Tracheal Stenosis

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Carabas

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Situation the other day:

Called to the floor for a respiratory code. Patient with known tracheal stenosis, hybercarbic (Co2 in the 90s) on 10L non-rebreather. BP is ~100/50, O2 sat at ~90%. Floor team wants him intubated. How do you proceed?
 
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If it's really a code with impending arrest, fent, lido atomizer, Glidescope look with small tube while prepping for Cricothyrotomy. If he's completely uncooperative, and about to arrest you just have to bite the bullet and go after attempting bag mask support. If you have time and an electronic anesthesia record, take 2 minutes to take a look first and consider better prep with precedex, etc.
 
Floor team can eat a d***. You need a lot more info. While you're getting that, ENT stat and go to the OR
 
Why the glidescope? What indication do we have that the airway is difficult? Cricothyrotomy might just access the trachea above the stenosis and do you no good. Why does he have the stenosis and where is it?

A room on the ward isn't the best place to do anything. This looks urgent, not emergent.
 
The glide can give you a good view down the hole to try to see where the stenosis is. It's a hell of a lot less stimulating than getting a 1/2 sedated view with a miller 2. Obviously, if it isn't really a code or even emergent, ENT standby in the OR with full gear is prudent after a record review.
 
Some more info:

ABG before being called was 7.15/90/90/28. Known history of tracheal stenosis secondary to trach in the past, s/p tracheal dilation. Extent of stenosis unknown. No reason to believe it's a difficult airway, thin patient and previous history of an easy intubation prior to the stenosis and trach.

Does that change anything as far as your urgency PGG?
 
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Tube him with ENT backup in the OR. He needs an airway to blow off the CO2 and correct his resp acidosis. Hypoxia isn't going to kill him right this second but his acidosis may. You want to have the ability to jet ventilate if needed emergently and this can be done in the OR with a rigid bronch and the bronch can diagnose the area of stenosis. After he is intubated the next thing would be to plan for either permant trach or trach reconstruction depending on where the stenosis is.
 
Carabas said:
Some more info:

ABG before being called was 7.15/90/90/28. Known history of tracheal stenosis secondary to trach in the past, s/p tracheal dilation. Extent of stenosis unknown. No reason to believe it's a difficult airway, thin patient and previous history of an easy intubation prior to the stenosis and trach.

Does that change anything as far as your urgency PGG?
Click to expand...

pH 7.15 IMO is still a get-this-done-in-the-next-30-minutes type scenario, not the next 2 minutes.

It would be really helpful to know what kind of dimensions you are dealing with. 10mm vs 5mm makes a difference obviously. Any semi recent CT scan would be money. There is likely also tracheomalacia

That said, would still bring to OR, sit up, topicalize, zero sedation, a little IV glycopyrrolate, and see what the trachea looks like with FOB. Assuming you can get at least a 5.0 in, go for it.

It doesn't address the fact that this person has this stenosis, and despite therapy has these life threatening sequelae of it. Most likely has some other pulmonary or extrapulmonary process like sepsis going on also, that might be reversible. Once this person's intubated (and maybe before) you can have some goals of care discussions. See what your interventionalist colleagues (ENT/Int.Pulm/CT surgery) can offer based on a new CT.
 
Let me guess - this was at 2am too?

I agree with above that we have a little time but not much. So start by reviewing available imaging and get the surgeon that did the dilatation on the phone. If the dilatation was fairly recent, he should be able to give you all the info you need.
 
Is his acute respiratory failure caused by the stenosis or is it something else like COPD exacerbation?
Looking at the patient and observing the breathing pattern will clarify that and could change the way you approach it
 
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I still wouldn't expect a glidescope to get me a useful view below the vocal cords.

A pure respiratory acidosis, in the absence of other nastiness, is very well tolerated, even down to the 7 range. That pH won't kill him, though the hypercarbia may well make him less cooperative and introduce some somnolence and upper airway obstruction, which won't help.

Feels like there's still something missing from the picture. His trachea was stenosed yesterday, right? What's different now? Does he have a respiratory infection or acute issue of another nature? Surely if this is known stenosis, he has imaging from sometime. Why's he in the hospital in the first place?

Agree with fakin the funk's plan.
 
I actually had a similar case come to me when I was covering our CVICU as a fellow. My patient was an obese 65 YO F who had been trached several times in the past for some sort of myopathy-related respiratory failure. She had was getting hypercarbic on the ward and was brought to our unit with similar gases (though CO2 was only in the 70s).

We called ENT for backup but they said she wasn't a candidate for another tracheostomy. My preference was to intubate awake and so I had several ETTs ready prepped from 5 to 6.5. She was given 200 mcg of glyco and had a tsp of 5% lido applied to to her tongue while I ran in a loading dose of dexmedetomidine. I then used a MAD to spray 2% lido over her tonsilar pillars and had her breathing in with sprays to topicalize her upper airway. Ended up having to use a pediatric scope and guided a 6.0 ETT down.

In your case, I think keeping them spontaneously breathing is best and I agree that the glidescope is less stimulating than usual DL as you don't have to lift up the tongue vigorously to see the cords if you were going to have an awake look. Use your favorite topicalization technique and it should work.
 
If the respiratory failure is PURELY from the stenosis, it's real bad and may need a rigid bronch to stent it when he's asleep. I agree there's likely some other process going on though.
Is there a reason they haven't tried non-invasive PPV?
Also, unless the patient just got there, someone should have warned you guys about this person already.
 
Information is vague, why not BiPap? Depends on reason for hypercapnia obviously. So more information.
 
Planktonmd said:
PO2 of 90 on 100% fio2 is oxygenating ok?
Click to expand...
"ok" is a relative term. 🙂 An SpO2 of 90% (PaO2 of 60) isn't great but it's not life threatening.

You do bring up a good point - even if 10 lpm by face mask isn't a FiO2 of 100%, it's a lot more than 21% and this guy has a significant A-a gradient. His A-a gradient can't be explained away with just hypoventilation secondary to tracheal stenosis, so there's something else going on too. Could be as simple as some atelectasis/shunt from breathing through his straw of a trachea, maybe he has COPD and lives at 90% because of a diffusion defect, maybe he's got mucus plugs, maybe he has pneumonia and that's why he's having his crisis today instead of yesterday.

As a rule, widened A-a gradients can't be fixed by increasing FiO2, so he may do just as well with a FiO2 of 40% as he's doing on 80%. Heliox might help with ventilation and give you more time to figure out why his oxygenation is only "ok". 🙂
 
Carabas said:
Patient with known tracheal stenosis, hybercarbic (Co2 in the 70s) on 10L non-rebreather. BP is ~100/50, O2 sat at ~90%. Floor team wants him intubated. How do you proceed?
Click to expand...

I can give you the academic answer but in all honesty this is the way im gonna do it:

Tracheal stenosis = ENT problem
My job is to insure patient doesnt die before ENT makes their assessment.

Inhouse call ENT: Easy. Let them make a quick assessment, agree on a plan, and take it from there with all the bat airway gadgets.

Outhouse call ENT (my current gig): makes my job a bit tougher but Ill still keep it simple.
Step 1: Smoothly call whatever backup anesthesia personal you have available and make sure they bring a difficult airway cart. Then call any ol surgeon to be around, but make sure they dont talk or lose their ****. They dont even need to be physically in the room, just "around".
Step 2: Keep calm and DO NOT make it look like its a big deal. This is very very important. I cant stress that enough.
Step 3: Have someone who knows what they are doin assist bag the patient every time they take a breathe.
Step 4: Before reaching for your bat gadgets, casually take out these 3 items out of your difficult airway cart: LMA#4, LMA#5, and 4.0 cuff tube. If patient becomes hypoxic, try each one of those items in that exact order. If all 3 fail, call that surgeon in the room and take one last attempt with a bat gadget before proceeding to an invasive airway. However if pt maintains sats, DO NOT do anything with the airway.
Step 5: Make some jokes, laugh a little, and keep overall stress level very very low.. All while using your bat detective skills to get a little history.
Step 6: ENT makes it there, let them make an assessment. Agree on a plan and proceed with the bat gadgets.

Chance of patient living will usually be pretty high.

How to severely decrease patient's chance of living:
A) Losing your **** or becoming inpatient. Staff stress level increases letting your run of the mill **** show spiral into a cluster f*ck. Things will go sour very fast, you can bet on that. This usually ends with bloody airways, yelling over each other, jamming whatever you can in the airway, M&M lecture preparation.
B) Walk in with some serious swagger and think you are mr know it all professor airway. Talking about PaO2 dissociation curves, talking down to RT, looking at CT scans and proceeding with fiberoptics and retrograde intubations because who needs ENT. Again this usually results in bloody airways, yelling over each other, jamming whatever you can in the airway, M&M lecture preparation.
C) Allow loud mouth outspoken nurses, CRNAs, other anesthesiologists derail the overall calmness and push you into either A or B.

So my point... I will do nothing without an ENT assessment unless I absolutely have to... Once I have that, then we can discuss this case further.
 
pie944 said:
Information is vague, why not BiPap? Depends on reason for hypercapnia obviously. So more information.
Click to expand...
I was wondering this as well. Positive pressure could help stent the airway and buy you time to get the patient to the OR for a proper assessment. If you've got the right equipment, you could theoretically even run a combination heliox+BiPAP setup that would maximize ventilation and hopefully keep your airway intact. This all really depends on the underlying pathology of the patient though- tracheal stenosis makes me think they had a long vent course with tracheostomy in the past (by far the most common type of patient I'd deal with tracheal stenosis in), so either had a complicated ICU course, severe pre-existing pulmonary disease, or something else that'd land them a long-term ride on a vent. Some conditions are far less condusive to BiPAP- a patient with severe asthma would seriously concern me in this scenario, for instance.
 
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pgg said:
"ok" is a relative term. 🙂 An SpO2 of 90% (PaO2 of 60) isn't great but it's not life threatening.

You do bring up a good point - even if 10 lpm by face mask isn't a FiO2 of 100%, it's a lot more than 21% and this guy has a significant A-a gradient. His A-a gradient can't be explained away with just hypoventilation secondary to tracheal stenosis, so there's something else going on too. Could be as simple as some atelectasis/shunt from breathing through his straw of a trachea, maybe he has COPD and lives at 90% because of a diffusion defect, maybe he's got mucus plugs, maybe he has pneumonia and that's why he's having his crisis today instead of yesterday.

As a rule, widened A-a gradients can't be fixed by increasing FiO2, so he may do just as well with a FiO2 of 40% as he's doing on 80%. Heliox might help with ventilation and give you more time to figure out why his oxygenation is only "ok". 🙂
Click to expand...
Actually the OP said the PaO2 is 90 (not the saturation) and PaCo2 is 90, so with my sincere apologies to those whom I offended by saying a non rebreather with 10L/min is FIO2 of 100%, please humor me and agree that this patient is recieving a very high FIO2 whatever that FIO2 migt be.
This patient with this very high FIO2( which is certainly not 100%) is able to only oxygenate to a PaO2 of 90, which is as you so eloquently stated a high Aa gradient and is not OK, and cannot be explained simply by tracheal stenosis.
This is what makes me think that this guy is probably in acute respiratory failure on top of chronic failure with chronic CO2 retention.
The stenosis is unlikely the only cause but could be a controbuting factor, so your Heliox is not relevant, actually Heliox is almost never relevant in my opinion.
This patient needs to be treated with non invasive ventilatory support while working on diagnosing and treating the underlying etiology of his respiratory deterioration.
The worst we can do is intubate this trachea unless it's the last resort.
 
RxBoy said:
I can give you the academic answer but in all honesty this is the way im gonna do it:

Tracheal stenosis = ENT problem
My job is to insure patient doesnt die before ENT makes their assessment.

Inhouse call ENT: Easy. Let them make a quick assessment, agree on a plan, and take it from there with all the bat airway gadgets.

Outhouse call ENT (my current gig): makes my job a bit tougher but Ill still keep it simple.
Step 1: Smoothly call whatever backup anesthesia personal you have available and make sure they bring a difficult airway cart. Then call any ol surgeon to be around, but make sure they dont talk or lose their ****. They dont even need to be physically in the room, just "around".
Step 2: Keep calm and DO NOT make it look like its a big deal. This is very very important. I cant stress that enough.
Step 3: Have someone who knows what they are doin assist bag the patient every time they take a breathe.
Step 4: Before reaching for your bat gadgets, casually take out these 3 items out of your difficult airway cart: LMA#4, LMA#5, and 4.0 cuff tube. If patient becomes hypoxic, try each one of those items in that exact order. If all 3 fail, call that surgeon in the room and take one last attempt with a bat gadget before proceeding to an invasive airway. However if pt maintains sats, DO NOT do anything with the airway.
Step 5: Make some jokes, laugh a little, and keep overall stress level very very low.. All while using your bat detective skills to get a little history.
Step 6: ENT makes it there, let them make an assessment. Agree on a plan and proceed with the bat gadgets.

Chance of patient living will usually be pretty high.

How to severely decrease patient's chance of living:
A) Losing your **** or becoming inpatient. Staff stress level increases letting your run of the mill **** show spiral into a cluster f*ck. Things will go sour very fast, you can bet on that. This usually ends with bloody airways, yelling over each other, jamming whatever you can in the airway, M&M lecture preparation.
B) Walk in with some serious swagger and think you are mr know it all professor airway. Talking about PaO2 dissociation curves, talking down to RT, looking at CT scans and proceeding with fiberoptics and retrograde intubations because who needs ENT. Again this usually results in bloody airways, yelling over each other, jamming whatever you can in the airway, M&M lecture preparation.
C) Allow loud mouth outspoken nurses, CRNAs, other anesthesiologists derail the overall calmness and push you into either A or B.

So my point... I will do nothing without an ENT assessment unless I absolutely have to... Once I have that, then we can discuss this case further.
Click to expand...
This is a fantastic post and so true!
 
To clarify a couple things, PaCo2 was in the 90s, not 70s as the first post said. I updated that subsequently.

All the history that was available was that patient had new onset cough and sputum production, no clear etiology for oxygenation and ventilation issues. I was just an extra pair of hands in this situation, but in hindsight I truly believe RxBoy's explanation would have been the most appropriate route. Unfortunately, that's not exactly what happened.

ENT resident is in house so they were called to bedside for standby. Attending decided that there wasn't sufficient time to move to the OR and wanted to intubate at bedside. Induced with etomidate and roc (not my choice), grade I DL view. 7.0 -5.0 ETT could not be passed. Still able to mask ventilate, though it's not that easy and sats are sitting in the upper 80s.

What do you do know?
 
Carabas said:
Situation the other day:

Called to the floor for a respiratory code. Patient with known tracheal stenosis, hybercarbic (Co2 in the 90s) on 10L non-rebreather. BP is ~100/50, O2 sat at ~90%. Floor team wants him intubated. How do you proceed?
Click to expand...

Been there done that, patient dead (not acutely but several days later). My situation was a morbidly obese ICU patient with previous trach (now decannulated) for tracheal stenosis that ICU team attempted to intubate but couldn't and then called me and ENT. I came along and pt was satting in 70s/80s and not responsive but still spontaneously breathing. I was able to get a 5.0 ETT through the vocal cords with glidescope but couldn't advance any further. Basically used it as a sort of LMA to help ventilate while ENT tried to get trach. They couldn't. Stenosis had worsened. Eventually they got airway access more distal but not easy and took a long time. Pt had several rounds of CPR during all the messing around and ended up having care withdrawn a week later.

Moral of the story? Tight enough tracheal stenosis and there ain't squat you can do from above other than support spontaneous respiration as much as possible. Other moral of the story? ICU team sat way too long and screwed around way too long on a patient they had no hope of securing airway. Pt should've been brought to OR for operative airway at least 1 day prior before circling the drain.
 
Well, that's an excellent example of what not to do. It's good to see these things as a resident so you don't do them as an attending. You now have a good story that starts, "You're not going to believe what they did at the U"...
Since I'm sure he has all the toys in his not so emergent bedside airway cart, use a peds fiber hooked to suction to suck out the blood from the brilliant idea of attempting to put a 7.0 and 6.0 tube in, then switch to O2, put the fiber on the carina, and give a bit of O2 there while you ease in the 4.0 cuffed tube that they should have used right after starting with a 5.0.
 
Carabas said:
To clarify a couple things, PaCo2 was in the 90s, not 70s as the first post said. I updated that subsequently.

All the history that was available was that patient had new onset cough and sputum production, no clear etiology for oxygenation and ventilation issues. I was just an extra pair of hands in this situation, but in hindsight I truly believe RxBoy's explanation would have been the most appropriate route. Unfortunately, that's not exactly what happened.

ENT resident is in house so they were called to bedside for standby. Attending decided that there wasn't sufficient time to move to the OR and wanted to intubate at bedside. Induced with etomidate and roc (not my choice), grade I DL view. 7.0 -5.0 ETT could not be passed. Still able to mask ventilate, though it's not that easy and sats are sitting in the upper 80s.

What do you do know?
Click to expand...
Stick an LMA, ventilate and wake him up, then place on BIPAP while you develop a better plan
 
I'll add one more thing, though I acknowledge it's hard for a junior resident, if you think that your staff is about to do something colossally stupid, like paralyze a patient that they probably will not be able to intubate, please speak up and at least tactfully suggest that it might not be the best plan. Bonus points for offering a better one. I did this as a resident more than once, and I honesty believe that it saved lives or at least prevented probable (and predictable) serious morbidity.
The worst thing that happens is they disagree and take the road less travelled (for a reason) and burn their own house down. Consider it a preemptive "I told you so." I'm often not the smartest guy in the room but in a true light your hair on fire and run around screaming emergency I am ice cold, calculating and deliberate. That is a trait that not all anesthesiologists posses, particularly ones that spend 1/2 or more of their time in non clinical pursuits and much of their clinical time sheltered in mundane cases where they can continue to work on administrative and research matters.
 
IlDestriero said:
The glide can give you a good view down the hole to try to see where the stenosis is.
Click to expand...

Disagree, I don't think you will be able to see stenosis at all.

pgg said:
I still wouldn't expect a glidescope to get me a useful view below the vocal cords.
Click to expand...

Agree.
 
This was billed as a code call for an apparently crashing patient with "tracheal stenosis". That could really be anything obstructing the airway until proven otherwise by a record review. The people that called the code overnight are usually panicked and only have half the facts, at best. This Is in contrast to the primary team that consults you for a controlled airway during the day that has 99.9% of the story right. The sedated, spont vent glide will determine if you even have a chance at a DL. When you're in there struggling, they'll say something like, oh yeah I think he had neck radiation for some cancer a few years ago... Oh yeah, that's why he got a trach, some mass. It's gone though...
Later we learned that it wasn't really emergent, hx of trach with stenosis at former trach site, (so actually tracheal stenosis). etc. that's a different situation as they likely have a normal and accessible upper airway, like this guy did. And as an aside, you can get a fair view down a couple centimeters below the cords if you get what I call the "resident view" with the glide way too close to the glottis. I do many peds bronchs and you can often see the stenosis when they go down initially to watch them breathing and spray the cords. You can also likely watch the tube pass easier than with a standard DL to try see the depth that you're getting hung up or if you're knocking on the door with oversized tubes is causing trauma that is about to get you in serious trouble.
 
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RxBoy said:
I can give you the academic answer but in all honesty this is the way im gonna do it:

Tracheal stenosis = ENT problem
My job is to insure patient doesnt die before ENT makes their assessment.

Inhouse call ENT: Easy. Let them make a quick assessment, agree on a plan, and take it from there with all the bat airway gadgets.

Outhouse call ENT (my current gig): makes my job a bit tougher but Ill still keep it simple.
Step 1: Smoothly call whatever backup anesthesia personal you have available and make sure they bring a difficult airway cart. Then call any ol surgeon to be around, but make sure they dont talk or lose their ****. They dont even need to be physically in the room, just "around".
Step 2: Keep calm and DO NOT make it look like its a big deal. This is very very important. I cant stress that enough.
Step 3: Have someone who knows what they are doin assist bag the patient every time they take a breathe.
Step 4: Before reaching for your bat gadgets, casually take out these 3 items out of your difficult airway cart: LMA#4, LMA#5, and 4.0 cuff tube. If patient becomes hypoxic, try each one of those items in that exact order. If all 3 fail, call that surgeon in the room and take one last attempt with a bat gadget before proceeding to an invasive airway. However if pt maintains sats, DO NOT do anything with the airway.
Step 5: Make some jokes, laugh a little, and keep overall stress level very very low.. All while using your bat detective skills to get a little history.
Step 6: ENT makes it there, let them make an assessment. Agree on a plan and proceed with the bat gadgets.

Chance of patient living will usually be pretty high.

How to severely decrease patient's chance of living:
A) Losing your **** or becoming inpatient. Staff stress level increases letting your run of the mill **** show spiral into a cluster f*ck. Things will go sour very fast, you can bet on that. This usually ends with bloody airways, yelling over each other, jamming whatever you can in the airway, M&M lecture preparation.
B) Walk in with some serious swagger and think you are mr know it all professor airway. Talking about PaO2 dissociation curves, talking down to RT, looking at CT scans and proceeding with fiberoptics and retrograde intubations because who needs ENT. Again this usually results in bloody airways, yelling over each other, jamming whatever you can in the airway, M&M lecture preparation.
C) Allow loud mouth outspoken nurses, CRNAs, other anesthesiologists derail the overall calmness and push you into either A or B.

So my point... I will do nothing without an ENT assessment unless I absolutely have to... Once I have that, then we can discuss this case further.
Click to expand...
That's all well and good, but there are many who practice at places where ENT isn't ever coming.
 
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IlDestriero said:
That's all well and good, but there are many who practice at places where ENT isn't ever coming.
Click to expand...

That is true. However it is equally true that you may not be able to do anything with their airway from above except temporize the situation and buy some time until somebody can get surgical access. Tight enough tracheal stenosis is a surgical problem.
 
It's interesting to me that there was a rally for the glide scope early on in this thread.

The view is not the problem. This patient can die with a grade 1 view of the cords
 
Docuronium said:
It's interesting to me that there was a rally for the glide scope early on in this thread.

The view is not the problem. This patient can die with a grade 1 view of the cords
Click to expand...

I think it was mentioned as a way to obtain that view with little to no sedation/apnea given the less stimulating placement of the glidescope blade vs mac or miller DL. This would be my plan A, but I would have low threshold to take an awake but sleepy DL look. If I cant pass a small cuffed tube with either semi awake glide or DL, but I have a view, I would turn it over to ENT and just continue to assist spontaneous ventilation possibly with an LMA to obtain larger TVs. Mask/LMA with PPV would be a last resort. I would prefer to do this in the OR with my machine and ETCO2 monitor.
 
pgg said:
I wouldn't sedate this person at all.
Click to expand...
This.

I would in no way want to run the risk of respiratory depression in this person. Even our beloved dexmedetomidine carries with it a small risk of respiratory depression. That's just begging for a disaster with this person. Besides a pCO2 of 90 is probably offering all of the sedation this person can handle, anyhow.
 
IlDestriero said:
use a peds fiber hooked to suction to suck out the blood from the brilliant idea of attempting to put a 7.0 and 6.0 tube in
Click to expand...

IlDestriero said:
you're getting hung up or if you're knocking on the door with oversized tubes is causing trauma that is about to get you in serious trouble
Click to expand...

Back in residency a wise old attending once told me "In medicine the right answer is rarely if ever: Push Harder"
 
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