Memorable patient

My Most Memorable Patient

Can’t ventilate, can’t intubate’ in a patient with tracheal stenosis

Habib Md Reazaul Karim, Mohammad Yunus, Vanlalhmangaihi Hmar, Nari M. Lyngdoh

Department of Anaesthesiology and Critical Care, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS) Mawdiangdiang Shillong – 793018 (India); Phone: 0364-2538026, 2538009; E-mail: drmdyunus@hotmail.com

Corresponding Author:  Mohammad Yunus , Head & Faculty In-Charge, Department of Emergency Medicine & Additional Professor, Department of Anaesthesiology and Critical Care, NEIGRIHMS, (North Eastern Indira Gandhi Regional Institute of Health and Medical Services), Shillong, Meghalaya (India)

Can’t ventilate, can’t intubate (CVCI) situation is a rare anaesthetic emergency requiring rapid and decisive management. This condition obviously has life-threatening implications and must be resolved within minutes, to avoid hypoxic brain damage or death. Repeated attempts at airway manipulations are common cause of airway deterioration and morbidity. The situation becomes worst when trachea is already compromised with a pre-existing pathology. The incidence is difficult to estimate; however, recent work has suggested an incidence during all anaesthetics of one in 50 000.1 American Society of Anesthesiologists (ASA)2 and Difficult Airway Society (DAS)3 have published guidelines on the management of CVCI situations. The DAS has produced a management algorithm3 which suggests rescue techniques like cricothyroidotomy for the CVCI situation. Emergency invasive airway access e.g. surgical airway, jet ventilation, and retrograde intubation must be kept in mind.

My patient was just an ordinary one in any way; a 4 years old girl, weighing 10 kg, average built with stable hemodynamics, who presented to the ENT department with progressively increasing difficulty in breathing with noisy sounds for the last one month. No history of fever, cough, trauma, asthma, tuberculosis found. Patient had had appendectomy one month ago under GA with endotracheal intubation. Previous anesthetic management record was not available, and there was no complaint of any postop complication. ENT surgeon planned for emergency laryngotracheoscopy under GA. Expected procedure duration was of 10 minutes. Difficult airway was not anticipated, so a routine general anesthesia management plan was chalked out; premedication with inj. glycopyrrolate 0.04 mg and inj. fentanyl 20 µg, preoxygenation with 100% oxygen,  induction with ketamine and maintenance with sevoflurane in oxygen with assisted BMV. Inj. succinylcholine 20 mg was given just before laryngotracheoscopy with ventilation in between apneic phases. Laryngotracheoscopy revealed tracheal stenosis about 2 to 2.5 cm below vocal cords and planned for dilatation on elective basis.

The real drama was unleashed during recovery when spontaneous breathing was found to be inadequate and laborious and patient desaturated progressively despite BMV with 100% oxygen. Treatment on the line of laryngospasm started immediately but not effective and SpO2 rapidly fell. Help was called and two senior anesthesiologists arrived, BMV with CPAP could not raise saturation >85% with 100% oxygen. Anesthesia deepened and intubation tried. Surprisingly, the glottis was seen wide open but even the smallest sized ETT (2.5 mm ID) could not be negotiated beyond stenosed part.

Patient’s condition deteriorated and saturation could not be corrected. LMA was inserted after laryngospasm was ruled out but ventilation was still inadequate leaving the patient in the face of impending death. Options of cricothyroidotomy and conventional tracheostomy were considered of doubtful benefit in view of the anatomic location of stenosis and its unknown lower level. But what other options were available to us? The child was rapidly drifting towards death. So after with good wish and best hope emergency low tracheostomy was done by the ENT surgeon. It turned the tide and saturation started improving to the relief of us all. Patient reversed uneventfully and was shifted to Pediatric Critical Care Unit after a prolonged period of observation on the table.

The patient was saved, but not the anesthesia and the operating team. The parents of the child refused to accept any explanations from surgical and anesthesia colleagues and compelled us to remove the tracheostomy tube. All reasoning fell flat on them. In fact during the battle for life for the child, there was no time to inform them or take consent regarding possible tracheostomy. Ultimately, this battle was also won with gentle handling and perseverance.

Patient recovered well with no neurological deficit noted clinically. Tracheal dilatation was done the following week under GA with tracheostomy tube in situ. Decannulation was done subsequently and she was discharged.

Low tracheostomy saved our patient and us, and the parents went home with a smile on face; but this incidence taught us few lessons; no case is a small case in anesthetic practice; the consent is all very necessary; and finally, documentation is very, very important.

References

  1. Kheterpal S, Martin L, Shanks AM, Tremper KK. Prediction and outcomes of impossible mask ventilation. Anesthesiology 2009; 110: 891–7.
  2. Apfelbaum J. L, Hagberg C. A, et al. Practice guidelines for the management of the difficult airway; an updated report by the American Society of Anesthesiologists Task Force on the management of the difficult airway. Anesthesiology 2013; 118:251–70.
  3. Henderson J, Popat M, Latto I, Pearce A. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anesthesia 2004; 59: 675-94.