Awake Tracheostomy Research Articles

P035: Continuing Trends in Awake Tracheotomy Airway Intervention

P035: Continuing Trends in Awake Tracheotomy Airway Intervention

Urgent awake tracheotomy for impending airway obstruction

Awake tracheotomy is performed for patients with impending airway obstruction. Few studies to date have addressed the issues surrounding awake tracheotomy. We sought to review the indications, complications, and outcome of awake tracheotomy for urgent airway control. We conducted a retrospective review of patients who underwent awake tracheotomy over a 4-year period from 2001 to 2004 at an urban tertiary medical center. Data were obtained from inpatient records and operative charts. We obtained data on 54 men and 19 women, with a mean age of 61 years. The majority of patients presented with hoarseness, dyspnea, and stridor. Twenty patients had obstruction from head and neck cancers. Nonmalignant causes included deep neck infections (n = 18), bilateral vocal cord paralysis (n = 17), trauma (n = 9), and laryngeal edema (n = 6). Other causes include laryngeal cyst, subglottic stenosis, and vocal cord granuloma. Six (8.2%) patients experienced complications, including postoperative hemorrhage, pneumothorax, and chest and wound infections. There were no long-term complications or deaths. Awake tracheotomy is efficacious and safe and has a low complication rate. Awake tracheotomy should be performed for impending airway obstruction and in a timely manner before complete obstruction occurs.

Necrotizing Fasciitis of the Skull Base and Neck in a Patient with AIDS and Non-Hodgkin's Lymphoma

Necrotizing fasciitis is a rapidly progressing, life-threatening soft tissue bacterial infection found more frequently in immunocompromised subjects and rarely in the head and neck. We report a rare case of a patient with acquired immunodeficiency syndrome (AIDS) and non-Hodgkin's lymphoma (NHL) who presented with a high fever and supraorbital cellulitis 1 week after undergoing chemotherapy. He received intravenous antibiotic therapy but soon developed dyspnea and trismus with rapid extension of the cellulitis to the face, ipsilateral infratemporal fossa (ITF), and bilateral neck. An awake tracheotomy was followed by surgical exploration and drainage and debridement of the supraorbital and ITF areas, parotid gland, and bilateral neck. He received intravenous antibiotic therapy and the surgical wound was regularly debrided for 10 days. Following a gradual recovery, the patient was discharged 2 weeks later. Early antibiotic therapy, wide surgical exploration, and a secured airway are the therapeutic mainstay for necrotizing fasciitis of the skull base and neck.

Duraprep and the risk of fire during tracheostomy

DuraPrep is a widely used, alcohol-based surgical prep solution. The risk of surgical fire associated with incomplete drying of this agent in the context of electrosurgical procedures has been described previously. To date, there have been no reports of fire during tracheostomy associated with a flammable prep agent before entering the airway. We describe an operating room fire occurring during awake tracheostomy associated with the use of DuraPrep. A 62-year-old man with copious body hair underwent tracheostomy in the operating room. The neck was prepared with DuraPrep surgical solution, and after at least 3 minutes, the operative field was draped. Activation of electrocautery ignited a fire, and the patient was burned on his neck and shoulders. The fire was extinguished, and the patient recovered from both the tracheostomy and the burns. This case illustrates that DuraPrep should be avoided in the hirsute patient, because body hair interferes with drying of this solution and increases the risk of fire.

Urgent Surgical Airway Intervention: A 3 Year County Hospital Experience

To review the indications, complications, and outcomes of patients undergoing urgent surgical airway intervention. The inpatient and outpatient charts of patients who underwent awake tracheostomy or were converted from cricothyrostomy to tracheostomy at our institutional-affiliated County Hospital over a 3 year period were reviewed. Ninety patients underwent awake tracheotomy, and seven were converted from cricothyrostomy to tracheostomy. Indications for awake tracheotomy included impending airway obstruction from malignancy of the aerodigestive tract or that causing extrinsic compression of the airway in 72 (80%) patients, neck abscess in 4 (4.4%), subglottic stenosis in 3 (3.3%), and a variety of other etiologies in 11 (12.2%). Thirty-eight (42%) patients were noted to have stridor. On fiberoptic laryngoscopy, 66 (80%) patients had moderate or severe airway obstruction, whereas 17 (20%) had mild or no obstruction. Of the 72 patients with squamous cell carcinoma, only 6 (8%) have been subsequently decannulated. Among the remainder, 13 of 18 (72%) have been decannulated. Complications occurred in seven (7.8%) patients after awake tracheotomy, none with untoward sequelae. Three severe complications occurred among the seven patients converted from cricothyrostomy to tracheostomy: anoxic brain injury in each, leading to death in two. Awake tracheostomy should be considered in any patient with impending or ongoing airway obstruction or with potential for difficult intubation. This should be performed in a timely manner before an emergent situation arises because the complications of emergency surgical airway can be devastating.

Critical incidents: the respiratory system

Critical incidents are events that cause harm or have the potential to cause harm if not recognized and acted upon. Critical incidents affecting the respiratory system are common events in anaesthesia. If not recognized and treated promptly they may lead to hypoxaemia and tissue damage. The appropriate use of preoxygenation to increase the body's oxygen stores and prevent rapid desaturation during respiratory critical incidents can be vital. Patients with airway obstruction are best managed by awake tracheostomy or inhalational induction and subsequent intubation or tracheostomy. Fibre-optic intubation may make partial obstruction complete. Patients with airway obstruction may be divided into two groups. Those who require local anaesthetic tracheostomy and those in whom intubation is considered possible. The safest approach in the latter is to perform inhalation induction. This will allow attempted laryngoscopy under deep inhalation anaesthesia, with subsequent intubation if laryngoscopy is successful, or tracheostomy under deep inhalational anaesthesia if it is not. The management of unanticipated airway obstruction following induction includes measures to improve the airway, intubation, laryngeal mask insertion and cricothyrotomy.

An unusual case of adult airway obstruction from a lymphatic/venous malformation

Objectives: Lymphatic, venous and mixed lymphovenous malformations are low-flow lesions that are present at birth and become clinically apparent before the age of 2 in 90% of cases. This case report puts forth an unusual presentation of a lymphovenous malformation in an adult. Methods: This is a case report of an unusual lymphovenous malformation. Results: A 19-year-old male presented to the emergency department with a 4-day history of worsening left sided odynophagia, fever, and voice changes. Exam revealed a left peritonsillar bulge consistent with a peritonsillar abscess; however, needle aspiration was negative. He was admitted for intravenous antibiotics, and over the ensuing 24 hours, his upper airway became acutely compromised. He was taken to the operating room emergently where he underwent an awake tracheotomy. Subsequent MRI revealed a large, poorly circumscribed heterogeneous left parapharyngeal mass that was isointense on T1 and hyperintense on T2 images consistent with a venous/lymphatic malformation. His lesion regressed after a course of steroids and antibiotics, and he was subsequently decannulated. Follow-up MRI shows marked reduction in the bulk of the lesion. Conclusion: A majority (70%-80%) of lymphatic and venous malformations present in the head and neck, primarily before 2 years of age. Rapid enlargement is common with trauma, spontaneous internal hemorrhage, or secondary infection, which is the likely scenario in our case. Treatment usually consists of sclerotherapy and/or surgical resection; however, the location and microcystic nature of our patient’s lesion was not amenable to these modalities. He remains asymptomatic over a year after his hospitalization.

Airway Management of a Patient with a Tracheal Mass

This case report describes a case of difficult and compromised airway due to a mediastinal mass. CASE REPORT A 67 year-old homeless male was admitted to the hospital because of a change in mental status following a fall. His past medical history included COPD, hepatitis, cerebral aneurysm, and chronic alcohol and tobacco abuse. The review of symptoms was significant for a 30 pound weight loss, anorexia, dysphagia, and productive cough. Pertinent findings on physical exam included dysphonia and expiratory stridor. A CT scan of the chest revealed an anterior mediastinal mass and mediastinal adenopathy. A CT scan of the neck region revealed a left-sided mass that caused distortion of the upper airway at the glottic (Figure 1) and subglottic (Figure 2) levels. Figure 1 Figure 1. The CT scan is taken at the glottic level where it can be seen that the tumor mass is pushing the airway to the patient's right side and distorting its shape. Figure 2 Figure 2. More severe compression and distortion of the trachea at a more caudad level. The patient was taken to the OR for direct laryngoscopy and biopsy of the neck mass. An awake fiberoptic intubation was planned. Bilateral superior laryngeal nerve blocks were performed with 2% lidocaine. Trans-tracheal anesthesia was attempted, but unsuccessful secondary to inability to definitively locate the tracheal lumen because of tumor effect. Flexible fiberoptic bronchoscopy revealed a complete loss of landmarks beyond the tongue base and marked rightward deviation of the trachea, and thus, inability to pass an endotracheal tube. An awake tracheostomy was performed using a flexible wire-reinforced endotracheal tube because of tracheal compression. DISCUSSION This case represents an example of both a difficult intubation and compromised airway. Induction of general anesthesia in this patient would have been extremely dangerous because of the high likelihood of tracheal collapse with the onset of muscle relaxation. It is also likely that positive pressure Airway Management of a Patient with a Tracheal Mass 2 of 3 ventilation would have been unsuccessful. The CT scans impressively demonstrate significant tracheal compression in the upper airway below the level of the mandible. Flexible fiberoptic bronchoscopy can be advantageous by decreasing the stimulation caused by endotracheal intubation while a patient is awake. But its usefulness is limited when the anatomy below the level of the mandible is altered, as in this case. In retrospect, the CT scan findings indicated that an orotracheal intubation would have been highly unlikely, and an awake tracheostomy was the only reasonable option. CORRESPONDENCE TO Ronald S. Litman, D.O. Associate Professor of Anesthesiology and Pediatrics Children's Hospital of Philadelphia 34th Street and Civic Center Blvd. Philadelphia, PA 19104 Voice: 215-590-5091 Fax: 708-810-4756 E-mail: Litmanr@email.chop.edu

Laryngeal Trauma

Laryngeal trauma is an uncommon but potentially life-threatening injury. Estimates of occurrence range from 1 in 5000 emergency department visits to 1 in 137,000 hospital admissions. The signs and symptoms are variable, and severe injuries may initially appear innocuous. The airway must always be thoroughly evaluated. If the airway is determined to be unstable, an awake tracheotomy should be performed. Intubation should not be attempted in these patients. Each case of laryngeal trauma is unique, and treatment must be individualized. However, in general, cases may be classified into five groups based on the severity of injury using the Schaefer–Fuhrman classification system. This article reviews the management of each group, with a particular emphasis on the most recent literature. Rational, expeditious management will minimize the potentially debilitating and life-threatening complications.

Anesthetic Implications of Laryngeal Trauma

Anesthetic Implications of Laryngeal Trauma

Laryngeal Mask Airway Facilitates Awake Fiberoptic Intubation in a Patient with Severe Oropharyngeal Bleeding

Laryngeal Mask Airway Facilitates Awake Fiberoptic Intubation in a Patient with Severe Oropharyngeal Bleeding