|Year : 2007 | Volume
| Issue : 2 | Page : 148
Cricothyrotomy can be hazardous in a difficult airway scenario
M.D., Resident Medical Officer/ Clinical Tutor, Department of Anaesthesiology, N. R. S. Medical College, Kolkata, West Bengal, India
|Date of Acceptance||28-Feb-2007|
|Date of Web Publication||20-Mar-2010|
75/2, Harish Chatterjee Street, Bhowanipore, Kolkata, West Bengal- 700025
Source of Support: None, Conflict of Interest: None
Difficult and compromised airway poses a significant challenge to the anaesthesiologist. The following is a report of management of a case of difficult airway caused by injury of a prior deliberate acid ingestion. A previous uneventful anaesthetic course gave us a false sense of security while proceeding with the next surgical procedure under anaesthesia. After administration of neuromuscular blocking agent, mask ventilation became increasingly difficult and under direct laryngoscopy, visualization of glottis revealed gross fibrosis with no opening visible at all. It was a 'cannot intubate, cannot ventilate (CICV)' scenario. Percutaneous transtracheal jet ventilation (PTJV) also could not be set up as canula could not be negotiated. Surgical ('stab') cricothyroidotomy allowed rapid restoration of ventilation and oxygenation in this CICV situation but not without its complications and compromised airway was imminent. Surgical airway in the form of definite tracheostomy offered the only solution and complications averted.
Keywords: Anticipated difficult airway, Cricothyroidotomy, Tracheostomy, Cannot intubate, Cannot ventilate
|How to cite this article:|
Ray R. Cricothyrotomy can be hazardous in a difficult airway scenario. Indian J Anaesth 2007;51:148
| Introduction|| |
Difficult and compromised airway poses a significant challenge to the anaesthesiologist. Among all sorts of difficult scenarios what anaesthesiologists still dread most is the "cannot intubate, cannot ventilate" scenario. Such a situation of compromised airway is sufficiently central and transtracheal ventilation, tracheostomy or similar surgical airway is required and these are not without their attendant risks. Anaesthetic management of a case is described in the following report where complications arose in a case of anticipated difficult airway which were successfully managed.
| Case report|| |
A 20year old male patient, weighing 55 kg, with height of 1.65 m with prior history of deliberate acid ingestion presented with inability to eat. He also developed respiratory distress after this episode. For feeding problems, feeding gastrostomy was done under monitored anaesthetic care with analgesic dose of ketamine and local anaesthetic infiltration and supplemental oxygen. This anaesthesia course was uneventful. The patient was advised indirect laryngoscopy but it was not possible because of inability of tongue protrusion.
In order to assess the extent of esophageal injury, esophagoscopy with a trial of insertion of an esophageal bougie, if possible, was planned by the surgeon. After detailed discussion, taking into account the previous uneventful anaesthetic management, the case was taken up.
The patient was thoroughly evaluated at preanaesthetic checkup. On examination, the patient was found to be cooperative but was unable to phonate properly and unable to swallow saliva but did not drool. The patient was breathless at rest with stridor and preferred sitting posture. Accessory muscles of respiration were active. He was tachypnoeic with respiratory rate 25 b.p.m, pulse 120 beats/ min, blood pressure 130/80 mmHg and SpO2 94% in room air.
Mouth opening was restricted to two fingers with difficulty in tongue protrusion. Mallampatti grade was IV, both neck flexion and extension was restricted, but range of movement was greater than 90°. Skin over the neck had a leathery feel. Trachea was central and cartilages were palpable. Difficult airway was anticipated.
Difficult airway cart was made ready with different types and sizes of laryngoscope blades and endotracheal tubes, jet injector, and emergency cricothyroidotomy and tracheostomy set.
The patient was preoxygenated, premedicated with inj. glycopyrrolate 0.2mg IV. Monitoring included ECG, pulse oximeter and NIBP. Inj. ketamine 1.5 mgkg -1 IV was given slowly. Adequacy of face mask ventilation was checked on induction. Despite some resistance to positive pressure ventilation, chest expansion was noted.
After induction, inj. succinylcholine 1 mgkg-1 was administered. Mask ventilation became increasingly difficult. After 1 minute, under direct laryngoscopy, intubation with a 7.0 mm ID endotracheal tube failed. The whole glottis was seen distorted, fibrosed and hardly any opening was seen. Vocal cords were shrunken and adherent in the midline. Bag and mask ventilation became impossible and a second attempt of introduction of a smaller ETT (5.0 mm ID) also failed. Thorough suctioning of airway was done but ventilation was impossible. It was a "cannot intubate, cannot ventilate" scenario and the patient started desaturating.
Cannula cricothyroidotomy was tried but cannula could not be negotiated owing to tough skin conditions. The patient became grossly cyanosed and arrhythmias developed. Immediately an incision was made over the same cricothyroid area using a scalpel and a 5.0 mm ID uncuffed endotracheal tube was inserted and Sanders injector was connected to a wall outlet that delivered oxygen at 4 bars and ventilation started. Chest expansion was noted and the patient gradually turned pink, arrhythmias resolved and Sp02 rose to 100%. The whole procedure took four minutes from the time, injection of succinylcholine was given. In another five minutes, spontaneous respiratory efforts returned.
But the wound bled profusely. Bleeding into ET tube required repeated suctioning and airway compromise was imminent. Ligation of bleeding vessels around the cricothyroidotomy site failed to stop bleeding. Suctioning of endotracheal tube was done repeatedly with removal of blood clots and in the mean time definitive tracheostomy was done well below the cricoid cartilage and airway secured and thereafter haemostasis was achieved.
Esophageal instrumentation was postponed. The patient was followed up in the recovery room, fully conscious, well oriented, and alert, with no respiratory distress, quietly breathing, haemodynamically stable and SpO2 99% in room air. The patient was doing well with tracheostomy.
| Discussion|| |
Securing and maintaining a patent airway remains one of the fundamental responsibilities of an anesthesiologist. Caplan et al , found that among main mechanisms of injury resulting in three-fourths of adverse respiratory events, the incidence of inadequate ventilation was as high as 38%. Benumof and Scheller  estimated that up to 30% of deaths attributable to anaesthesia are caused by the inability to successfully manage the difficult airway. And central to this management is formulation of a thorough plan using the ASA Difficult Airway Algorithm as a guide. ,,,,
We observed in this case that difficultly in face mask ventilation may unfold after administration of muscle relaxant not apparent till spontaneous effort is abolished. Also PTJV may not offer any solution as cannula introduction failed and stab cricothyrodotomy also proved to be hazardous owing to uncontrolled bleeding and resultant compromised airway. Formulation of a thorough plan using difficult airway algorithm could only help avoid catastrophes.
Indeed, maintenance of spontaneous ventilation and awake intubation of trachea when a difficult airway is recognized have always been stressed. ,,, But Conacher et al  has pointed out that local anaesthesia approaches for securing airway and gaseous inductions are usually contraindicated in cases of upper airway compromise as the risk of precipitating a life-threatening coughing fit is very high.
The use of neuromuscular blocking agents for facilitating airway access is not without its risks. During spontaneous ventilation, the larger airways are supported by negative intrathoracic pressure, which decreases with diminution/cessation of spontaneous ventilation. Furthermore, the functional integrity of the supraglottic airway requires coordinated tone in the patency-maintaining muscles. With administration of NMBAs this mechanism is lost and assisted bag-and-mask ventilation becomes difficult. So, neuromuscular blockade in such patients with marginal airway may lead to total airway obstruction,  just as what happened in our case.
Fiberoptic intubation is an excellent choice, but in such a case of airway compromise, this is likely to be unsuccessful as it takes a long time for manipulation. Blind techniques are contraindicated, so are LMA and Combitube. Transtracheal jet ventilation (TTJV), cricothyroidotomy, and tracheostomy are the only options left. 
Cricothyroidotomy (cannula/surgical) and TTJV are the techniques of emergent oxygenation and ventilation and are useful in this challenging "cannot intubate, cannot ventilate" scenario. The complication rate varies from 6% to 8% for elective cricothyroidotomy to 10% and 40% for emergency cricothyroidotomy. , Percutaneous catheter placement through the cricothyroid membrane i.e. canula cricothyroidotomy requires the least amount of skill and is the quickest to perform.  Friedman et al , demonstrated that percutaneous dilational technique is faster with fewer complications than surgical tracheostomy.
In our case, cannula introduction failed. Hence surgical (stab) cricothyroidotomy and tracheostomy remained the only possible option. 
In Conventional transtracheal ventilation,  in a completely patent upper airway, the Venturi effect contributes 75% of the gas delivered to the lungs. Smith et al  recognized that obstructive lesions above the larynx can retard expiration and predispose to gas trapping and barotrauma and maintenance of upper airway patency is vitally required. , But in our patient, glottis was fibrosed and hardly any opening could be seen.
Owing to the potential for barotrauma, conversion to more secure techniques of airway maintenance is paramount.  Associated complications of transtracheal ventilation include soft-tissue emphysema, prolonged expiration, arterial perforation, esophageal puncture, bleeding, haematoma. ,,, In our case, what we faced was uncontrolled bleeding and airway management required assessment and treatment within rigid time constraints. Surgical airway in the form of definite tracheostomy offered the only solution to avert complications.
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