Morbidly obese pt for Trach exchange

[excalibur]

33 y/o DM with bad OSA that required trach placement. Pt is 5'10" and 300#. The trach appears to be malfunctioning possibly occluded per CT surgeon. Normally he does trach exchanges in the office but for this pt, he would prefer to do it in the OR.

Surgeon says that it is possible that upon removal of the trach, he may not need to replace it as he believes the trach is occluded, and the pt has been breathing fine from his upper airways for a while now.

I prepare all sorts of airway equipment. I provide 0.5 mg of Versed and 25 mcg of fentanyl. Upon CT surgeon trying to remove trach, pt is grimacing in obvious pain, and surgeon cannot remove trach. Surgeon says it is pretty fixed and will need more force to remove, but yes we will need more sedation. He states though he fully understands our possible concerns for increased amounts of sedation or even GA. He states he is fine with whatever plan we choose. He also states that it is possible that when he removes the trach, he cannot guarantee that there will not be bleeding that may need cautery.

How would you proceed?

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[deleted126335]

Alot wold depend on my impression of the patient, the surgeon's facility with this procedure and if the trach was patent. Hook it up to the circuit and see if air is flowing through it or is he breathing around it from above? I am assuming that this is a mature trach that has been there for a while.
I wouldn't have given any narcotics in this circumstance. Maybe a slug of ketamine with a kiss of midazolam. Depending on my impression and if patent, I would consider elevating the head of bed and oxygen/air/sevo inhalational analgesia via trach.

 

[excalibur]

The trach is not patent. Surgeon can't pass suction through. Pt coughs and bucks at any attempt to do so. Trach is not easily removable either, and pt in pain upon slight tugging.

 

[Agast]

The trach is not patent. Surgeon can't pass suction through. Pt coughs and bucks at any attempt to do so. Trach is not easily removable either, and pt in pain upon slight tugging.

Sounds like it's stuck to something, if tugging on it is painful to the patient I don't think forcing it out is a great idea. I'd convert to GA (with sux and backup airway equipment) and give optimal surgical conditions because that thing is getting cut out eventually. He's fat but not necessarily a difficult airway.

 

[nap$ter]

plug trach with tegaderm.

LMA.

if it doesn't pop right out stick a tube in; confirm the cuff is past the trach c fob.

 

[Idiopathic]

ett from above, this sounds like it will be a real case

 

[Southpaw]

ett from above, this sounds like it will be a real case

agreed. what was the indication for the original trach? does he appear to be a difficult airway?

 

[VentdependenT]

agreed. what was the indication for the original trach? does he appear to be a difficult airway?

This case is not emergent. stop. get an ENT consult. This is not a usual trach exchange and the CT surgeon will fook it up.

At the minimum he needs video laryngoscopy with local before you put his ass to sleep and cant pass a tube beyond the trach...

 

[Idiopathic]

i think you could probably hook up the trach to the circuit, hold the patients nose and see if he could breath himself down, after which you could just FOI with a tube from above, this way you have some security if/when there is a lot of bleeding. if he cant breathe through the trach, i think you topicalize and do an awake FOI. ive had a few of these that were miserable because they were granulated in and almost impossible to get out and get back in, lots of bleeding, etc. would be nice to be able to have the patient asleep

 

[excalibur]

This case is not emergent. stop. get an ENT consult. This is not a usual trach exchange and the CT surgeon will fook it up.

At the minimum he needs video laryngoscopy with local before you put his ass to sleep and cant pass a tube beyond the trach...

Small community hospital. No ENT in house. Occasionally ENT's from neighboring hospital will come in for scheduled cases, but there is no in house ENT attending on call.

 

[VentdependenT]

Small community hospital. No ENT in house. Occasionally ENT's from neighboring hospital will come in for scheduled cases, but there is no in house ENT attending on call.

Well good luck. I would still look with Fiberoptic through the nose before i let this dude yank out a trach for which neither you nor he knows the etiology of.

 

[Idiopathic]

Well good luck. I would still look with Fiberoptic through the nose before i let this dude yank out a trach for which neither you nor he knows the etiology of.

the etiology is OSA

 

[VentdependenT]

the etiology is OSA

The etiology of why its "stuck"

 

[deleted126335]

The etiology of why its "stuck"

dried mucus which turned to rubber cement most likely.

 

[jwk]

Small community hospital. No ENT in house. Occasionally ENT's from neighboring hospital will come in for scheduled cases, but there is no in house ENT attending on call.

Small community hospital with a CT surgeon and no ENT?

 

[excalibur]

Small community hospital with a CT surgeon and no ENT?

From my understanding many years ago the ENT's had a bit of a falling out with either administration or with some restructuring. So they packed up and went to the neighboring smaller hospital. They come every 3 weeks or so to do some peds T+A's and ear tubes, but you don't pick up the phone and consult ENT at our hospital.

Yes, we have 2 CT surgeons and do CABG, valves, AAA, thoracotomies, etc.

 

[pgg]

Sounds like fun. I think I'd preO2 to ETO2 of 85+, inhalation induction vs ketamine with a bit of Versed, maintain SV, gentle attempt at ETT placement +/- Glidescope. If the tube doesn't pass easily, as it probably won't if the trach is cemented in there, plan B is a proseal LMA. When airway is secured (even if it's just the LMA) reduce FiO2 so electrocautery doesn't set the patient on fire. Avoid opiates and ask the surgeon to use some local prior to wakeup.

 

[Dwindlin]

I love reading through the cases you guys post, but it does have the unfortunate side effect of reminding me I still have a full year until I get to the OR doing what I actually enjoy.

 

[fakin' the funk]

You have time. This is elective. Do some investigation. Plug the trach with your finger and see how the patient does. Hook up your circuit to the trach and see if you get etCO2. Pass suction catheter through trach. Easy enough.

If you wanna get fancy, you can topicalize with minimal/no sedation and fiber through mouth or nose or trach and check out larynx and trachea.

Assuming all is well and pt is breathing through a patent upper a/w, prop/sux/tube. Have CT surgeon eff around with trach. Keep FOB in room for case. Pt wakes up with trach, either same size or smaller, and all is good.

 

[imfrankie]

If trach ever becomes a patent one, put a small tube changer through it for safe keeping of a passage.

 

[excalibur]

Thanks for the replies.

I opted to go with AFOI. It just did not seem like a good patient to me to induce GA without securing the airway.

Nasotracheal intubation as the trach got pulled.

Pt did well when trach was removed.

As someone mentioned in a previous post, the problem was that there was dried mucus in the trach which now became like a hardened plaque.

Thank you for the replies