Users Online: 294 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  
Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 
 

 
Table of Contents
LETTER TO EDITOR
Year : 2017  |  Volume : 33  |  Issue : 1  |  Page : 133-134

Emergency airway management of intratracheal tumor in a patient with respiratory distress


Department of Anesthesiology and Palliative Care, Dr. Brairch, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication15-Mar-2017

Correspondence Address:
Rakesh Garg
Department of Anaesthesiology, DR. Brairch, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.168258

Rights and Permissions

How to cite this article:
Garg R, Saini S, Kumar V, Gupta N. Emergency airway management of intratracheal tumor in a patient with respiratory distress. J Anaesthesiol Clin Pharmacol 2017;33:133-4

How to cite this URL:
Garg R, Saini S, Kumar V, Gupta N. Emergency airway management of intratracheal tumor in a patient with respiratory distress. J Anaesthesiol Clin Pharmacol [serial online] 2017 [cited 2017 Mar 26];33:133-4. Available from: http://www.joacp.org/text.asp?2017/33/1/133/168258

Sir,

Patients with tracheal tumors can present with catastrophic airway obstruction.[1] We report a case of young female who presented with severe respiratory distress due to intratracheal mass with near total occlusion.

A 25-year-old woman presented with severe respiratory distress. On examination, the patient was using accessory muscles and stridor was auscultated on expiration. The tracheal tug was present in suprasternal area. The respiratory rate was around 40 breaths/min. Chest X-ray revealed narrowing of the lower tracheal lumen. Computed tomography scan was suggestive of tracheal growth on anterior wall covering 90% of the lumen, approximately 2 cm above carina. Fiberoptic visualization of the lower airway was done which revealed near total occlusion of the tracheal lumen. The fiberoptic bronchoscope could not be negotiated beyond the tracheal mass. Rigid bronchoscopy and debulking of tumor were planned on emergent basis. In the operating room, intravenous access was secured and monitors were attached. She had an pulse rate of 142 beats/min, and oxygen saturation of 91%. She was nebulized with adrenaline (1 mg diluted in 5 ml of saline). Intravenous dexmedetomidine (1 mcg/kg) over 10 min followed by 0.5 mcg/kg/h was initiated. Anesthesia was induced with incremental doses of sevoflurane in 100% oxygen. Intravenous fentanyl (50 mcg) was administered, and rigid bronchoscope was inserted. Lungs were then ventilated with side ventilating port of the rigid bronchoscope [Figure 1]. Boluses of intravenous propofol (20 mg bolus) were administered. The bronchoscope was negotiated and a core through with the rigid bronchoscope was attempted through the tumor mass [Figure 2]. The intratracheal mass was removed with the forcep. The rest of the mass was removed piecemeal. The oxygen saturation fluctuated between 85% and 95% during removal of tumor but increased to around 95% after the mass was removed. The bronchoscope was removed and trachea intubated with endotracheal tube. Tracheal tube's cuff was positioned and inflated 3 cm from carina so as to achieve tamponade effect of cuff over the excised mass. The sevoflurane and dexmedetomidine were also discontinued and patient's trachea was extubated on return of conscious level.
Figure 1: Rigid bronchoscope in situ and ventilation via ventilation port

Click here to view
Figure 2: Rigid bronchoscope picture of intratracheal tumor

Click here to view


The perioperative anesthetic management is very challenging in patient of tracheal tumor especially with intratracheal mass due to ventilatory concerns and suitable airway gadget for securing airway. Also, the intratracheal mass may get detached and dislodged distally leading to distal airway obstruction.[2] The bleeding during removal may also lead to issues with efficient gas exchange in lungs. Knowledge of the various techniques for airway management is crucial. Planning needs to be discussed among bronchoscopist, surgeon, and anesthetist. Various airway management techniques include ventilation through rigid bronchoscope, tracheostomy, high-frequency jet ventilation, cardiopulmonary bypass, or extracorporeal membrane oxygenation.[3] In our case, tracheostomy was not an option as the tumor was low lying. High-frequency jet ventilation could be other option, but movement of the mass itself can obstruct the airway completely and also risk of barotrauma to lungs is a possibility due to obstructed exhalation.[4],[5] Use of cuffed endotracheal tube with cuff placed over the excised area of the trachea provides tamponade action and avoid any oozing of the blood in the postoperative area. We conclude that coring of mass using a rigid bronchoscope along with optimal hemostasis may be life-saving procedure in patients of lower intratracheal tumor with severe respiratory distress.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Gaissert HA, Mark EJ. Tracheobronchial gland tumors. Cancer Control 2006;13:286-94.  Back to cited text no. 1
    
2.
Koul A, Sood J. Leiomyoma of trachea: An anaesthetic challenge. Indian J Anaesth 2013;57:412-4.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Chiang YY, Ke CC, Wu RS, Chen KB, Shen ML, Poon KS. Endoscopic resection of tracheal tumor in an elderly woman under extracorporeal membrane oxygenation. Int J Gerontol 2011;5:56-8.  Back to cited text no. 3
    
4.
Garg SK, Tiwari RL, Garg MK, Chaturvedi S. Anesthetic management for successful removal of intratracheal tumor. Ann Card Anaesth 2011;14:232-5.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Satoh M, Hirabayashi Y, Seo N. Spontaneous breathing combined with high frequency ventilation during bronchoscopic resection of a large tracheal tumour. Br J Anaesth 2002;89:641-3.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
   References
   Article Figures

 Article Access Statistics
    Viewed116    
    Printed0    
    Emailed0    
    PDF Downloaded19    
    Comments [Add]    

Recommend this journal