CODE BLUE in a patient with tracheal stent: Are we fully equipped?

Abstract

Sir, Airway stents have long been used to maintain luminal integrity of compromised airway in case of obstruction and malignancy.[1] The complications associated with airway stent placement are malposition, haemorrhage, airway rupture during placement, migration, impaction, formation of granulation tissue, and stent fracture.[2] We present here a challenging case of an airway emergency in a patient with a tracheal stent inserted for a malignancy. A 29-year-old woman diagnosed with adenoid cystic carcinoma of trachea 2 years back had undergone debulking of tumor, tracheal stenting with a metallic stent, and chemo-radiotherapy elsewhere. On the second day of admission, CODE BLUE was activated in view of acute onset biphasic stridor, with air hunger and low oxygen saturation. Despite resuscitation measures, the patient had persistent tachycardia, tachypnea, and hypoxia with non-rebreathing mask (15 L/min of O2). A review of Computed Tomography (CT) neck revealed a tracheal narrowing 1.7 cm distal to vocal cords with narrowest diameter of 6 mm [Figure 1a], complicating an imminent intubation for the patient. She was pre-oxygenated with a non-invasive ventilation mask. Intravenous boluses of fentanyl 75 mcg, muscle relaxant (suxamethonium 100 mg) was given and intubated with a 5.0 mm ID cuffed endotracheal (ET) tube through direct laryngoscopy. A chest x-ray confirmed the position of the ET tube but it fell short of bypassing the tracheal stent, which was reflected in decreased tidal volumes and increased peak pressure. As the length of the 5.0 mm ET tube (23 cm) was not enough to bypass the stent, we had to increase the length by rail roading another 6.5 mm ID tube at the distal end, after removing the connector [Figure 1b]. This step significantly improved the tidal volumes (350-400 ml) without much rise in peak pressure with marked improvement in the oxygenation of patient in the blood gas analysis. Patient underwent bronchoscopic biopsy and excision of mass around the stent after putting on veno-venous extracorporeal membrane oxygenation for oxygenation. Post-procedure ET tube was removed after suctioning and intubated with 7.0 mm ID ET tube for postoperative ventilation and eventually extubated.Figure 1: (a) image showing CECT neck with tracheal stent in situ. (b) image showing the proximal end of 6.5 mm ID tube is cut and railroaded over 5.0 mm ID tube to increase the lengthSecuring airway in an in-hospital CODE blue needs quick thinking and swift action. This case highlights a unique situation where a tracheal stent precluded a “conventional intubation.” A tracheostomy could damage the stent and a supraglottic airway device risked aspiration.[3] A fibre-optic bronchoscope is essential and the best available option to ensure correct position of the tube within the stent or just above the stent. It can also avoid stent-related complications but is not readily available everywhere.[4] No formal guidelines are available in terms of airway management with tracheal stents in situ. A literature search also revealed paucity of data with regard to management in similar case scenarios. Microlaryngeal surgery (MLS) tubes can be made available in the CODE BLUE kits anticipating such scenarios, as they are longer than conventional ET tubes with same internal diameter.[5] This case though uncommon highlights the need to incorporate airway management in cases of tracheal stents as part of our teaching curriculum. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.