection, posted for parietal lobe metastasis excision. Due to her pulmonary comorbidities with an oxygen saturation of 88%, she was posted for an awake craniotomy. HFNO was used to maintain her oxygenation intraoperatively. In this patient, HFNO effectively improved the patient’s oxygenation, comfort and compliance without compromising her involvement in neurological testing.