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Case report
Intubation in two patients with difficult airway management and tracheal stenosis after tracheostomy in thoracic surgery
Intubación en dos pacientes con vía aérea difícil y estenosis traqueal tras traqueostomía en cirugía torácica
M. Granell Gil, P. Solís Albamonte
Corresponding author
paulasolisalbamonte@gmail.com

Corresponding author.
, C. Córdova Hernández, I. Cobo, R. Guijarro, J.A. de Andrés Ibañez
Departamento de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospitalario Universitario General de Valencia, Valencia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lung isolation in thoracic surgery is challenging in patients with difficult intubation&#44; and is even more complex and difficult in the presence of unanticipated tracheal stenosis&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> Subglottic tracheal stenosis and tracheal stenosis are major late complications of both tracheostomy and tracheal intubation&#46; Studies suggest that some degree of stenosis develops in up to 20&#8211;30&#37; of patients with tracheostomy&#44; but only 1&#8211;2&#37; of these are symptomatic or have severe stenosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Recent advances in percutaneous dilation tracheostomy &#40;PDT&#41; have increased the number of patients presenting with more proximal tracheal stenosis&#46; PDT-related lesions are usually more proximal&#44; whereas open tracheostomy-related stenosis typically occurs more distally&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Stenosis due to PI or post-tracheostomy &#40;PT&#41; are rare entities&#46; However&#44; when they occur they can be life-threatening&#44; especially in an emergency context&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We report two cases of difficult airway and unanticipated tracheal stenosis managed using different devices&#58; the standard Univent&#174; and the new generation Vivasight SL&#174; endotracheal tubes&#46; Their advantages and disadvantages are analysed&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case 1</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 60-year-old man receiving chemotherapy and radiotherapy underwent surgery for extensive squamous cell carcinoma of the tongue in 2005 with subsequent tracheostomy that was closed after 1 year&#46; One week after surgery&#44; the ENT specialist changed the cannula for one without a cuff&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient was scheduled in our hospital for resection of a lung metastasis in the right lower and upper lobes&#46; In view of the difficult airway caused by the previous surgery&#44; the patient underwent awake intubation using a flexible fiberscope&#46; No tracheal stenosis was observed in either the CT scan or with the fiberscope&#46; Introduction of the endotracheal tube &#40;8<span class="elsevierStyleHsp" style=""></span>mm&#41; was uneventful&#46; Following this&#44; a 14Fr tube exchanger was inserted to replace the endotracheal tube with a Univent&#174; tube with an 8<span class="elsevierStyleHsp" style=""></span>mm internal diameter &#40;ID&#41; bronchial blocker&#44; without any apparent resistance&#46; However&#44; acute tracheal bleeding was observed&#44; which stopped after inflating the tube cuff&#46; We thought that the bleeding was caused by exchanging the endotracheal tube for the Univent&#174;&#44; which has a larger external diameter&#46; The surgery was completed without incident&#44; and at the end of the procedure we decided to secure the airway with a new tracheostomy to avoid the risk of a new episode of tracheal haemorrhage after extubation&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case 2</span><p id="par0030" class="elsevierStylePara elsevierViewall">This case involves a 56-year-old female patient previously diagnosed with squamous carcinoma in the lower mouth&#46; She had been treated with intraoral resection and chemo-radiotherapy&#44; and subsequently underwent tracheostomy with a number 8 cuffed cannula that remained in place until the seventh postoperative day&#44; after which it was changed for another cannula without cuff&#46; The tracheostomy was closed after three months&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">During this time&#44; the patient underwent superior right lobectomy&#46; The preoperative evaluation revealed several difficult airway predictors&#58; inter-incisor gap &#40;&#60;3<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; Mallampati class IV&#44; serious limitation on neck movement and upper lip bite test class II&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">We decided to carry out awake intubation&#46; After proper sedation and administration of local anaesthesia&#44; we attempted to insert a VivaSight SL&#174; endotracheal tube &#40;8<span class="elsevierStyleHsp" style=""></span>mm ID&#41; through a VAMA cannula using a Frova introducer &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#59; however&#44; a glottic distortion was observed &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; We were able to pass the Frova introducer and VivaSight SL&#174; through the vocal cords&#44; but tracheal stenosis was observed on the VivaSight screen&#44; probably caused by a previous tracheostomy &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The 8<span class="elsevierStyleHsp" style=""></span>mm ID VivaSight SL tube was too large to pass through the stenosis&#44; so we replaced it with a smaller calibre Vivasight SL&#174; tube &#40;7<span class="elsevierStyleHsp" style=""></span>mm ID&#41;&#44; and achieved intubation&#46; Finally&#44; a Cohen 9Fr bronchial blocker was inserted in the main right bronchus using this tracheal tube with integrated camera as a guide&#44; without the need for a fiberscope &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Tracheal stenosis usually appears close to the endotracheal tube cuff or in the tracheostomy stoma&#44; due to the development of granulation tissue after surgery&#46; According to Grillo&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> a cuff pressure of over 30<span class="elsevierStyleHsp" style=""></span>mmHg could cause mucosal ischemia and lead to tracheal stenosis 3&#8211;6 weeks later&#46; Incidence of tracheal stenosis can be reduced with the use of high-volume&#44; low pressure cuffs&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Most tracheal stenoses may go unnoticed&#44; and symptoms depend on the degree of obstruction &#40;when stenosis reaches 70&#37; and the tracheal lumen is reduced to less than 5<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Previous airway management or long stays in critical care units are a risk factor&#46; Physical examination&#44; difficult airway predictors&#44; and complementary imaging tests&#44; such as computer tomography &#40;CT&#41; scans&#44; are crucial&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In our cases&#44; the patients presented significant anatomical changes that led to difficult airway and asymptomatic tracheal stenosis due to previous tracheostomy&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In the first case&#44; the patient was intubated while awake using a flexible fiberscope&#46; However&#44; the stenosis had reduced the internal tracheal diameter to 13<span class="elsevierStyleHsp" style=""></span>mm&#44; which was slightly smaller than the external diameter &#40;13&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#41; of the Univent&#174; tube with 8<span class="elsevierStyleHsp" style=""></span>mm ID&#46; This was probably what caused the tracheal bleeding&#44; and was related to the previous tracheostomy &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In the second case&#44; the VivaSight SL&#174; device allowed us to perform awake intubation and detect significant tracheal stenosis&#44; thus avoiding potential tracheal damage&#46; The integrated camera gave us uninterrupted&#44; real-time visualisation of the trachea and main bronchus while inserting the bronchial blocker&#44; without the need for a flexible fiberscope&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The bronchial blocker is a safer alternative to the double-lumen tube when performing one lung ventilation in patients with tracheal stenosis and&#47;or difficult airway&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Several decades have passed since 1936&#44; when Magill performed the first lung isolation using a bronchial blocker&#46; The single-lumen endotracheal Univent&#174; tube has an integrated bronchial blocker&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> It is easy to insert and achieves efficient lung isolation in patients with difficult airway&#46; The greatest drawback&#44; however&#44; is its large external diameter and greater rigidity compared to standard endotracheal tubes&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The VivaSight SL&#174; device is a single-lumen airway tube with an integrated high-resolution camera with an innovative design&#46; In our opinion&#44; it has several advantages over other similar devices&#44; such as facilitating awake intubation in patients with difficult airway&#44; guided insertion of bronchial blockers&#44; continuous airway visualisation and control of the position of the endotracheal tube without the need for a flexible fiberscope&#46; It has a lipophobic coating that reduces the incidence of obscured vision due to fogging&#44; secretions or airway bleeding&#44; and provides optimal ventilation&#46; Giglio et al&#46;&#44; in a study of 80 patients&#44; showed the usefulness of the ETView for correct positioning of bronchial blockers in all patients without the needed for a flexible fiberscope&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The two cases described make an interesting contribution to the scant literature on the difficulties and complications of intubation in patients with previous tracheostomy in thoracic surgery&#46; In addition&#44; the bleeding observed after insertion of the Univent&#174; tube is a rare but serious complication&#46; Univent is a device with an integrated bronchial blocker that is still used today&#44; although the latest REDAR guidelines recommend using independent bronchial blockers in patients with difficult airways&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Finally&#44; the second case presents a novel use of the VivaSight SL&#174; device in an awake patient with difficult upper airway and tracheal stenosis&#58; the integrated camera guided insertion of the bronchial blocker without the need for a flexible fiberscope&#46; VivaSight SL ensures patient safety because the same device detects the presence of stenosis&#44; thus enabling the anaesthesiologist to replace it with a smaller diameter tube&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Financial support</span><p id="par0090" class="elsevierStylePara elsevierViewall">This work was funded by the Department of Anaesthesiology&#44; Hospital General de Valencia&#44; Valencia&#44; Spain&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Case 1"
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          "titulo" => "Case 2"
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    "fechaRecibido" => "2017-10-09"
    "fechaAceptado" => "2017-12-21"
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            0 => "Thoracic surgery"
            1 => "Lung isolation"
            2 => "Difficult airway management"
            3 => "Tracheal stenosis"
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            0 => "Cirug&#237;a tor&#225;cica"
            1 => "Aislamiento pulmonar"
            2 => "Manejo v&#237;a a&#233;rea dif&#237;cil"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lung isolation in thoracic surgery is a challenge&#44; and this is even more complex in the presence of unknown tracheal stenosis &#40;TS&#41;&#46; We report two cases of unknown TS and its airway management&#46; TS appears most frequently after long term intubation close to the endotracheal tube cuff or in the stoma of tracheostomy that appears as a consequence of the granulation tissue after the surgical opening of the trachea&#46; Clinical history&#44; physical examination&#44; difficult intubating predictors and imaging tests &#40;CT scans&#41; are crucial&#44; however most of tracheal stenosis may be unnoticed and symptoms depend on the degree of obstruction&#46; In our cases&#44; the patients presented anatomical changes due to surgery and previous tracheostomy that led to a TS without symptoms&#46; There is scarce literature about the intubation in patients with previous tracheostomy in thoracic surgery&#46; In the first case&#44; a Univent<span class="elsevierStyleSup">&#174;</span> tube was used using a flexible fiberscope but an acute tracheal hemorrhage occurred&#46; In the second case&#44; after intubation with VivaSight SL<span class="elsevierStyleSup">&#174;</span> in an awake patient&#44; the insertion of a bronchial blocker was performed through an endotracheal tube guided by its integrated camera without using flexible fiberscopy&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El aislamiento pulmonar en cirug&#237;a tor&#225;cica es un reto para el anestesi&#243;logo&#44; pero la presencia de estenosis traqueal no conocida complica m&#225;s esta situaci&#243;n&#46; Describimos dos casos de estenosis traqueal desconocida y el manejo de la v&#237;a a&#233;rea&#46; La estenosis traqueal aparece frecuentemente tras intubaci&#243;n de larga duraci&#243;n en la zona del neumotaponamiento o en el estoma de la traqueotom&#237;a como consecuencia del tejido de granulaci&#243;n que aparece tras la apertura quir&#250;rgica de la tr&#225;quea&#46; Son cruciales la historia cl&#237;nica&#44; la exploraci&#243;n f&#237;sica&#44; los predictores de v&#237;a a&#233;rea dif&#237;cil y las im&#225;genes diagn&#243;sticas &#40;TAC&#41;&#46; Sin embargo&#44; muchas estenosis traqueales pasan desapercibidas y la aparici&#243;n de s&#237;ntomas depende del grado de obstrucci&#243;n&#46; En estos casos&#44; los pacientes presentaron cambios anat&#243;micos debido a la cirug&#237;a y traqueotom&#237;a previa que ocasionaban estenosis traqueal sin s&#237;ntomas&#46; Existe escasa literatura sobre intubaci&#243;n en pacientes con traqueotom&#237;a previa en cirug&#237;a tor&#225;cica&#46; En el primer caso se utiliz&#243; un tubo Univent<span class="elsevierStyleSup">&#174;</span> utilizando un fibrobroncoscopio pero se produjo una hemorragia traqueal aguda&#46; En el segundo caso&#44; tras la intubaci&#243;n con VivaSight SL<span class="elsevierStyleSup">&#174;</span> en paciente despierto&#44; se realiz&#243; la inserci&#243;n de un bloqueador bronquial a trav&#233;s de un tubo endotraqueal guiado por la c&#225;mara integrada sin necesidad de control con fibrobroncoscopio&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Granell Gil M&#44; Sol&#237;s Albamonte P&#44; C&#243;rdova Hern&#225;ndez C&#44; Cobo I&#44; Guijarro R&#44; de Andr&#233;s Iba&#241;ez JA&#46; Intubaci&#243;n en dos pacientes con v&#237;a a&#233;rea dif&#237;cil y estenosis traqueal tras traqueostom&#237;a en cirug&#237;a tor&#225;cica&#46; Rev Esp Anestesiol Reanim&#46; 2018&#59;65&#58;347&#8211;350&#46;</p>"
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Original language: English
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