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 radiotherapy Denied any other systemic disease One episode of massive bleeding from nose and oral cavity on 2/7 Vital sign stable, consciousness clear Anterior packing with V-G and posterior packing with Foley catheter for stopping bleeding

Intra-operation Tracheostomy and TAE were suggested Emergent tracheostomy was initiated in OR under local anesthesia ENT doctor asked us of setting ventilator after tracheostomy was inserted De-saturation and consciousness loss was noted when we arrived High pressure while resuscitation bagging, capnography showed no end-tidal concentrations of CO2

Intra-operation The suction tube can’t be passing through the tracheostomy tube Tube mal-positioning was suspected and the ENT doctors kept trying to insert the tube Saturation below 60% and downward in seconds Bredycardia  atropine 1mg was given Trismus  fiberoptic nasal intubation was performed Standstill  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 size Clear lung field.no significant pneumothorax Diffuse subcutaneous emphysema from the bilateral neck to the abdominal wall Bilateral chest tube Endotracheal tube with the tip above the carina

Outcome On arriving SICU, deep coma with loss of light reflex was noted CXR showed diffuse subcutaneous emphysema and bilateral pneumothorax  bilateral chest tubes were inserted Next day (2/8), pupils returned to 2.0mm with positive light reflex and stable vital signs without any inotropic agent Anisocoria 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 CCRT Recurrence  posterior pharyngeal tumor s/p excision and chemotherapy He suffered from choking while oral intake Consciousness drowsy with unstable hemodynamics He 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 angle Increased lung marking on both sides with some peribronchial infiltrations over the right perihilar and left lung field

Intra-operation Aspiration pneumonia with sepsis was impressed Establishing a patent airway was indicated due to easily choking, consciousness drowsy, oxygenation improvement, correction of metabolic and respiratory acidosis, aggressive chest care Difficult intubation was noted  the ER doctor consulted us and ENT doctors for airway management  fiberoptic guide intubation “or” tracheostomy Awake fiberoptic nasal intubation was performed smoothly in OR

Intra-operation After intubation, the tracheostomy went on Unfortunately, mal-position of the tracheostomy tube happened again!! Tube exchanger guiding  failed Endotracheal tube advanced again  cuff ruptured  failed ventilation Rapid desaturation and then asystole  replace a new ETT via tube exchanger and CPR  ROSC Fiberoptic guide to insert the tracheostomy tube Send 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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