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Subglottic kinking of endotracheal tube (ett); Could a murphy’s eye be a saviour?
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Abstracts / Trends in Anaesthesia and Critical Care 16 (2017) 27e39
maintain ventilation and FAI via LMA was successfully achieved. Surgery and extubation were uneventful. Results and discussion: Difficult airway algorithms (DAA) are described in literature to aid in airway management. In this case, and following published algorithms, being confronted with an UDA led us to awaken the patient. However, given the urgent nature of the surgery, TI was necessary and awake FAI was attempted, as described in DAA. After being unsuccessful, we were faced to find another option that would be safe and effective. SADs already play a major role in international airway management algorithms as a difficult airway rescue when a “cannot ventilate/ cannot intubate” scenario develops2. In this case, when presented with the difficulty to ventilate and secure the airway, the use of a SAD also served as a conduit to TI, while preserving adequate oxygenation and ventilation throughout the procedure. Conclusions: In cases of a failed TI in which a secure airway is necessary, the primary insertion of a SAD that will allow FAI to follow should be considered. This concept is not only an option for UDAs, but can also be used in controlled settings1. References 1 Metterlein T, Dintenfelder A, Plank C, Graf B, Roth G. A comparison of various supraglottic airway devices for fiberoptical guided tracheal intubation. Rev Bras Anestesiol. 62 (2017) 166-171. valo-Ludenac J, Arcas-Bellas JJ, Alvarez-Rementeria R, Alameda LEM. 2 Are Fiberoptic-guided intubation after insertion of the i-gel airway device in spontaneously breathing patients with difficult airway predicted: a prospective observational study. Journal of Clinical Anesthesia. 35 (2016) 287292. SUBGLOTTIC KINKING OF ENDOTRACHEAL TUBE (ETT); COULD A MURPHY’S EYE BE A SAVIOUR? *
J. Norhuzaimah , H. Nur Azreen, W.A. Wan Nur Madihah. Miri General Hospital, Malaysia * Corresponding author. E-mail address: [email protected] (J. Norhuzaimah).
Background and goal of study: Obstruction of the ETT can occur in many ways. In nasotracheal intubation, soft, small and thin-walled tubes are therefore needed to ease the insertion. Despite the advancement of specially designed nasal tubes, which usually remould, obstruction in the form of kinking still occurs. 1 Material and methods: Written consent was obtained from patient for publication. A 54 year-old man with squamous cell carcinoma over left posterior mandible was scheduled for elective wide excision, neck dissection and reconstruction. There was no previous history of systemic diseases, surgery or radiotherapy. Standard monitors were placed and general anaesthesia was induced with fentanyl, propofol and succinylcholine. Nasotracheal intubation was done by using McCoy laryngoscope #3 nasally with Portex PolarTM Preformed Tracheal Tube internal diameter (ID) 7.0 mm and Cormack Lehane classification was graded IIb. ETT was then advanced using MaGill forceps. Attempt to ventilate, however encountered 45 cmH2O peak airway pressure, minimal chest expansion and distant breath sounds on auscultation without gastric insufflation. ETT cuff subsequently deflated and pulled out by 2 cm in an attempt to exclude endobrochial intubation, and small etco2 tracing observed. Bronchospasm was suspected. Despite treatments including rocuronium, desaturation to 88% occurred and attempt made to visualise ETT with Glidescope revealed in-situ placement. ETT suction 14 Fr was inserted with difficulty presumably due to shape of the ETT. The suction revealed minimal blood secretion. Sounding of the ETT with 14 Fr 65 cm Bougie to eliminate ETT obstruction was unhelpful. Ventilatory difficulties remained till saturation was beyond acceptable; hence, the hard decision of reverting to mask ventilation despite knowing difficult intubation in this patient. UnoflexTM oral tube size ID 7 was successfully inserted with glidescope. Inspection of ETT after it was removed showed kinking above the cuff. The ETT had no Murphy’s Eye. Results and discussion: Soft ETT forced past the glottic opening might have kinked. When the cuff inflated in small calibre trachea, it could have augmented the bend, causing the bevel to be wedged against the trachea
wall. If the tube had a Murphy’s Eye, a kink might have not presented as difficulty in ventilation. However, complete kink might have occurred during surgery and might have been even more difficult to diagnose and manage. Conclusion: Intratracheal kinking may not be common, be it with Murphy’s Eye or not, maintaining a high index of suspicion could save the day. 2-3
References 1. Cook, T. (2012). “Airway Management Equipment.” In A.J. Davey & A. Diba (Eds), Edinburgh, Ward’s Anaesthetic Equipment (pp.139-205). Edinburgh, Saunders. 2. Leissner, K.B. et al. 2007. Kinking of an endotracheal tube within the trachea: a rare cause of endotracheal tube obstruction. Journal of clinical Anesthesia 19: 75-81. 3. Lee, Y. W. et al. 2003. Intratracheal kinking of endotracheal tube. Canadian Journal of Anesthesia 50: 311-315. DIFFICULT AIRWAY MANAGEMENT OF PEDIATRIC PATIENT WITH SEVERE BURN SCARS AND SUBGLOTTIC STENOSIS DURING AND AFTER CARDIOPULMONARY RESUSCITATION: A CASE REPORT E. Sezer*, J. Ergil, A. Perdi. University of Health Sciences, Dıskapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey * Corresponding author. E-mail address: [email protected] (E. Sezer).
Background and goal of study: Physicians encounter many difficulties in airway management of burned patients due to the degree of burn and localization of scar contracture. However this situation is more important in pediatric patients because of their rapid hemodynamic changes. In this case report we present difficult airway management of pediatric patient with severe burn scars and subglottic stenosis during cardiopulmonary resusitation and its further outcome. Material and methods: Six years old, 18 kg, ASA I, male child with severe burn scars was planned to undergo operation for subglottic stenosis in Ear Nose and Throat clinic. The patient had multiple scars on the big part of the sculp, face, chin, neck, ears, and also on extremities (Fig. 1 and 2). About twenty days ago a dilatation for subglottic stenosis was tried but respiratory problems and distress were still continuing. During the preoperative examination the respiration of the patient was superficial and had retractions.Also the patient had high temperature (38 degrees Celsius). Although the child recieved oxygen given with mask, his oxygen saturation ranged between 85-88% and he also had bradycardia (Heart rate:65-70beat/min). The arterial blood gas analysis showed hypoxemia and hypercarbia (PaO2¼45mmHg, PCO2¼60mmHg) so intubation was decided to be performed. The patient was sedated with propofol maintaining his spontaneous respiration and ventilated with ambu face mask securely. After achieving adequate ventilation, the first intubation trial with Macintosh laryngoscope and stylet guiding was unsuccessful and while continuing mask ventilation cardiac arrest developed so we started cardiopulmonary resuscitation(CPR). While performing cardiac compressions replacement of Laryngeal Mask Airway (LMA) and video laryngoscope (VL) guided intubation attempts were also unsuccessful, so emergent tracheotomy was opened by Ear Nose and Throat Clinic. After 50 minutes of performing CPR spontaneous circulation turned back, so the patient was sent to intensive care unit (ICU) together with inotropes and mechanical ventilation support. After 25 days in ICU the patient was extubated and tracheostomy was closed. After thirty days the patient was planned to undergo one more operation for subglottic stenosis. In the operating room after obtaining adequate and secure mask ventilation flexible fiberoptic bronchoscopy guided intubation was successfully performed. After the end of operation the patient was successfully extubated and sent to the service with stable hemodynamic parameters. Results and discussion: Pediatric patients whith severe head and neck postburn scars present difficulties in ventilation and intubation due to changes in anatomy after burns. Adequate knowledge of normal pediatric
Abstracts / Trends in Anaesthesia and Critical Care 16 (2017) 27e39
maintain ventilation and FAI via LMA was successfully achieved. Surgery and extubation were uneventful. Results and discussion: Difficult airway algorithms (DAA) are described in literature to aid in airway management. In this case, and following published algorithms, being confronted with an UDA led us to awaken the patient. However, given the urgent nature of the surgery, TI was necessary and awake FAI was attempted, as described in DAA. After being unsuccessful, we were faced to find another option that would be safe and effective. SADs already play a major role in international airway management algorithms as a difficult airway rescue when a “cannot ventilate/ cannot intubate” scenario develops2. In this case, when presented with the difficulty to ventilate and secure the airway, the use of a SAD also served as a conduit to TI, while preserving adequate oxygenation and ventilation throughout the procedure. Conclusions: In cases of a failed TI in which a secure airway is necessary, the primary insertion of a SAD that will allow FAI to follow should be considered. This concept is not only an option for UDAs, but can also be used in controlled settings1. References 1 Metterlein T, Dintenfelder A, Plank C, Graf B, Roth G. A comparison of various supraglottic airway devices for fiberoptical guided tracheal intubation. Rev Bras Anestesiol. 62 (2017) 166-171. valo-Ludenac J, Arcas-Bellas JJ, Alvarez-Rementeria R, Alameda LEM. 2 Are Fiberoptic-guided intubation after insertion of the i-gel airway device in spontaneously breathing patients with difficult airway predicted: a prospective observational study. Journal of Clinical Anesthesia. 35 (2016) 287292. SUBGLOTTIC KINKING OF ENDOTRACHEAL TUBE (ETT); COULD A MURPHY’S EYE BE A SAVIOUR? *
J. Norhuzaimah , H. Nur Azreen, W.A. Wan Nur Madihah. Miri General Hospital, Malaysia * Corresponding author. E-mail address: [email protected] (J. Norhuzaimah).
Background and goal of study: Obstruction of the ETT can occur in many ways. In nasotracheal intubation, soft, small and thin-walled tubes are therefore needed to ease the insertion. Despite the advancement of specially designed nasal tubes, which usually remould, obstruction in the form of kinking still occurs. 1 Material and methods: Written consent was obtained from patient for publication. A 54 year-old man with squamous cell carcinoma over left posterior mandible was scheduled for elective wide excision, neck dissection and reconstruction. There was no previous history of systemic diseases, surgery or radiotherapy. Standard monitors were placed and general anaesthesia was induced with fentanyl, propofol and succinylcholine. Nasotracheal intubation was done by using McCoy laryngoscope #3 nasally with Portex PolarTM Preformed Tracheal Tube internal diameter (ID) 7.0 mm and Cormack Lehane classification was graded IIb. ETT was then advanced using MaGill forceps. Attempt to ventilate, however encountered 45 cmH2O peak airway pressure, minimal chest expansion and distant breath sounds on auscultation without gastric insufflation. ETT cuff subsequently deflated and pulled out by 2 cm in an attempt to exclude endobrochial intubation, and small etco2 tracing observed. Bronchospasm was suspected. Despite treatments including rocuronium, desaturation to 88% occurred and attempt made to visualise ETT with Glidescope revealed in-situ placement. ETT suction 14 Fr was inserted with difficulty presumably due to shape of the ETT. The suction revealed minimal blood secretion. Sounding of the ETT with 14 Fr 65 cm Bougie to eliminate ETT obstruction was unhelpful. Ventilatory difficulties remained till saturation was beyond acceptable; hence, the hard decision of reverting to mask ventilation despite knowing difficult intubation in this patient. UnoflexTM oral tube size ID 7 was successfully inserted with glidescope. Inspection of ETT after it was removed showed kinking above the cuff. The ETT had no Murphy’s Eye. Results and discussion: Soft ETT forced past the glottic opening might have kinked. When the cuff inflated in small calibre trachea, it could have augmented the bend, causing the bevel to be wedged against the trachea
wall. If the tube had a Murphy’s Eye, a kink might have not presented as difficulty in ventilation. However, complete kink might have occurred during surgery and might have been even more difficult to diagnose and manage. Conclusion: Intratracheal kinking may not be common, be it with Murphy’s Eye or not, maintaining a high index of suspicion could save the day. 2-3
References 1. Cook, T. (2012). “Airway Management Equipment.” In A.J. Davey & A. Diba (Eds), Edinburgh, Ward’s Anaesthetic Equipment (pp.139-205). Edinburgh, Saunders. 2. Leissner, K.B. et al. 2007. Kinking of an endotracheal tube within the trachea: a rare cause of endotracheal tube obstruction. Journal of clinical Anesthesia 19: 75-81. 3. Lee, Y. W. et al. 2003. Intratracheal kinking of endotracheal tube. Canadian Journal of Anesthesia 50: 311-315. DIFFICULT AIRWAY MANAGEMENT OF PEDIATRIC PATIENT WITH SEVERE BURN SCARS AND SUBGLOTTIC STENOSIS DURING AND AFTER CARDIOPULMONARY RESUSCITATION: A CASE REPORT E. Sezer*, J. Ergil, A. Perdi. University of Health Sciences, Dıskapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey * Corresponding author. E-mail address: [email protected] (E. Sezer).
Background and goal of study: Physicians encounter many difficulties in airway management of burned patients due to the degree of burn and localization of scar contracture. However this situation is more important in pediatric patients because of their rapid hemodynamic changes. In this case report we present difficult airway management of pediatric patient with severe burn scars and subglottic stenosis during cardiopulmonary resusitation and its further outcome. Material and methods: Six years old, 18 kg, ASA I, male child with severe burn scars was planned to undergo operation for subglottic stenosis in Ear Nose and Throat clinic. The patient had multiple scars on the big part of the sculp, face, chin, neck, ears, and also on extremities (Fig. 1 and 2). About twenty days ago a dilatation for subglottic stenosis was tried but respiratory problems and distress were still continuing. During the preoperative examination the respiration of the patient was superficial and had retractions.Also the patient had high temperature (38 degrees Celsius). Although the child recieved oxygen given with mask, his oxygen saturation ranged between 85-88% and he also had bradycardia (Heart rate:65-70beat/min). The arterial blood gas analysis showed hypoxemia and hypercarbia (PaO2¼45mmHg, PCO2¼60mmHg) so intubation was decided to be performed. The patient was sedated with propofol maintaining his spontaneous respiration and ventilated with ambu face mask securely. After achieving adequate ventilation, the first intubation trial with Macintosh laryngoscope and stylet guiding was unsuccessful and while continuing mask ventilation cardiac arrest developed so we started cardiopulmonary resuscitation(CPR). While performing cardiac compressions replacement of Laryngeal Mask Airway (LMA) and video laryngoscope (VL) guided intubation attempts were also unsuccessful, so emergent tracheotomy was opened by Ear Nose and Throat Clinic. After 50 minutes of performing CPR spontaneous circulation turned back, so the patient was sent to intensive care unit (ICU) together with inotropes and mechanical ventilation support. After 25 days in ICU the patient was extubated and tracheostomy was closed. After thirty days the patient was planned to undergo one more operation for subglottic stenosis. In the operating room after obtaining adequate and secure mask ventilation flexible fiberoptic bronchoscopy guided intubation was successfully performed. After the end of operation the patient was successfully extubated and sent to the service with stable hemodynamic parameters. Results and discussion: Pediatric patients whith severe head and neck postburn scars present difficulties in ventilation and intubation due to changes in anatomy after burns. Adequate knowledge of normal pediatric