We present the case of a 66-yr-old male admitted for elective surgery to a post-radiotherapy recurrence of a squamus cell carcinoma of the tonsil, soft palate and base of tongue. The procedure involved a tracheostomy (a tracheo-twist size 8 cuffed tube) placed under local anaesthesia because of severe trismus secondary to his recurrent tumour and prior radiotherapy. This was followed by a commando procedure, with reconstruction using a pectoralis major flap. The patient was nursed in the specialist maxillo-facial ward after operation, with regular tracheostomy care including suctioning and cuff pressure monitoring (25 mmHg). On the second postoperative day he began to bleed profusely around the tracheostomy site. Blood coming up the trachea was intermittently obstructing the airway and leading to desaturation. Pressure was applied to the tracheostomy site and he was taken to the operating theatre.
Blood was aspirated using a suction catheter via the tracheostomy and oxygen administered. Then anaesthesia was induced with etomidate 6 mg, fentanyl 100 μg and muscle paralysis achieved with rocuronium 50 mg. However, it became impossible to ventilate the patient's lungs, arterial desaturation rapidly occurred, with rapid progression to bradycardia and cardiac arrest. After one cycle of cardiopulmonary resuscitation with epinephrine 1 mg and atropine 3 mg, cardiac output returned and the lungs could again be easily ventilated. It was noticed that the left side of the chest was moving considerably less than the right, and oxygen saturation remained in the low-nineties despite ventilation with pure oxygen. The surgical team then coagulated or tied off the bleeding points around the original incision, and changed the tracheostomy, again to a size 8 cuffed tube, after which no further bleeding occurred.
As lung ventilation remained unequal, fibreoptic bronchoscopy was performed using an endoscope (Pentax F1-10P2® - external diameter 3.4 mm) kept in the emergency theatre and normally used to facilitate tracheal intubation; this endoscope only has a narrow lumen suction port (1.4 mm). During the bronchoscopy, the patient's lungs continued to be ventilated via the tracheostomy around the endoscope with 100% oxygen and 1.5% isoflurane to maintain anaesthesia. A large fibrous blood clot was found situated just below the carina, almost completely occluding the left main bronchus. We attempted several times to aspirate the clot with the endoscope, also squirting saline onto it, but the clot was much too large for the suction port, and could not be dislodged. Therefore an endobronchial suction catheter (size 12, 60 cm) connected to a separate suction source was passed alongside the endoscope. This was visualized as it passed down the trachea. As it entered the right main bronchus, the tip of the endoscope was used to manoeuvre the catheter into the left main bronchus. With the end of the suction catheter in the clot, suction to both the endoscope and the catheter was connected and this was sufficiently powerful to dislodge the clot and permit it to be pulled up the trachea. The clot was pulled as far as the tip of the inner tracheostomy tube and then the tube, the endoscope and the suction catheter were all removed together, along with the clot. This was over 8 cm in length and solid in nature (Fig. 1) accounting for the difficulty in removing it.
Further bronchoscopy revealed no other obstructing lesions, and minimal soiling of the endobronchial tree. Lung ventilation improved dramatically and the patient was weaned from the ventilator, awakened and transferred to the recovery room. Chest radiography showed generalized increased opacity of the entire left lung and right base, but no lung collapse. The patient had no neurological deficit and later returned to the maxillo-facial ward.
This case illustrates the use of equipment readily available in the theatre suite of most hospitals to manage a serious complication. This patient presented for emergency surgery out of hours. Once anaesthesia had been induced, it was quickly apparent that the airway had become blocked, and rapid deterioration led to cardiac arrest. We assume that cardiopulmonary resuscitation, or forceful 'bagging', or both, had dislodged the clot that had obstructed the trachea, and that the clot had then moved distally.
After the operation, the priority was to diagnose and treat the cause of the reduced ventilation of the left lung, presumed at first to be a foreign body. The fibreoptic endoscope in the theatre suite is usually used for tracheal intubation, and is narrow in diameter: its suction port will not admit instruments. The suction generated was insufficient to dislodge the foreign body, forcing us to consider a number of options.
Removal of tracheobronchial foreign bodies via the rigid ventilating bronchoscope remains the definitive standard of care . Because of our patient's high oxygen dependency, rigid bronchoscopy may have caused further deterioration so was not undertaken. Another alternative is the use of wide-bore flexible bronchoscopy and instrumentation . In our patient, a larger bronchoscope may have caused difficulty with ventilation when passed down the tracheostomy, as it would occupy a greater proportion of the available space leading to higher peak airway pressures and positive end-expiratory pressure .
A. A. Klein
Department of Anaesthesia; Royal London Hospital; London, UK
P. S. G. F. Hardee
Department of Maxillo-facial Surgery; Royal London Hospital; London, UK
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