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Tracheal intubation and lung isolation with Viva Sight SL and Cohen bronchial blocker in a patient with difficult upper airway management and tracheal stenosis

Background

The incidence of tracheal stenosis after tracheostomy and / or postintubation is of 4.9 patients in a million per year1. Nikolaos Zias2 concluded that the most common profile of patients with tracheal stenosis were women (75%), obesity (66%) and others. Cooper and Grillo3 indicate that the incidence of this complication has decreased due to the use of high volume and low pressure cuff inflation and performing an early tracheostomy in patients with prolonged invasive ventilation.

Key words: Tracheal stenosis postracheostomy; intubation; lung isolation

Material and methods

A 56 year-old female patient was diagnosed with squamous carcinoma in the lower mouth area, which had been treated with radical surgery, intraoral resection and tracheostomy seven months before, with subsequent chemotherapy and radiotherapy, and also suffered from arterial hypertension and hypothyroidism.

This time, the patient was scheduled for pulmonary resection due to pulmonary nodule in the right upper lobe. The preoperative evaluation revealed predictors of difficult intubation, limited mouth opening, important limitation for cervical mobilization and Mallampati IV (Fig 1).

The suspected difficult intubation and the CT scan images were the reason to perform an intubation while the patient was awake using an endotracheal tube Viva Sight SL and a Frova introducer (Fig 2).

Results

After local anesthesia through the VivaSight SL we proceeded to intubation. In a first attempt we used an 8 mm endotracheal tube, but tracheal stenosis was observed, which made an adequate intubation impossible (Fig. 3) despite the presence of the Frova introducer. We decided to replace the endotracheal tube with a 7 mm Viva Sight SL tube through a Frova introducer, being successful this time.

In this case our patient had many important factors. In the first place, previous radical surgery and subsequent treatments provoked several and important changes in mouth, pharynx and larynx. In addition, the patient received 30 cycles of radiotherapy, which contributed to those changes.

Conclusion

The Viva Sight SL tube was very useful in avoiding tracheal injury during tracheal intubation, and it also allowed us to insert the bronchial blocker guided with a continuous view of the carine without using a flexible fiberscope (Fig. 4). CT scan diagnosis is advisable after tracheostomy and/or prolonged intubation. We found a tracheal stenosis area with a diameter of 9.3mm in the thinnest zone (Fig 5).

Fortunately, this situation was handled successfully and both surgery and the postoperative period were complication-free. After 24hrs in the Intensive Care Unit this patient was discharged to thoracic surgery ward.

References

  1. Shiroh Isono. M.D.Anesthesiology, V 112 • No 4 • April 2010
  2. Zias N. BMC Pulm Med. 2008; 8: 18.
  3. Grillo HC. J Thorac Cardiovasc Surg 1971; 62: 898–907.

 

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Fig.2.

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General University Hospital of Valencia

Dept. of Anaesthesiology
Granell M., Cordova C., Solís P., de Andrés JA

Critical Care and Pain Relief
García E., Guijarro R.

Thoracic Surgery, University of Valencia
Granell M., Guijarro R., de Andrés JA

Corresponding author's e-mail: mgranellg@hotmail.com

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