Emergency percutaneous tracheostomy.
|Article Type:||Case study|
Airway obstruction (Medicine) (Patient outcomes)
Airway obstruction (Medicine) (Research)
|Publication:||Name: South African Journal of Surgery Publisher: South African Medical Association Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2007 South African Medical Association ISSN: 0038-2361|
|Issue:||Date: August, 2007 Source Volume: 45 Source Issue: 3|
|Topic:||Event Code: 310 Science & research|
|Geographic:||Geographic Scope: South Africa Geographic Code: 6SOUT South Africa|
We present a case of acute upper airway obstruction secondary to angio-oedema. The patient underwent emergency percutaneous tracheotomy. Other options available for emergency surgical airway are discussed.
Complete upper airway obstruction that cannot be alleviated by supraglottic intubation devices is a rare situation in emergency medicine. The primary aim in the management of such patients is to provide rapid oxygenation. The options available to the physician include temporary (needle transtracheal jet ventilation, cricothyroidotomy) or definitive airway procedures (tracheostomy). The fastest method available to provide oxygenation is an emergency cricothyroidotomy, (1,2) which can be performed within 10 seconds.3 Percutaneous tracheostomy (PCT) is becoming more popular in intensive care units (ICUs), and the guidewire dilator forceps technique described by Giggs et al. (4,5) is well documented in non-emergency situations. PCT has the advantage of being feasible under local anaesthesia, at the bedside and without first requiring airway access. It has been performed within 3 minutes in the emergency situation6 and the average time was 5 1/2 minutes in a study done by Ben-nun et al. (7) on trauma patients.
A 76-year-old man presented to our emergency department with sudden onset of difficulty in breathing and swelling of his face, lips and tongue. He was a known hypertensive on hydrochlorothiazide and used doxazosin for benign prostate hypertrophy. On clinical examination he had swelling of his face, lips and tongue with marked respiratory difficulty.
The patient's breathing rapidly became more laboured and he subsequently developed acute upper airway obstruction. He required airway support, and endotracheal intubation was attempted by the anaesthetist using 10 mg intravenous midazolam. Endotracheal intubation was unsuccessful and the EnT specialist was consulted. After injecting a local anaesthetic, a small skin incision was made over the upper part of the trachea. A large-bore cannula was inserted into the trachea and the position was confirmed by aspirating air. The guidewire was inserted via the cannula into the trachea. A percutaneous dilator was inserted over the guidewire. After dilating the subcutaneous soft tissue a tracheotomy tube was inserted over the guide wire. This procedure was performed within 2 minutes with no complications.
A diagnosis of acute upper airway obstruction secondary to angio-oedema was entertained. Further enquiry revealed that the patient used aspirin regularly and this was the presumed cause of the angio-oedema. The patient developed acute renal failure and nosocomial pneumonia over the next week. He died 12 days after admission in the ICU.
Of the emergency surgical airway interventions, cricothyroidotomy is well recognised. There are two potential problems in performing a cricothyroidotomy. Firstly, it might be difficult to identify the cricothyroid membrane correctly, especially in patients who have sustained trauma to their larynx. Secondly, it might be potentially difficult to maintain the airway once a needle cricothyroidotomy has been performed. The plastic cannula described in textbooks is often very soft and can kink easily. It is also difficult to secure this tube after insertion and it can become displaced. Apart from these potential problems a needle cricothyroidotomy is only a temporary solution until a definitive airway can be provided, for example by means of a tracheotomy.
Conventional breathing systems deliver low flow because of the small internal diameter of the cannula, and jet ventilation can cause barotrauma in complete upper airway obstruction. (1) Surgical cricothyroidotomy is a more definitive option. The danger of a surgical cricothyroidotomy is the risk of injuring the cricoid cartilage, which is the only complete ring in the upper airway. Injury to the cricoid cartilage can cause scarring, with subsequent subglottic stenosis. Indications for performing a cricothyroidotomy (surgical or needle) are very limited. It is therefore extremely difficult to gain experience and become confident in performing this procedure.
When using local anaesthetic skin infiltration to perform an open tracheotomy the patient needs to be very co-operative for the duration of the procedure, which is often difficult for distressed and hypoxic patients.
In the early publications most authors considered obesity and a short neck as relative contraindications for percutaneous tracheostomy, whereas cervical injury, paediatric age and emergency were regarded as absolute contraindications. Since then PCT has been performed safely in obese patients with short or fat necks and in trauma patients without cervical spine clearance. (10-12) The study performed by Ben-nun et al. (7) concluded that in experienced hands emergency PCT in trauma patients is feasible and safe.
It is important to stress that there are potential complications with this technique, especially when performed in the emergency setting. It is therefore important that only staff already trained in performing this procedure should consider doing it in the emergency setting. The advantage of the PCT method is that the same technique is utilised in both elective and emergency situations, therefore the surgeon can easily acquire considerable experience, which will make it safer to use in the emergency setting. A number of comparative studies (13-16) between PCT and open tracheotomy demonstrated either a lower complications rate with PCT or no statistical difference between the two methods.
In experienced hands, PCT may be considered an option when definitive emergency access is required within 10 minutes.
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M. S. MOODLEY, F.C.S. (S.A.)
B. SINGH, F.C.S. (S.A.), M.D.
V. TALLAPANENI, M.B. B.S.
Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban
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