| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
From the Department of Anesthesia, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.
Address correspondence to: Dr. Peter C. MacDougall, Department of Anesthesia, University Health Network, Toronto General Hospital, 200 Elizabeth Street, Eaton North Wing, 3rd Floor, Room 424, Toronto, Ontario M5G 2C4, Canada. E-mail: pcmacdou{at}dal.ca
 |
Abstract |
|---|
 TOP Abstract IntroductionCase reportDiscussionReferences |
|---|
Clinical features: A 29-yr-old man presented to a rural hospital with sudden onset neck pain and progressive dyspnea. Five days earlier the patient had undergone tracheal resection for tracheal stenosis related to prolonged intubation. The patient informed the emergency room staff that the attending anesthesiologist had made note of a "difficult airway". The community hospital had neither a portable storage unit for difficult airway management nor a bronchoscope available. In the presence of a general surgeon, an initial attempt at an awake intubation was unsuccessful. During this time the patient developed massive subcutaneous emphysema obliterating surgical landmarks and causing stridor. A modified rapid sequence intubation was performed. Intubation was successful using a Jackson-Wisconsin #3 straight blade and styletted endotracheal tube. The patient was transferred to a tertiary care centre where he underwent a primary repair of the trachea.
Conclusion: Management of tracheal rupture in the patient with a difficult airway is a challenging problem, especially, in a rural hospital. This case highlights the need for skilled staff and resources to manage a difficult airway in the emergency room.
|
Introduction |
|---|
|
TOPAbstractIntroductionCase reportDiscussionReferences |
|---|
Written consent for publication of this information was obtained from the patient, in accordance with local institutional guidelines.
|
Case report |
|---|
|
TOPAbstractIntroductionCase reportDiscussionReferences |
|---|
Four months prior to presentation he had undergone flexible bronchoscopy with laser therapy to a stenotic area of the trachea 3 cm below the vocal cords. Anesthesia records indicated that a grade IV Cormack-Lehane5 laryngoscopic view was obtained with a MacIntosh #3 blade. The attending anesthesiologist was unable to intubate with a styletted endotracheal tube and intubation was accomplished with the aid of a fibreoptic bronchoscope. The endotracheal tube was positioned above the stenosis. The stenotic area was initially too small to allow passage of a 6-mm bronchoscope. Laser therapy was carried out and at the end of the procedure an 8.5 mm endotracheal tube was passed through the stenotic area. The patient was discharged without incident on postoperative day one.
Two months prior to presentation the patient again had laser ablation of the stenotic area of the trachea. This was accomplished by rigid bronchoscopy. The patient was managed by jet ventilation and his trachea was not intubated. At the end of the procedure the rigid bronchoscope could be passed beyond the stenotic area. The patient continued to have exertional dyspnea and a tracheal resection with primary anastamosis was undertaken. Insertion of a rigid bronchoscope immediately before tracheal resection was noted to require the aid of a MacIntosh laryngoscope blade. Intubation after the rigid bronchoscopy required the aid of a gum elastic bougie. Following tracheal resection the patient was uneventfully extubated and his immediate postoperative course was uneventful. He was discharged on postoperative day three.
Initial examination in the emergency room revealed moderate bilateral cervical subcutaneous emphysema. Airway examination revealed moderate micrognathia, full teeth and a Mallampati II view of the pharynx. The patient was afebrile with oxygen saturation of 99% on room air. His heart rate was 108, blood pressure was 135/91 mmHg and he had a respiratory rate of 20 min–1. Supplemental oxygen was provided via nasal prongs and the patient was transferred to the resuscitation room.
Unfortunately, the community hospital emergency department was not equipped with a ‘difficult airway’ setup and a fibreoptic bronchoscope was not available in the hospital. MacIntosh #3 and #4 blades and a Jackson-Wisconsin #3 blade were obtained from the operating room. With the general surgeon standing by for a potential surgical airway, topical airway anesthesia was obtained with 4% lidocaine. A single attempt was made at awake laryngoscopy and a Cormack-Lehane5 grade IV view was obtained. This attempt was made 35 min after initial hospital registration. By that time the patient had developed massive subcutaneous emphysema extending from the tragus to the nipples and he became stridulous secondary to tracheal compression. In addition to compression of the airway, the subcutaneous emphysema obliterated surgical landmarks.
In light of the patient’s impending airway obstruction, a decision was made to proceed to a rapid sequence intubation. Anesthesia was induced with propofol 200 mg iv and the patient was paralyzed with succinylcholine 120 mg iv. Attempted intubation with the MacIntosh #3 blade revealed a grade IV Cormack-Lehane5 view. A second attempt was made with the Jackson-Wisconsin blade. A grade II laryngoscopic view was obtained and an 8.0 mm endotracheal tube was passed with the aid of a stylet. Correct position of the endotracheal tube was confirmed by the presence of bilateral breath sounds on auscultation and chest radiography. At no time did the patient become hypoxemic or hemodynamically unstable. Prior to and during transport, he was sedated and paralyzed in order to reduce the risk of inadvertent endotracheal tube dislodgement. He was transferred to the regional tertiary care centre where he had a primary anastamosis of the tracheal rupture, which unfortunately, broke down necessitating a second repair. At that time a low tracheostomy was performed and repair of the trachea was again undertaken. This required an anterior commisurotomy and placement of a Montgomery keel stent to maintain vocal cord separation. He recovered uneventfully. The tracheotomy tube and stent were removed three months later.
|
Discussion |
|---|
|
TOPAbstractIntroductionCase reportDiscussionReferences |
|---|
Tracheal rupture may present with mediastinal emphysema, subcutaneous emphysema, and pneumothorax.6 Stridor and hemoptysis may develop when the upper airway is involved.7 Rupture of the tracheobronchial tree may also present in a subtle manner with gradual progression of symptoms.1,3,4 In a historical review of the tracheobronchial injuries Kiser et al.1 noted that patients presenting late had an increased survival, and this is likely due to the severity of associated injuries.
In patients with symptoms of respiratory distress rapid airway control is necessary.7–10 Management of the patient with an extrathoracic tracheal rupture was described by Devitt and Boulanger.7 They suggest that fibreoptic bronchoscopy should be the initial choice in intubating patients in whom the cervical spine is clear and airway obstruction is not imminent. This ensures that the endotracheal tube is placed beyond the tracheal disruption and avoids inadvertent mediastinal intubation.7–9 In this group of patients rigid bronchoscopy may also be a useful adjunct if available.7 Further, they suggest that tracheotomy should be the primary mode of securing the airway in the patient with impending airway obstruction.7 This would then be followed by endoscopy and surgical repair of the airway.
Desjardins and Varon8 have suggested that the airway management of patients with penetrating neck injuries be divided into three categories: emergent, urgent and elective, depending upon the injury and the patient status. They suggest that patients with penetrating neck injuries involving the airway requiring emergent intubation should be intubated via the orotracheal route with in-line immobilization of the cervical spine. They also suggest that those patients requiring urgent or elective airway control be intubated with the aid of a fibreoptic bronchoscope.8
Management of the patient with a difficult airway has been outlined in the American Society of Anesthesiologists Difficult Airway algorithm.11 The algorithm states that in addition to assessment of the airway and provision of supplemental oxygen one should consider the following dichotomies: 1) awake intubation vs intubation after induction of general anesthesia; 2) non-invasive vs invasive approach to intubation; 3) preservation vs ablation of spontaneous ventilation. Failed awake intubation is followed by consideration of other options or invasive surgical access. In the case of failed intubation after induction of general anesthesia, airway management relies initially upon supraglottic devices followed by invasive airway control.11
This case involved two additional challenges in addition to tracheal disruption and known difficult airway. They were lack of dedicated difficult airway management tools and sudden onset of stridor with impending airway obstruction. Certainly awake intubation, preferably with a bronchoscope, was the technique of choice in this setting. However, awake laryngoscopy was the only awake intubation option as no bronchoscope was available. Failure of awake intubation is followed in the American Society of Anesthesiologists guidelines by invasive intubation.11 The development of massive subcutaneous emphysema obliterated tracheal landmarks and resulted in stridor. Although a general surgeon was available, this patient posed a significant technical and temporal challenge. Consideration was given to an invasive airway, but careful review of patient status and available resources made this option untenable.
Finally, the management of this patient’s airway required consideration of preservation vs ablation of spontaneous ventilation. Inhaled induction of anesthesia requires that the patient be in an operating room or that the anesthesia machine be transported to the emergency room. Given the rapidly changing nature of the patient’s respiratory status, neither of these options was safe. Thus, the patient had an unsuccessful attempt at awake intubation, and was an unsuitable candidate for primary tracheotomy or inhaled induction of anesthesia. Further, supraglottic devices and bag valve mask ventilation were contraindicated as they may serve to increase the subcutaneous emphysema and increase the airway obstruction. Therefore, while the preferred method of airway control would have been an awake fibreoptic intubation, the lack of equipment and impending airway obstruction forced us to utilize a rapid sequence technique to secure the airway. This was done with the additional challenge of a known difficult airway.
Overall management of the ruptured trachea can be divided into immediate and long-term strategies. Immediate management involves placement of an endotracheal tube with the cuff inflated distal to the tracheal rupture. As described, this is best accomplished with the aid of a fibreoptic bronchoscope to ensure correct positioning and avoid placement of the endotracheal tube through the disruption in the trachea.7–9 However, placement of the endotracheal tube should not be delayed if fibreoptic bronchoscopy is not immediately available. Translaryngeal intubation may be preferred over emergent tracheotomy as the subcutaneous emphysema may make tracheotomy difficult. Further, tracheotomy requires that the level of the tracheal disruption be known and above the level of the insertion of the tracheal tube.
Long-term management of tracheal rupture may be surgical or non-surgical.6,12–14 Gabor et al.6 suggest that short lacerations not involving the whole thickness of the trachea can safely be treated with antibiotics and intubation with the cuff inflated distal to the site of the tear. Madden et al.13 report the use of a tracheal stent to repair an iatrogenic tracheal tear. However, most patients will require surgical intervention for repair of the tracheal tear.1,6–10 In the case of this patient, two surgeries were required to create a stable anastamosis.
Of considerable importance in the management of this patient was the lack of appropriate resources for management of the difficult airway. The American Society of Anesthesiologists guidelines for the management of the difficult airway11 outline a list of suggested contents of a portable storage unit for difficult airway management. While the specific contents of the portable storage unit are suggestions and should be tailored individually to meet the needs, skills and preferences of the institution, its presence should be strongly considered in institutional settings where airway management is practiced. Additionally, there should be available skilled practitioners familiar with the available airway management equipment, with a good working knowledge of the assessment and management of the difficult airway. Availability of such skilled personnel is particularly important in the rural hospital, as there may be limited backup resources.
In summary, a case of late dehiscence of a tracheal anastamosis in a patient with a difficult airway is reported. Management of the difficult airway in the setting of an extrathoracic rupture of the trachea is reviewed. This case highlights the need for emergency department personnel to be familiar with the principles of difficult airway management. Further, it highlights the need for rural hospitals to have available an appropriate array of tools for management of difficult airway.
|
Acknowledgments |
|---|
|
Footnotes |
|---|
Assessed November 3, 2004. Accepted for publication May 5, 2005. Revision accepted October 12, 2005.
|
References |
|---|
|
TOPAbstractIntroductionCase reportDiscussionReferences |
|---|
2 Swan KG Jr, Swan BC, Swan KG. Decelerational thoracic injury. J Trauma 2001; 51: 970–4.[Medline]
3 Hofmann HS, Rettig G, Radke J, Neef H, Silber RE. Iatrogenic ruptures of the tracheobronchial tree. Eur J Cardiothorac Surg 2002; 21: 649–52.
4 Kaloud H, Smolle-Juettner FM, Prause G, List WF. Iatrogenic ruptures of the tracheobronchial tree. Chest 1997; 112: 774–8.
5 Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia 1984; 39: 1105–11.[Medline]
6 Gabor S, Renner H, Pinter H, et al. Indications for surgery in tracheobronchial ruptures. Eur J Cardiothorac Surg 2001; 20: 399–404.
7 Devitt JH, Boulanger BR. Lower airway injuries and anaesthesia. Can J Anaesth 1996; 43: 148–59.
8 Desjardins G, Varon AJ. Do you really want the surgeon to take care of the airway? (Letter). Can J Anaesth 1996; 43: 1181–2.[Medline]
9 Jackimczyk K. Blunt chest trauma. Emerg Med Clin North Am 1993; 11: 81–96.[Medline]
10 Balci AE, Eren N, Eren S, Ulku R. Surgical treatment of post-traumatic tracheobronchial injuries: 14-year experience. Eur J Cardiothorac Surg 2002; 22: 984–9.
11 The American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98: 1269–77.[Medline]
12 Jougon J, Ballester M, Choukroun E, Dubrez J, Reboul G, Velly JF. Conservative treatment for postintubation tracheobronchial rupture. Ann Thorac Surg 2000; 69: 216–20.
13 Madden BP, Sheth A, Ho TB, McAnulty G. Novel approach to management of a posterior tracheal tear complicating percutaneous tracheostomy. Br J Anaesth 2004; 92: 437–9.
14 Carbongnani P, Bobbio A, Cattelani L, Internullo E, Caporale D, Rusca M. Management of postintubation membranous tracheal rupture. Ann Thorac Surg 2004; 77: 406–9.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
