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
, C. Córdova Hernández, I. Cobo, R. Guijarro, J.A. de Andrés Ibañez
Corresponding author
Departamento de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospitalario Universitario General de Valencia, Valencia, Spain
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Granell Gil, P. Solís Albamonte, C. Córdova Hernández, I. Cobo, R. Guijarro, J.A. de Andrés Ibañez" "autores" => array:6 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Granell Gil" ] 1 => array:4 [ "nombre" => "P." "apellidos" => "Solís Albamonte" "email" => array:1 [ 0 => "paulasolisalbamonte@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Córdova Hernández" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Cobo" ] 4 => array:2 [ "nombre" => "R." "apellidos" => "Guijarro" ] 5 => array:2 [ "nombre" => "J.A." "apellidos" => "de Andrés Ibañez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospitalario Universitario General de Valencia, Valencia, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Intubación en dos pacientes con vía aérea difícil y estenosis traqueal tras traqueostomía en cirugía torácica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 450 "Ancho" => 600 "Tamanyo" => 41716 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Tracheal stenosis observed on the VivaSight SL®.</p>" ] ] ] "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, and is even more complex and difficult in the presence of unanticipated tracheal stenosis.<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. Studies suggest that some degree of stenosis develops in up to 20–30% of patients with tracheostomy, but only 1–2% of these are symptomatic or have severe stenosis.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Recent advances in percutaneous dilation tracheostomy (PDT) have increased the number of patients presenting with more proximal tracheal stenosis. PDT-related lesions are usually more proximal, whereas open tracheostomy-related stenosis typically occurs more distally.<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 (PT) are rare entities. However, when they occur they can be life-threatening, especially in an emergency context.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We report two cases of difficult airway and unanticipated tracheal stenosis managed using different devices: the standard Univent® and the new generation Vivasight SL® endotracheal tubes. Their advantages and disadvantages are analysed.</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. One week after surgery, the ENT specialist changed the cannula for one without a cuff.</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. In view of the difficult airway caused by the previous surgery, the patient underwent awake intubation using a flexible fiberscope. No tracheal stenosis was observed in either the CT scan or with the fiberscope. Introduction of the endotracheal tube (8<span class="elsevierStyleHsp" style=""></span>mm) was uneventful. Following this, a 14Fr tube exchanger was inserted to replace the endotracheal tube with a Univent® tube with an 8<span class="elsevierStyleHsp" style=""></span>mm internal diameter (ID) bronchial blocker, without any apparent resistance. However, acute tracheal bleeding was observed, which stopped after inflating the tube cuff. We thought that the bleeding was caused by exchanging the endotracheal tube for the Univent®, which has a larger external diameter. The surgery was completed without incident, 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.</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. She had been treated with intraoral resection and chemo-radiotherapy, and subsequently underwent tracheostomy with a number 8 cuffed cannula that remained in place until the seventh postoperative day, after which it was changed for another cannula without cuff. The tracheostomy was closed after three months.</p><p id="par0035" class="elsevierStylePara elsevierViewall">During this time, the patient underwent superior right lobectomy. The preoperative evaluation revealed several difficult airway predictors: inter-incisor gap (<3<span class="elsevierStyleHsp" style=""></span>cm), Mallampati class IV, serious limitation on neck movement and upper lip bite test class II.</p><p id="par0040" class="elsevierStylePara elsevierViewall">We decided to carry out awake intubation. After proper sedation and administration of local anaesthesia, we attempted to insert a VivaSight SL® endotracheal tube (8<span class="elsevierStyleHsp" style=""></span>mm ID) through a VAMA cannula using a Frova introducer (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>); however, a glottic distortion was observed (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). We were able to pass the Frova introducer and VivaSight SL® through the vocal cords, but tracheal stenosis was observed on the VivaSight screen, probably caused by a previous tracheostomy (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The 8<span class="elsevierStyleHsp" style=""></span>mm ID VivaSight SL tube was too large to pass through the stenosis, so we replaced it with a smaller calibre Vivasight SL® tube (7<span class="elsevierStyleHsp" style=""></span>mm ID), and achieved intubation. Finally, a Cohen 9Fr bronchial blocker was inserted in the main right bronchus using this tracheal tube with integrated camera as a guide, without the need for a fiberscope (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</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, due to the development of granulation tissue after surgery. According to Grillo,<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 3–6 weeks later. Incidence of tracheal stenosis can be reduced with the use of high-volume, low pressure cuffs.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Most tracheal stenoses may go unnoticed, and symptoms depend on the degree of obstruction (when stenosis reaches 70% and the tracheal lumen is reduced to less than 5<span class="elsevierStyleHsp" style=""></span>mm).<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. Physical examination, difficult airway predictors, and complementary imaging tests, such as computer tomography (CT) scans, are crucial.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In our cases, the patients presented significant anatomical changes that led to difficult airway and asymptomatic tracheal stenosis due to previous tracheostomy.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In the first case, the patient was intubated while awake using a flexible fiberscope. However, the stenosis had reduced the internal tracheal diameter to 13<span class="elsevierStyleHsp" style=""></span>mm, which was slightly smaller than the external diameter (13.5<span class="elsevierStyleHsp" style=""></span>mm) of the Univent® tube with 8<span class="elsevierStyleHsp" style=""></span>mm ID. This was probably what caused the tracheal bleeding, and was related to the previous tracheostomy (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In the second case, the VivaSight SL® device allowed us to perform awake intubation and detect significant tracheal stenosis, thus avoiding potential tracheal damage. The integrated camera gave us uninterrupted, real-time visualisation of the trachea and main bronchus while inserting the bronchial blocker, without the need for a flexible fiberscope.</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/or difficult airway.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Several decades have passed since 1936, when Magill performed the first lung isolation using a bronchial blocker. The single-lumen endotracheal Univent® tube has an integrated bronchial blocker.<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. The greatest drawback, however, is its large external diameter and greater rigidity compared to standard endotracheal tubes.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The VivaSight SL® device is a single-lumen airway tube with an integrated high-resolution camera with an innovative design. In our opinion, it has several advantages over other similar devices, such as facilitating awake intubation in patients with difficult airway, guided insertion of bronchial blockers, continuous airway visualisation and control of the position of the endotracheal tube without the need for a flexible fiberscope. It has a lipophobic coating that reduces the incidence of obscured vision due to fogging, secretions or airway bleeding, and provides optimal ventilation. Giglio et al., in a study of 80 patients, showed the usefulness of the ETView for correct positioning of bronchial blockers in all patients without the needed for a flexible fiberscope.<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. In addition, the bleeding observed after insertion of the Univent® tube is a rare but serious complication. Univent is a device with an integrated bronchial blocker that is still used today, although the latest REDAR guidelines recommend using independent bronchial blockers in patients with difficult airways.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Finally, the second case presents a novel use of the VivaSight SL® device in an awake patient with difficult upper airway and tracheal stenosis: the integrated camera guided insertion of the bronchial blocker without the need for a flexible fiberscope. VivaSight SL ensures patient safety because the same device detects the presence of stenosis, thus enabling the anaesthesiologist to replace it with a smaller diameter tube.</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, Hospital General de Valencia, Valencia, Spain.</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.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1042060" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec994817" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1042059" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec994818" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case 1" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Case 2" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Financial support" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-10-09" "fechaAceptado" => "2017-12-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec994817" "palabras" => array:4 [ 0 => "Thoracic surgery" 1 => "Lung isolation" 2 => "Difficult airway management" 3 => "Tracheal stenosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec994818" "palabras" => array:4 [ 0 => "Cirugía torácica" 1 => "Aislamiento pulmonar" 2 => "Manejo vía aérea difícil" 3 => "Estenosis traqueal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lung isolation in thoracic surgery is a challenge, and this is even more complex in the presence of unknown tracheal stenosis (TS). We report two cases of unknown TS and its airway management. 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. Clinical history, physical examination, difficult intubating predictors and imaging tests (CT scans) are crucial, however most of tracheal stenosis may be unnoticed and symptoms depend on the degree of obstruction. In our cases, the patients presented anatomical changes due to surgery and previous tracheostomy that led to a TS without symptoms. There is scarce literature about the intubation in patients with previous tracheostomy in thoracic surgery. In the first case, a Univent<span class="elsevierStyleSup">®</span> tube was used using a flexible fiberscope but an acute tracheal hemorrhage occurred. In the second case, after intubation with VivaSight SL<span class="elsevierStyleSup">®</span> in an awake patient, the insertion of a bronchial blocker was performed through an endotracheal tube guided by its integrated camera without using flexible fiberscopy.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El aislamiento pulmonar en cirugía torácica es un reto para el anestesiólogo, pero la presencia de estenosis traqueal no conocida complica más esta situación. Describimos dos casos de estenosis traqueal desconocida y el manejo de la vía aérea. La estenosis traqueal aparece frecuentemente tras intubación de larga duración en la zona del neumotaponamiento o en el estoma de la traqueotomía como consecuencia del tejido de granulación que aparece tras la apertura quirúrgica de la tráquea. Son cruciales la historia clínica, la exploración física, los predictores de vía aérea difícil y las imágenes diagnósticas (TAC). Sin embargo, muchas estenosis traqueales pasan desapercibidas y la aparición de síntomas depende del grado de obstrucción. En estos casos, los pacientes presentaron cambios anatómicos debido a la cirugía y traqueotomía previa que ocasionaban estenosis traqueal sin síntomas. Existe escasa literatura sobre intubación en pacientes con traqueotomía previa en cirugía torácica. En el primer caso se utilizó un tubo Univent<span class="elsevierStyleSup">®</span> utilizando un fibrobroncoscopio pero se produjo una hemorragia traqueal aguda. En el segundo caso, tras la intubación con VivaSight SL<span class="elsevierStyleSup">®</span> en paciente despierto, se realizó la inserción de un bloqueador bronquial a través de un tubo endotraqueal guiado por la cámara integrada sin necesidad de control con fibrobroncoscopio.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Granell Gil M, Solís Albamonte P, Córdova Hernández C, Cobo I, Guijarro R, de Andrés Ibañez JA. Intubación en dos pacientes con vía aérea difícil y estenosis traqueal tras traqueostomía en cirugía torácica. Rev Esp Anestesiol Reanim. 2018;65:347–350.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1032 "Ancho" => 950 "Tamanyo" => 119738 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Insertion of the VivaSight SL® endotracheal tube and Frova introducer.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 460 "Ancho" => 600 "Tamanyo" => 34610 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Glottic distortion observed on the VivaSight SL®.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 450 "Ancho" => 600 "Tamanyo" => 41716 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Tracheal stenosis observed on the VivaSight SL®.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 446 "Ancho" => 600 "Tamanyo" => 41899 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Placing the bronchial blocker guided by the VivaSight SL® camera.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 669 "Ancho" => 850 "Tamanyo" => 45155 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">CT scan image of tracheal stenosis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Case scenario: perioperative airway management of a patient with tracheal stenosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. 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