Case of difficult tracheostomy tube insertion: A novel yet simple solution to the dilemma.

Difficulties arising during tracheostomy tube insertion can be rapidly fatal if the airway is not adequately controlled. We report a case of difficult tracheostomy in a gentleman with severe subcutaneous emphysema following a previously failed tracheostomy attempt. Tracheostomy tube insertion through the pre-existing stoma failed repeatedly due to rapidly increasing distance of trachea from the skin and unexpected false passages; however, the trachea was eventually cannulated using a regular endotracheal tube.

INTRODUCTION

Airway management can sometimes be a challenging task. We hereby report a novel way of managing a case of a difficult tracheostomy tube insertion. As the conventional tracheostomy tube insertion proved futile due to the rapidly increasing depth of the trachea from the skin (secondary to surgical emphysema), an endotracheal tube was used instead and the patient was successfully resuscitated. This is the first reported case of such a technique being used.

CASE REPORT

A 30-year-old averagely built gentleman was referred to our hospital with alleged history of ingestion of an organophosphorus compound three days prior. He was previously admitted to a private hospital, where he was intubated in view of low mentation, and need for respiratory support. On day 3 of admission there, a routine surgical tracheostomy was attempted but failed and the patient was referred to our hospital with a gauze bandage applied over the tracheostomy stoma wound and on ambu bag ventilation via a cuffed size 7, endotracheal tube.

He arrived in our emergency room within two hours and was found to be semiconscious, with a GCS of E2M4VT. He had small sized, sluggishly reacting pupils, was diaphoretic, with heart rate of 101 per minute, blood pressure of 160/100 mm of Hg, and a peripheral oxygen saturation of 100% on an FiO2 of 1. He had moderate subcutaneous emphysema extending to the face, neck, and upper arms. The tracheostomy stoma was roughly 2 × 2 cm wide with a tracheal rent of about 1.5 cm. There was an audible air leak from the site of tracheostomy stoma, despite the cuff of the endotracheal tube being well below the site of the stoma. An urgent chest radiograph was ordered and the patient was shifted to the intensive care unit for further management. By the time the patient had arrived in the ICU, the subcutaneous emphysema was found to have increased substantially and had by now involved the entire chest, abdomen, genetalia, and thighs, extending cranially up to the head and face. The patient was unconscious and unresponsive by then and his airway peak pressures were extremely high resulting in near impossible ventilation. A clinical diagnosis of tension pneumothorax was made and bilateral infraclavicular needles were placed to relieve air under tension. The chest radiograph confirmed the diagnosis of severe pneumothorax [Figure 1]. ENT surgeons attempted a tracheostomy through the previous stoma using a portex cuffed tracheostomy tube sized 7.5. However, as the skin to tracheal distance was very large, approximately 7-8 cm (due to the expanding subcutaneous emphysema), the tube kept slipping into the wrong track, anterior to the trachea. Repeated attempts at placing the tracheostomy tube proved unsuccessful. Then, an attempt was made to insert an endotracheal tube size 7.5 (cuffed) into the stoma which was immediately successful and ventilation was rapidly resumed [Figure 2]. Meanwhile, bilateral tube thoracostomies were performed. The endotracheal tube was fixed at a depth where air entry was equal in both lung fields. The lungs rapidly expanded and patient was subsequently ventilated successfully. By day 2, the emphysema had reduced substantially and the neck to tracheal tube distance had reduced. By the fifth ICU day, he was weaned off the ventilator and discharged from the ICU on the seventh day.

Figure 1

Chest radiograph of the patient showing bilateral severe tension pneumothorax with subcutaneous emphysema

Figure 2

Endotracheal tube inserted through the tracheostomy stoma (soon after insertion)

DISCUSSION

Airway management is an essential part of the training and skills needed to be acquired by every critical care physician. A difficult airway is defined as the clinical situation in which a conventionally trained anesthesiologist experiences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both. A difficult tracheostomy is defined as the inability to insert the tracheostomy tube. Although tracheostomies are commonly performed in critically ill patients, the reported complication rates following insertion of tracheostomy vary widely, from as low as 2.1% to as high as 20%.[1] The rate of major or serious insertion complications like major bleeding, posterior tracheal wall injury, pneumothorax, and death is approximately 6%.[234] Pneumothorax and subcutaneous emphysema following tracheostomy has been reported to occur in 2 to 5% of cases.[56] Most cases of difficult tracheostomy insertions have been reported in patients with morbid obesity because of their increased skin to tracheal distance. In our patient, the difficulty in the tube placement was due to a similar cause, albeit due to air in the subcutaneous space which causes an increase in the skin to tracheal distance. In the morbidly obese population, the incidence of complications from tracheostomy has been reported to be approximately 25% with an estimated mortality of 2%, attributed mainly to the loss of airway accessibility.[7] Suction catheters, nasogastric tubes, endotracheal tube exchangers, guidewires, and Eschmann tracheal tube introducers have all been variously used in the management of difficult tracheostomy tube insertion.[89] These have mainly been used as guides to railroad the tracheostomy cannulae. In morbidly obese patients, cervical lipectomy or “defatting” tracheostomy have been successfully employed to access the trachea prior to tracheostomy.[10] Various new tracheostomy tubes, including adjustable length tracheostomy tubes, which can be adjusted according to the depth to which the tube is inserted, and extra length tubes with spiral wire reinforced flexible design, are now available for use in the morbidly obese patients.[1112]

In our case, securing the airway was an immediate priority due to the rapidly deteriorating control over the patient's airway and ventilation. Since the problem was with the depth of the trachea from the skin, the solution lay in inserting an airway device with sufficient depth to reach the trachea. An endotracheal tube was the ideal answer to this problem. Although longer tracheostomy tubes are now available in the market, they may not be immediately available in an ICU, especially in an emergency situation. It is even doubtful whether such extra long tracheostomy tubes would have had sufficient length to be used in our patient. Endotracheal tubes are very useful in these cases as they are easily available and can be used as a temporary measure to gain airway access and tide over the emergent crisis. The same may also be applied in patients with morbid obesity where the anterior tracheal to skin distance is increased.

In conclusion, we would like to emphasize that surgical tracheostomies may pose unanticipated difficulties in airway control and in cases such as the one we have described, using an endotracheal tube in lieu of a conventional tracheostomy tube can facilitate quick airway access which can be life saving.