1. Surgical Airway—the last strategy in airway management
Presented by Kang, Ting-jui

2. CASE ( I )

3. 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

4. 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

5. 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

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

9. 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

10. 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

11. 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

12. Review and Discussion What did / should we do in this situation?
Apnea under local anesthesia in a related healthy person?

13. CASE ( II )

14. 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

16. 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

17. 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

18. 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

20. 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

22. 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

23. 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?

24. Tracheostomy

26. 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)

27. 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

28. 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

29. ~~Have A Nice Day~~