The failed airway remains a major cause of anesthetic morbidity and mortality. Two unusual and difficult airway scenarios were encountered in the same patient under different circumstances, presenting interesting clinical challenges. This manuscript adheres to the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines for case reports. Written Health Insurance Portability and Accountability Act (HIPAA) authorization was obtained from the patient for publication of this case report.
A 34-year-old morbidly obese woman with a body mass index of 48 kg/m2 presented to our hospital following a bicycle accident. Injuries included fractures of the skull, nasal bones, and thoracic vertebrae. She had been intubated before arrival using a 7.0-mm internal diameter (ID) endotracheal tube (ETT). She was extubated the following day and subsequently reintubated for surgical repair of the vertebral fractures. Over the next 2 weeks, she underwent 2 additional surgeries that required endotracheal intubation with a 7.0-mm ID ETT using videolaryngoscopy. The intubations were documented as easy and atraumatic. She was subsequently discharged to a rehabilitation facility. Three weeks after discharge, she was readmitted for an operative procedure for a wound infection that complicated her recovery after vertebral surgery. In the preoperative area, she was found to have a cough with copious sputum production. She reported the cough to be progressively worsening over the past 2 weeks with occasional shortness of breath and wheezing. The surgical procedure was postponed due to her suboptimal respiratory status and a vacuum-assisted closure of the wound was performed as a temporizing measure without any anesthetic intervention. Unfortunately, her perioperative optimization over the next 48 hours was not followed by the anesthesiology team.
Two days later, the anesthesiology team was called to this patient’s bedside after she was found somnolent and in respiratory failure in an inpatient unit. Her arterial blood gas analysis showed hypercapnic respiratory acidosis (pH 6.9, partial pressure of carbon dioxide [Pco2] 133 mm Hg, partial pressure of oxygen [Po2] 192 mm Hg). Following the administration of intravenous propofol, endotracheal intubation was attempted with direct laryngoscopy followed by videolaryngoscopy. Despite good visualization of the vocal cords, resistance was encountered during the advancement of the ETT. Even a 5.5-mm ID ETT could not be advanced further after traversing the vocal cords. A supraglottic airway was placed with successful ventilation. Bedside flexible bronchoscopy revealed critical airway stenosis. Following an improvement in oxygen saturation after manual positive pressure ventilation, she was transferred to the operating room for a tracheostomy. We administered general anesthesia with oxygen and an inhalational anesthetic through the supraglottic airway. The otolaryngologist inserted a 6.0-mm ID Shiley cuffed tracheostomy tube (Medtronic, Minneapolis, MN) between the third and fourth tracheal rings and confirmed its position by tracheoscopy. The patient was transferred to the postanesthesia care unit with ongoing sedation and placed on ventilatory support. Shortly thereafter, patient-ventilator asynchrony was observed associated with decreasing oxygen saturation, and the tracheostomy tube appeared to be dislodged. Flexible bronchoscopy through the tube did not reveal tracheal rings. We removed the tracheostomy tube and called for help. The stoma was covered manually, and a supraglottic airway was placed orally to support ventilation. The otolaryngologist was able to insert an extended-length 6.0-mm ID Shiley cuffed tracheostomy tube through the stoma under direct vision.
A week later, direct laryngoscopy and bronchoscopy in the patient revealed normal vocal cords and a grade III Myers-Cotton tracheal stenosis involving the upper tracheal rings and extending to 5 mm below the glottis with severe diffuse tracheomalacia (Figures 1, 2). After dilation of the stenosis to 15 mm (Figure 3), she was discharged to a rehabilitation facility. In the following 6 months, she underwent tracheal dilation 3 times. After consistently failing tracheostomy capping trials, she has since been offered reconstructive surgery.
Tracheal stenosis is a rare but serious complication of endotracheal intubation. It commonly results from overinflation of the cuff causing pressure necrosis of the adjacent tracheal wall.1 Changes in the tracheal mucosa may occur within 15 minutes of cuff inflation with a potential for ischemic damage if the cuff pressure exceeds the mucosal capillary pressure (20–30 mm Hg).2 Ulceration, chondritis and, eventually, fibrosis and tracheomalacia can occur in 3–6 weeks.
Tracheal stenosis should be suspected in patients with a history of prolonged intubation or tracheostomy who present with symptoms such as dyspnea, wheezing, and cough with expectoration.1,2 Despite the presence of risk factors and suggestive symptoms (Figure 4), an early diagnosis of tracheal stenosis was not made in our patient. After postponement of the case and following a negative chest X-ray, a pulmonologist had been consulted and the patient underwent bedside spirometry. A suboptimal performance on spirometry precluded any definitive conclusions, although the test appeared suggestive of a fixed upper airway obstruction (Figure 5). The pulmonologist recommended a bronchoscopy to establish a diagnosis. The patient deteriorated before the bronchoscopy could be performed.
Airway stenosis should be suspected when resistance is encountered in advancing the ETT beyond the vocal cords despite good glottic visualization during laryngoscopy. Causes include iatrogenic, tumor, trauma, foreign body, autoimmune disorders, radiation therapy, infection, idiopathic, and severe tracheal deviation.3 After the establishment of satisfactory ventilation, a definitive airway should ideally be secured under controlled conditions. Deep inhalational anesthesia and the maintenance of spontaneous ventilation without neuromuscular blockade are recommended until a definitive airway is established.4
Airway management in undiagnosed tracheal stenosis depends on the location and extent of stenosis, type and urgency of surgery, and the availability of specialized personnel and equipment. In a nonurgent situation, the patient may be awakened and evaluated by an otolaryngologist.4,5 If urgent and feasible, anesthesia can be continued via a facemask or supraglottic airway while maintaining spontaneous ventilation.4,5 Tracheal tubes have been successfully placed above the stenosis with the application of a throat pack to minimize air leak.4,6 Rigid bronchoscopy has been used to confirm the diagnosis and facilitate ventilation and dilation of the stenosis enabling safe intubation with an adequate-sized ETT and completion of surgery.4 Repetitive efforts at intubation may lead to laryngeal edema resulting in hypoxia.7 Jet ventilation, although feasible,4 may be dangerous in critical stenosis because of inadequate outflow from the lungs, causing hypotension and barotrauma.8 A surgical airway is considered in the “cannot ventilate, cannot intubate” scenario.9 However, cricothyrotomy and tracheostomy may be ineffective if the stenosis is distal. Extracorporeal membrane oxygenation or cardiopulmonary bypass remains a last resort,5 but these techniques may not be immediately available.
Following tracheostomy in the operating room, tube displacement occurred postoperatively. Tracheostomy-related emergencies can be catastrophic in patients with an immature stoma. Assessment for evidence of breathing should be the first step in these patients. A suction catheter may be passed through the tracheostomy tube after removal of the inner cannula to assess patency,10,11 while preparing for flexible bronchoscopy. Deflating the cuff may allow airflow past a partially displaced or blocked tracheostomy tube to the upper airways.10 If the suction catheter cannot be passed and deflating the cuff fails to improve the clinical condition, the tracheostomy tube may be completely blocked or displaced and should be removed as soon as it is established.10
Reinsertion of a tracheostomy tube through a mature stoma (>7–14 days after insertion) is usually straightforward. However, blind attempts at insertion through an immature stoma may create a false track and may not be required immediately if the patient is not hypoxic.10–12 If reinsertion appears challenging and the patient is deteriorating, attempts should be made to secure and maintain the airway via the glottis after covering the stoma. Ventilation may also be performed through the stoma, using a facemask or supraglottic airway applied externally with a sufficient seal.11 Flexible bronchoscopy and airway exchange catheters may be used to visualize the trachea and facilitate endotracheal tube insertion through the stoma.10,12 If reinsertion is difficult, cricothyrotomy or revision tracheostomy remains an option.
Risk factors for tracheostomy tube displacement include obesity, tracheal anomalies, inadequate sedation, airway edema, increased pulmonary secretions, and suboptimal placement.10–13 A large-sized neck, tracheal stenosis, and tracheomalacia might have contributed to the dislodgement of the tracheostomy tube in our patient. The dislodgement might have been prevented by using a longer tracheostomy tube initially. The situation was corrected by the placement of an extended-length tracheostomy tube and confirmation of its position by flexible bronchoscopy.
In patients with a history of endotracheal intubation who present with respiratory symptoms, tracheal stenosis should be included in the differential diagnosis.1 Practitioners tend to overinflate the ETT cuff, and the use of a manometer is recommended to achieve acceptable cuff pressures.14 Inflating with a 5-mL syringe is a practical alternative to the traditionally used 10-mL syringe.15 Anesthesiologists must be prepared to handle tracheostomy-related emergencies. Details regarding the tracheostomy (eg, surgical versus percutaneous technique, date and indication for placement, the type of tube used, and a plan for accidental displacement) should be available at the patient’s bedside.10
Flexible bronchoscopy remains a valuable diagnostic tool for difficult airway management due to tracheal pathology. We propose 2 algorithms regarding the management of the inability to advance an endotracheal tube despite good glottic visualization and displacement of a fresh tracheostomy tube (Figures 6, 7). These will serve as valuable decision-making tools for practitioners faced with similar airway difficulties.
The authors thank Suryanarayana Pothula, MD, Department of Anesthesiology, New York Medical College, Westchester Medical Center, Valhalla, NY, for his valuable guidance in the preparation of this manuscript.
Name: Arjun Tara, DO.
Contribution: This author helped conceive and prepare the manuscript.
Name: Sangeeta Kumaraswami, MD.
Contribution: This author helped conceive and prepare the manuscript.
Name: Craig Berzofsky, MD.
Contribution: This author helped prepare the manuscript.
This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.
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