Veno-venous-extracorporeal membrane oxygenation as a bridge to surgical airway in an intellectual disability patient with a large thyroid goiter: a case report.

Introduction: Large thyroid goiters are uncommon in Western countries but remain relatively frequent in the Middle East and parts of Africa. These goiters can compress or displace the trachea, causing airway narrowing, respiratory distress, and higher anesthetic risk. Airway management becomes even more challenging in uncooperative or cognitively impaired patients. In such cases, extracorporeal membrane oxygenation (ECMO) can provide a valuable alternative to conventional intubation, though it introduces distinct challenges for surgeons, intensivists, and anesthesiologists. Case Presentation: We report a 31-year-old man with intellectual disability and a large multinodular goiter causing severe airway compression. He presented with hypoxemic hypercapnic respiratory failure and a pneumonia. Due to highly challenging airway management, veno-venous (VV) ECMO was initiated to stabilize the patient and permit safe surgical airway management, after which total thyroidectomy was performed uneventfully. Discussion: Large goiters pose major challenges for anesthesiologists and surgeons, particularly when airway anatomy is distorted. Although fiberoptic intubation and tracheostomy are standard techniques for difficult airway management, these may be unsafe or impractical in patients with altered anatomy or limited cooperation. This case demonstrates that ECMO can act as a crucial bridge to safe induction and surgery, avoiding emergency tracheostomy and enabling controlled airway access. Conclusion: VV-ECMO represents a safe, effective strategy for airway management in complex thyroid surgeries, especially when conventional approaches are restricted by anatomical distortion or cognitive impairment. Optimal outcomes depend on careful patient selection and close multidisciplinary coordination.