Tracheostomy, an operative procedure used to create an opening in the trachea, is one of the most ancient surgical procedures, and over the centuries, it has remarkably remained one of the most commonly performed surgical procedures.1 When patients who have undergone a tracheostomy need to undergo a subsequent surgical intervention, it is usually necessary to exchange the tracheostomy tube for a tracheal tube to meet intraoperative requirements for anesthesia and surgery. For most patients with a well-established tracheostomy, the tract has already matured, which makes the exchange generally straightforward and uneventful. Consequently, the presence of a tracheostomy may give anesthesia providers a false sense of security concerning airway management. In stark contrast, in patients who have recently undergone a tracheostomy, the tract is not well formed. Under these circumstances, if the tracheostomy tube (which keeps the tract open) is removed, it may be very difficult to reinsert another tube into the tracheal lumen. This complication could possibly result in a life-threatening loss of airway. This report describes a case in which an airway exchange catheter was used to safely exchange a tracheostomy tube for a tracheal tube in a patient with a fresh tracheostomy. The patient gave written permission to publish this case report.
A 53-year-old woman (weight, 63 kg; height, 157 cm) with a history of squamous cell carcinoma of the oral cavity was taken to the operating room for incision, drainage, and debridement of a neck wound. Her medical history included hypertension, hypothyroidism, and iron deficiency anemia. An airway examination showed that she had a Mallampati class-3 airway score, with a restricted mouth opening and an interincisor distance of 4 cm. Her neck showed normal range of motion. She had undergone a tracheostomy, right hemimandibulectomy, neck dissection, mandible reconstruction with a left fibula osteocutaneous free flap, and donor site reconstruction with a split-thickness skin graft. The operation was completed without incident. On postoperative day 6, the patient developed edema on the right side of the neck and a purulent discharge. A computed tomography scan of the neck revealed a fluid collection lateral and inferior to the right mandibular reconstruction site, which indicated postoperative fluid collection and/or an abscess.
The anesthetic management for this patient, who had undergone a tracheostomy only 7 days earlier, required that the tracheostomy tube be exchanged for a cuffed endotracheal tube to provide positive pressure ventilation intraoperatively and to allow free access to the surgical site. The plan was to replace her 6.0 Shiley tracheostomy tube (Covidien Ltd, Mansfield, MA) with a cuffed 6.0 reinforced endotracheal tube. In the operating room, she was preoxygenated through her tracheostomy tube with 100% oxygen. She was given 2 mg of midazolam IV. Topical anesthesia of the airway was achieved with a 4% lidocaine hydrochloride solution sprayed into the tracheostomy using an atomizer. The inner cannula was removed, and a 14Fr Cook airway exchange catheter (Cook Incorporated, Bloomington, Ind) was inserted through the outer cannula (Figure 1). After the exchange catheter was successfully advanced into the tracheal stoma, the outer cannula of the tracheostomy tube was removed (Figure 2). Next, a size 6.0 wire-reinforced endotracheal tube was advanced over the Cook catheter into the tracheal lumen. After the endotracheal tube was in place, the airway exchanger was removed (Figure 3). A successful exchange was confirmed by measuring end-tidal CO2 and by listening for breath sounds in both lung fields. After the airway had been properly secured, the surgery proceeded uneventfully.
One of the earliest accounts of a tracheostomy can be found in Rig Veda, the sacred Hindu book of medicine that was written around 2000 BC, which describes a “healing incision in the throat.”2 The first successful tracheotomy was performed by Antonio Brassavola in Ferrara, Italy, the details of which were published in 1546.3 At present, tracheostomy is still one of the most commonly performed surgical procedures. Currently, the main indications for tracheostomy include upper airway obstruction, long-term mechanical ventilation, and surgeries of the head and neck, especially extensive tumor resection with complex plastic reconstruction. When a patient with a tracheostomy undergoes a subsequent surgery, the tracheostomy tube must be removed and exchanged for a cuffed endotracheal tube so that the anesthesiologist can deliver positive-pressure ventilation while the patient is under general anesthesia. Furthermore, a low-profile endotracheal tube is preferable to a bulky tracheostomy tube because it provides unrestricted access and optimal exposure of the surgical field.
There is a distinct difference between a mature and a fresh tracheostomy. This difference can have vital implications for patients who must undergo another surgical procedure. In patients with a mature tracheostomy, exchanging the tracheostomy tube for an endotracheal tube is usually straightforward and uneventful. The tract is already well formed, with the tracheal lumen in close proximity to the level of the skin. Therefore, the stoma is unlikely to recoil back into the deep plane of the neck when the tracheostomy tube is removed. The risks associated with exchanging tubes generally decrease as the stoma matures. Usually, tracheostomies are considered fresh if they were performed within the past 7 days,4 and it has been suggested that the time period necessary for the tracheal-cutaneous tract to fully mature is 2 to 3 weeks.5,6 However, in many patients, it may be difficult to determine with certainty when the tract is fully mature. Comorbidities, such as malignancy, immunosuppression, diabetes, and poor wound healing, may delay maturation of the tract. In patients with a fresh tracheostomy, the tract is not well formed. Removal of the tracheostomy tube without using an airway exchanger to keep the trachea in place could allow it to recede into the deep neck compartment. The stoma would then revert back to a slit-like opening, which would make it exceedingly difficult to reinsert a tube. During unsuccessful attempts to reinsert a tube, the tip of the tracheal tube could slide downward, creating false paths from the pretracheal space into the anterior mediastinum. Inadvertent insufflation with positive-pressure ventilation in these pseudotracts within the anterior mediastinum has been reported to cause edema, subcutaneous emphysema, pneumomediastinum, pneumothorax, and cardiac arrest.
Patients at high risk for difficulties during decannulation and tube changes include those who are morbidly obese and those with short bulky necks because the increased thickness of the pretracheal tissues in these patients makes it difficult to access the trachea. Similarly, patients for whom it is difficult to palpate the midline neck anatomy and patients with a tracheal shift attributable to pathological changes, such as an enlarged thyroid goiter, should also be considered at high risk for a difficult tracheostomy tube exchange. Finally, a difficult tracheostomy tube exchange should be anticipated for patients who have a distortion in their neck anatomy from radiation changes and for patients who have undergone an extensive surgical resection with reconstructive flaps. When repeated attempts to reinsert the tube into the tracheostomy stoma are unsuccessful and complete airway obstruction is impending, one can attempt to gain control of the airway by intubation of the trachea through the vocal cords from above. Unfortunately, many of the patients who have undergone a tracheostomy had a difficult airway in the first place. Patients with head and neck cancers may have a difficult airway because the tumors may be causing an obstruction or because they have recently undergone surgical resection of cancerous tissue within the airway, combined with a complex plastic free-flap reconstruction. Furthermore, tracheostomy is often performed to establish airway patency in patients who otherwise would be unable to achieve adequate oxygenation and ventilation on their own. If a tracheostomy tube cannot be replaced in a timely manner, the airway obstruction causes the patient to panic and become agitated and restless, further jeopardizing attempts to regain control of the airway. These patients usually cannot tolerate even short periods of apnea, and airway obstruction may lead rapidly to catastrophic cardiorespiratory arrest. Under these dire circumstances, last-ditch efforts consist of emergent cricothyrotomy or tracheotomy.
The insertion of a long and stiff catheter into the tracheal lumen carries the risks of tracheobronchial injuries and pneumothorax.7 Consequently, utmost caution should be exercised throughout the exchange. The use of a fiberoptic bronchoscope can detect granulation tissue, which may be a cause of airway obstruction and bleeding during the exchange. Bronchoscopy also allows estimation of the relatively short distance from the tracheostomy stoma to the carina and the length of catheter necessary for safe insertion. Alternatively, tracheal suction catheters and red rubber urethral catheters have been used successfully for this purpose with less risk of tracheobronchial trauma. Unfortunately, they cannot provide uninterrupted delivery of supplemental oxygen and rescue ventilation.
The tracheostomy bypasses upper airway obstruction and establishes a bridge to allow access to the tracheal lumen. Removal of the tracheostomy tube without taking any precautions will result in burning that bridge. The use of an exchange catheter, as described in our case, represents preservation of the bridge. Having the catheter in the airway during each step of the exchange provided continuous direct access to the trachea during the entire exchange procedure.
Anesthesiologists are usually familiar with the use of an exchange catheter to exchange a tracheal tube for another tracheal tube. Similarly, surgeons often perform tracheostomy tube exchanges for another tracheostomy tube. This report advocates the routine use of an exchange catheter of a fresh tracheostomy tube for a tracheal tube, an area that has rarely been reported. The exchange of a tracheostomy tube for a tracheal tube could be fraught with serious dangers that may be overlooked or underestimated by anesthesia providers. This case provides a new heightened awareness of these risks. When a fresh tracheostomy tube is removed and cannot be replaced, the inability to ventilate the patient can escalate rapidly to a life-threatening crisis. It is very difficult to determine the degree of maturity of a patient’s tracheostomy cutaneous tracheal tract on the basis of the number of days elapsed since creation or a visual examination of the neck alone. Taking into account the potential risk of catastrophic loss of the airway and the simple precautionary measure that can be used to prevent it, we advocate for the systematic use of an exchange catheter when operating on patients who require exchange of a tracheostomy tube for a tracheal tube. Hopefully, this recommendation will be widely adopted by anesthesia providers who are already adept at using airway exchange catheters.
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