An Airway Conundrum A Case Presentation Jen Brooke, RRT

Airway Conundrum (AC) • AC is a 62 yr man who was involved in an MVC on September 15th, 2009 . Intubated @ the scene. Multiple injuries including: occipital condyle fracture, right orbital floor fracture, dislocated mandible, and C-Spine fracture resulting in tetrapalegia.

Tracheostomy • Due to the high level of his C-spine injury he likely would not be able to be weaned from the ventilator, and multiple discussions with his family members were had with the ICU Team. • Patient awakened for consent, tracheostomy approved.

OR 9/25/09 for Tracheostomy •

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Stay sutures were placed on either side through the second and third tracheal rings Opening made on anterior trachea using first the 11 blade and then the Mayo scissors, as his tracheal rings were quite calcified. Trach spreader placed and a Shiley 8.0 XLT Distal was attempted to be placed but found to be too large, Shiley 6.0 XLT Distal placed but the cuff wouldn’t hold air, a 2nd 6.0 XLT Distal placed.

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A #7 armored ETT was placed, however given that this tube was not a permanent tube as it did not have a flange to secure it to the skin, MD felt that it would be better to replace it with a Bivona type armored tube and this was secured from Respiratory Therapy. (we’re always helping) Over an Eschmann tube, replaced the non flanged armored tube with the new Bivona tube and this went smoothly. The cuff was inflated with a good hold of the air in the cuff. But…Anesthesia noted that it was getting difficult to ventilate. Tube pulled back 1cm, tube was likely right mainstemmed. Desaturating & unable to ventilate, anasthesia could not orally intubate. Sutures removed and #6 armored ETT placed. Verified w/bronchoscope and sutured in place. Note, during this time patient did have a period of hypoxia of about ten minutes, though no episode of anoxia. He also became bradycardic and was asystolic for a few seconds before he got Atropine and epinephrine and underwent about two minutes of CPR with good return eventually of his heart rate, blood pressure and saturations.

Let's Catch up with Busy AC - How many tubes so far? - What did they find? - Otolaryngology (OTO) consulted for long term airway decision.

9/28/2009 OTO Findings • Trachea was angulated in a very posterior direction making access difficult • It was very difficult to identify further laryngeal landmarks, and there were some ragged calcified edges that were removed with the rongeur • Would not be a candidate for placing a tracheotomy lower because there is no healthy bridge of tracheal tissue to separate it, and it would just make a larger defect of the anterior tracheal wall • A #7 Bivona Cuffed Trach with an adjustable flange, with the flange positioned at 12-cm. (2-3 cm above the carina)

Rongeur An instrument for cutting tissue, particularly bone

9/29/2010 ICU • •

At 0400 cuff leak heard by RT. OTO contacted. No respiratory distress noted. OTO bedside: Fiberoptic scope passed through trach, showing carina 2 cm below trach tube. Trach removed and balloon found to not inflate. Stoma was mature and patent though small. Attempted to pass a size 7 proximal XLT trach tube with some resistance. We removed this and continued ventilation with a small ET tube that was easily passed. Next a Bivona was placed without difficulty. This was secured with a velcro tie. There was a very small leak around the cuff but patient was otherwise ventilating well.

10/01/2009 • OTO requests RT to order Bivona Foamed Cuff. • Do we like these for long term? • Pt waits in ICU while this is ordered.

10/6/2009 OTO Trach Change • Stay sutures removed • Trach tract mature though deep • Shiley 6 XLT Distal placed without difficulty (using obturator) • Transferred to Rehab

10/8/2009 2 Days Later •

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RT found that AC had an audible cuff leak at beginning of night. After numerous attempts to put more air in cuff, the leak was still present. No desaturation episodes. 0915 – Patient codes, CPR done for 2-3 mins. OTO bedside to change trach to a new Shiley 6.0 XLT Distal, unable to hold pressure in cuff Trach changed to Bivona 6 TTS and filled with 2 ml sterile water. Both Shiley 6 XLT Distal noted to have tears, one on left side and one on front of cuff

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OTO decides to take patient back to ICU to stablize and then to OR for possible trach revision. 10/12/2009 OTO findings in OR - Significant sharp shards of calcified trachea that was impinging on the stoma site. Unusual and may reflect the calcification of his tracheal rings with age such that they did not remodel over time as happens in the majority of cases. These were carefully removed under direct visualization with a curved rongeur. We were able to evaluate with our finger that the edges were significantly smoothened. We were able to easily change his trach tube to a Shiley 6 XLT Proximal which had been difficult in the past.

10/13/2009 • Bronchoscopy with lavage done for pneumonia

10/20/2009 – 11/04/2009 • Patient transferred back to Rehab • Weaning attempts for cuff deflation and voice training attempted with Speech • Patient unable to tolerate due to LOC

11/4/2009 - 11/13/2009 • •

Spontaneous trials done with T-Piece and cuff deflated, patient able to voice well. 11/13/2009 OTO consulted due to dysphagia Pooling of thick saliva in the supraglottis. Slight paresis of left arytenoid. But adduction and abduction present. Difficult to fully assess glottal closure secondary to secretion. Membranous vocal cords without obvious lesions.

11/17/2009 – 11/18/2009 • • • • •

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Shiley 6 XLT Proximal Cuffless Unable to tolerate capping Tolerates PassyMuir Valve Overnight has SOB and poor ABG OTO - does have good vocal fold motion, but there is significant pooling in the piriform sinuses with reflux overflow into the larynx and secretions coming in and out of the larynx with each respiration. Shiley 6 XLT Proximal Cuffed placed and back on ventilator due to SOB and desaturation.

12/1 to Present Day • Shiley 6 XLT Proximal Cuffed was the airway of choice for AC.

What caused all of these airway problems?

Tracheobronchopathia Osteochondroplastica: A Rare Large Airway Disorder

Tracheobronchopathia osteochondroplastica (TO) is a rare disorder of the large airways characterized by the development of submucosal cartilaginous and bony nodules. The nodules involve the anterior and lateral walls and typically spare the posterior membranous wall. The clinical presentation of TO is variable and ranges from incidental diagnosis in asymptomatic patients during workup or management for unrelated medical problems, to devastating disease with central airway obstruction. Bronchoscopy remains the gold standard for diagnosing this condition. Radiographic studies play an important role in suggesting the diagnosis of TO and in the follow-up of this condition. The treatment of TO is usually symptomatic. with emphasis on the management and prevention of recurrent respiratory infections. Bronchoscopic or surgical treatment is usually reserved for symptomatic patients with severe airway narrowing and airflow obstruction.