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Loss of the airway during tracheostomy: rescue oxygenation and re-establishment of the airway

[La perte du contrôle des voies aériennes pendant la trachéotomie: l'oxygénation de secours et le rétablissement de la ventilation]

Glenn McGuire, MD^*, Hossam El-Beheiry , MBBCH PhD FRCPC^* and Dale Brown , MD FRCSC

^* From the Departments of Anaesthesia,Toronto Western Hospital, University Health Network and Mount Sinai Hospital and
Otolaryngology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Address correspondence to: Dr. Hossam El-Beheiry, Toronto Western Hospital, University Health Network, Room EC 2–046, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada. Phone: 416-603-5118; Fax: 416-603-6494; E-mail: beheiry{at}uhnres.utoronto.ca

Purpose: To describe loss of the airway during tracheostomy and suggest a method for re-establishment of the airway and providing rescue oxygenation.

Clinical features: A 22-yr-old female diagnosed with encephalomyelopathy was admitted to the intensive care unit with a progressively deteriorating level of consciousness and respiratory failure requiring intubation and ventilation. Several weeks later, an elective tracheostomy was performed under anesthesia. The surgeon made an anterior tracheal wall incision and inserted a cuffed #6 Shiley tracheostomy tube. No end-tidal CO₂ was detected and the patient could not be ventilated. After another failed attempt at insertion of a second tracheostomy tube, the diagnosis was made of a false passage within the trachea. The Shiley tracheostomy tube was removed and a #6 regular endotracheal tube was introduced in the trachea through the tracheostomy incision. The patient now could be ventilated with difficulty and low readings of end-tidal CO₂ were noted. Despite all efforts to further ventilate the patient, the arterial oxygen saturation never recovered, resulting in cardiac arrest.

Conclusion: To restore a lost airway during tracheostomy, we recommend that a jet ventilation airway exchange catheter (JVAE) be inserted in the endotracheal tube through a bronchoscope port attachment prior to surgical entry into the trachea. The JVAE will also ensure continued ability to oxygenate the patient.

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