NM-355
A difficult airway, a 10 hour facial reconstruction, and you just sawed through my awake fiberoptically placed nasal tube?
1Jin C, 2Davis M, 3Webber A
1University of Rochester Medical Center, Rochester, NY, USA; 2URMC, Rochester, NY, USA; 3URMC Medical Center, Rochester, NY, USA
A 17 year old male with a history of prior awake fiber optic intubations (FOI) for difficult airway and difficult mask ventilation due to Treacher Collins Syndrome was scheduled for a 10 hour complex surgical reconstruction with both plastic and oromaxillary facial surgery. He had an uneventful awake nasal FOI, and the case progressed smoothly until hour 6 when a significant air leak was noted during the LeFort I osteotomy. We were able to ventilate the patient with extremely high flows (15 L) but the leak necessitated an intraoperative tube exchange . Surgery was stopped and after a discussion the surgeons determined they could not proceed with an oral ETT and thus we had to exchange the nasal tube for another nasal tube. The issues facing the exchange were as follows. 1) a side by side nasal tube exchange impossible because the unintubated choanae was atretic – evidenced on 3D CT reconstruction as well as noted during the initial FOI. 2) The airway was significantly bloody 3) Due to the patient’s anatomy we could not visualize the glottic opening with either a Glidescope or CMAC to witness the tube exchange 4) Blind nasal tube exchange with an airway exchange catheter is prone to complications including displacement of the exchange catheter which in this particular case would have been disastrous. The surgeons had a trach tray at the ready and another attending anesthesiologist was enlisted for the tube exchange.
At this point a small Williams airways was inserted into the mouth. The fiberoptic scope was loaded with a 6.0mm endotracheal tube (our backup airway) and introduced into the oropharynx. After approximately 20 minutes of scope maneuvering it was advanced into the glottis past the in situ nasal tube and advanced into the trachea until carina was visualized. A Cook airway exchange catheter was introduced through the nasal tube and intentionally mainstemmed into the right bronchus. We confirmed ability to ventilate with the exchanger prior to removing the nasal tube. Under direct visualization via the fiberoptic scope we were able to confirm that the exchanger was still in the trachea and had not been dislodged. A new 6.5 mm nasal RAE tube was then advanced over the airway exchanger and into the trachea under direct visualization. Its final position was confirmed via the scope, and end tidal CO2 and bilateral breath sounds were confirmed before removing the scope. Examination of the original tube revealed a laceration where the surgical saw had sliced through, just above the pilot cuff tubing. The patient’s vital signs remained stable throughout, and at no point did we have oxygen desaturations. The trachea remained free of blood and debris since the cuff and its pilot tubing were uncompromised.
Had the surgeons sawed through the nasal tube completely leaving us entirely unable to ventilate the situation would have been much more dire, and it is likely an emergency tracheostomy would have had to be performed. As things stood, we were able to rapidly troubleshoot various options and create a plan that was safe, controlled, and effective.
The surgery was completed without issue and the patient remained intubated at the end of the procedure. He was extubated post op day 2.
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