David T Wong1, Ashok Kumar, Atul Prabhu. 1. Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Ontario M5T 2S8, Canada. david.wong@uhn.on.ca
Abstract
PURPOSE: A 'cannot intubate-cannot ventilate' situation requires emergency insertion of an infraglottic surgical airway. We present a case of postoperative macroglossia requiring emergency insertion of an uncuffed percutaneous cricothyroidotomy tube. The supraglottic leak was eliminated by the insertion of a laryngeal mask airway with an occluded 15-mm connector. CLINICAL FEATURES: A 49-yr-old man underwent clipping of a left posterior inferior cerebellar artery aneurysm and his tracheal tube was removed postoperatively. Two hours later, he became dyspneic and developed significant macroglossia. After application of topical anesthesia, direct laryngoscopy, oral fibreoptic bronchoscopy and laryngeal mask insertion were unsuccessful. The patient became progressively hypoxemic, pulseless electrical activity ensued, and cardiopulmonary resuscitation was initiated. An uncuffed percutaneous cricothyroidotomy tube was inserted. Oxygenation and hemodynamics were restored. As the cricothyroidotomy tube was uncuffed, there was a large supraglottic leak with manual ventilation. A laryngeal mask airway was inserted and the cuff was inflated. The 15-mm connector was occluded by a piece of tape. Subsequently, there was no further supraglottic leak with manual ventilation. He was taken to operating room and a surgical tracheotomy was performed. CONCLUSION: In a patient with postoperative macroglossia in a 'cannot intubate-cannot ventilate' situation, effective oxygenation was restored by insertion of an uncuffed cricothyroidotomy, but ventilation was affected by a substantial supraglottic leak. A new strategy using an inflated laryngeal mask airway with an occluded connector was utilized to successfully terminate the supraglottic leak, thereby restoring effective lung ventilation.
PURPOSE: A 'cannot intubate-cannot ventilate' situation requires emergency insertion of an infraglottic surgical airway. We present a case of postoperative macroglossia requiring emergency insertion of an uncuffed percutaneous cricothyroidotomy tube. The supraglottic leak was eliminated by the insertion of a laryngeal mask airway with an occluded 15-mm connector. CLINICAL FEATURES: A 49-yr-old man underwent clipping of a left posterior inferior cerebellar artery aneurysm and his tracheal tube was removed postoperatively. Two hours later, he became dyspneic and developed significant macroglossia. After application of topical anesthesia, direct laryngoscopy, oral fibreoptic bronchoscopy and laryngeal mask insertion were unsuccessful. The patient became progressively hypoxemic, pulseless electrical activity ensued, and cardiopulmonary resuscitation was initiated. An uncuffed percutaneous cricothyroidotomy tube was inserted. Oxygenation and hemodynamics were restored. As the cricothyroidotomy tube was uncuffed, there was a large supraglottic leak with manual ventilation. A laryngeal mask airway was inserted and the cuff was inflated. The 15-mm connector was occluded by a piece of tape. Subsequently, there was no further supraglottic leak with manual ventilation. He was taken to operating room and a surgical tracheotomy was performed. CONCLUSION: In a patient with postoperative macroglossia in a 'cannot intubate-cannot ventilate' situation, effective oxygenation was restored by insertion of an uncuffed cricothyroidotomy, but ventilation was affected by a substantial supraglottic leak. A new strategy using an inflated laryngeal mask airway with an occluded connector was utilized to successfully terminate the supraglottic leak, thereby restoring effective lung ventilation.