Surgical Airway—the last strategy in airway management

Presented by Kang, Ting-jui

CASE ( I )

Brief History

57 y/o female with NPC s/p radiotherapyDenied any other systemic diseaseOne episode of massive bleeding from nose and oral cavity on 2/7Vital sign stable, consciousness clearAnterior packing with V-G and posterior packing with Foley catheter for stopping bleeding

Intra-operation

Tracheostomy and TAE were suggestedEmergent tracheostomy was initiated in OR under local anesthesiaENT doctor asked us of setting ventilator after tracheostomy was insertedDe-saturation and consciousness loss was noted when we arrivedHigh pressure while resuscitation bagging, capnography showed no end-tidal concentrations of CO2

Intra-operation

The suction tube can’t be passing through the tracheostomy tubeTube mal-positioning was suspected and the ENT doctors kept trying to insert the tubeSaturation below 60% and downward in secondsBredycardia atropine 1mg was givenTrismus fiberoptic nasal intubation was performedStandstill CPR start, bosmin and cardiac massage ROSC in 5 minutes send to SICU

CXR

Normal heart size.Bilateral pneumothorax and diffuse subcutaneous emphysema.Endotracheal tube with the tip above the carina

CXR

Normal heart sizeClear lung field.no significant pneumothoraxDiffuse subcutaneous emphysema from the bilateral neck to the abdominal wallBilateral chest tubeEndotracheal tube with the tip above the carina

Outcome

On arriving SICU, deep coma with loss of light reflex was notedCXR showed diffuse subcutaneous emphysema and bilateral pneumothorax bilateral chest tubes were insertedNext day (2/8), pupils returned to 2.0mm with positive light reflex and stable vital signs without any inotropic agentAnisocoria was noted in the early morning of 2/10

Outcome

Brain CT showed severe brain swelling, blunting of cortex-white matter junction, cistern and sulci effacement and brain stem compression

Hypoxic encephalopathy was impressed. Cushing triad develped gradually and DI appeared

The patient died of brain death at 10:00AM on 2005/2/11

Review and Discussion

What did / should we do in this situation?

Apnea under local anesthesia in a related healthy person?

CASE ( II )

Brief History

62 y/o male patient with NPC, T4N3aM0, Stage 4b s/p CCRTRecurrence posterior pharyngeal tumor s/p excision and chemotherapyHe suffered from choking while oral intakeConsciousness drowsy with unstable hemodynamicsHe was brought to our ER on 2/27 in the evening

CXR

Normal heart size with calcification of tortuous aorta. Irregular and lobulated consolidation over the right mid-to lower lung field with blunting of right CP angleIncreased lung marking on both sides with some peribronchial infiltrations over the right perihilar and left lung field

Intra-operation

Aspiration pneumonia with sepsis was impressedEstablishing a patent airway was indicated due to easily choking, consciousness drowsy, oxygenation improvement, correction of metabolic and respiratory acidosis, aggressive chest careDifficult intubation was noted the ER doctor consulted us and ENT doctors for airway management fiberoptic guide intubation “or” tracheostomyAwake fiberoptic nasal intubation was performed smoothly in OR

Intra-operation

After intubation, the tracheostomy went onUnfortunately, mal-position of the tracheostomy tube happened again!!Tube exchanger guiding failedEndotracheal tube advanced again cuff ruptured failed ventilationRapid desaturation and then asystole replace a new ETT via tube exchanger and CPR ROSCFiberoptic guide to insert the tracheostomy tubeSend the patient to ICU under high doses of inotropic agents

Outcome

In trauma ICU, poor saturation around 80% under 100% O2 and gradually downhill

Hemodynamic unstable under inotropics

Asystole on 2/28 in the early morning, CPR for 30 minutes but in vain

CXR

S/P tracheostomy. Pneumothorax and pneumomediastinum with mild subcutaneous emphysema over the left lower neck, supraclavicular area and upper chest wall

Massive pleural effusion on right side with passive atelectasis of the right lung, R/O hemothorax

Increased lung marking with prominent peribronchial infiltration on both sides

Review and Discussion

Was tracheostomy the necessary procedure for the patient in this situation?

Could we reacted better when tracheostomy tube mal-positioning?

What was the important diagnosis we missing?

Tracheostomy

Complications of Tracheostomy

Immediate (at the termination of the operation) Apnea due to loss of hypoxic stimulation of

respiration Hemorrhage Surgical injury of neighboring structures, i.e.

esophagus, recurrent laryngeal nerve, and cupula of the pleura

Pneumothorax and pneumomediastinum Injury of the cricoid cartilage (high

tracheostomy)

Complications of Tracheostomy

Intermediate (the first few hours or days) Tracheitis and tracheobronchitis Tracheal erosion and hemorrhage Hypercapnia Atelectasis Displacement of the tracheostomy tube Obstruction of the tracheostomy tube Subcutaneous emphysema Aspiration and lung abscess

Complications of Tracheostomy

Late (for a prolong period) Persistent tracheocutaneous fistula Stenosis of the larynx or trachea Tracheal granulations Tracheomalacia Difficult decannulation Tracheoesophageal fistula Problem with the tracheostomy scar

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