FAILED intubation, coupled with the inability to ventilate the lungs of an apneic patient by use of facemask, is a life-threatening emergency. Transtracheal jet ventilation (TTJV) is an established technique of providing emergency airway access and maintaining gas exchange in a cannot-intubate, cannot-ventilate situation. 1,2This is, however, a temporary measure, and it may be necessary to establish a definitive airway. The authors report a case in which emergency ventilation in a cannot-intubate, cannot-ventilate situation in the intensive care unit (ICU) was initiated with TTJV through an endotracheal cannula inserted below the cricoid cartilage. Airway access was secured by percutaneous tracheostomy performed over a guide wire inserted through the transtracheal cannula.
A 66-yr-old, 59-kg woman was brought to the ICU with severe airway obstruction from a large 8 × 10 cm, stony hard, lobulated tumor on both sides of the neck and crossing the midline. She was unresponsive and cyanotic, with slow, gasping respirations, Her heart rate was 70 beats/min and Spo2was 70%. Urgent tracheal intubation was performed by the consultant intensivist. Laryngoscopy allowed us to easily visualize the larynx; however there was considerable resistance to passage of the endotracheal tube beyond the vocal cords. The airway was secured with a 6.0-mm cuffed endotracheal tube and mechanical ventilation was initiated. After 1 h, the patient was conscious and responsive, her Spo2had increased to 98%, and she was hemodynamically stable. She received chemotherapy for a presumptive diagnosis of lymphoma. The plan was to extubate the trachea, if the tumor proved to be responsive to chemotherapy. The patient also received enteral feeds via a nasogastric tube.
Five days later, there was minimal reduction in the size of the tumor. That afternoon, the patient self-extubated. There was considerable bleeding from the oral cavity. At the same time, she vomited. Oral suction was performed, and 100% oxygen was given by facemask and a self-inflating bag with a reservoir. Her saturation concentration decreased to 85%. Direct laryngoscopy failed to visualize the larynx because of profuse bleeding, the presence of vomitus, and distorted anatomy. The patient then became apneic, and bag and mask ventilation proved to be impossible, despite insertion of an oropharyngeal airway. Her Spo2decreased to 65%. We then decided to perform TTJV.
On extension of the neck, the cricoid cartilage could be identified with some difficulty. The cricothyroid membrane was covered by the tumor and could not be identified; however, the tumor mass was not as prominent about a finger's breadth below the cricoid cartilage. By this time Spo2had decreased to 40%. A 14-gauge needle was inserted at the first attempt into the trachea, below the cricoid cartilage. Jet ventilation was delivered by a manual jet injector connected to the wall oxygen outlet, with the pressure reduced to 40 psi. There was effective expansion of the chest; simultaneously, air was noticed blowing out from the pharynx and mouth. Manual jet ventilation was continued to produce adequate chest expansion, at a rate of 10–12 breaths/min. The patient's Spo2increased to 95%.
We then proceeded with a percutaneous tracheostomy using the Griggs technique 3and the SIMS Portex (SIMS Portex Limited, Hythe, Kent, UK) kit. 4A guide wire was passed through the tracheal cannula, into the trachea, and the cannula was removed. A skin incision was made around the guidewire. A short tapered dilator was smoothly introduced into the trachea over the guide wire. The guide wire was removed, the jet injector was then connected to the hub of this dilator, and jet ventilation was given for 2 min more. Spo2was steady at 96–97%. The guide wire was reintroduced through the dilator. The dilator was removed and the skin and subcutaneous tissues, including the tumor, were dilated with the guide wire dilating forceps. The dilating forceps were introduced one more time to dilate the opening in the trachea. The tracheostomy tube was then passed into the trachea over the guide wire. There was no bleeding or difficulty in stretching the tumor tissue, and the procedure, from the time of needle entry into the trachea, took less than 5 min. After confirming the position of the tracheostomy tube, the patient underwent mechanical ventilation and FiO2was 1.0. Her Spo2increased to 99%, heart rate was 110 beats/min, and blood pressure was 150/90 mmHg. The next morning she was fully awake, responsive, and could be weaned from mechanical ventilation.
Several techniques, including TTJV, ventilation via a laryngeal mask airway, or percutaneous tracheostomy has been used to manage difficult or failed intubation. 1,5–7Needle or surgical cricothyroidotomy have also been advocated to obtain rapid and safe access to the airway in an emergency because the cricothyroid membrane has no major anatomic structures closely related to it, is relatively avascular, and is easy to locate by palpation of the neck. However, in our patient, palpation of the thyroid cartilage was impossible; the cricoid cartilage was located with difficulty, and the cricothyroid membrane was obscured by the tumor. It was possible to puncture the trachea below the cricoid cartilage. Having obtained airway access and established adequate ventilation by TTJV, it was now possible to proceed with percutaneous tracheostomy by introducing the guide wire through the same cannula.
The SIMS Portex PT kit contains a short, hollow, tapered dilator to calibrate the hole made by the needle in the trachea to the size of the guide wire dilating forceps. The ability to attach the jet injector to the hub of the dilator and perform TTJV through it increased the safety of the procedure. It enabled us to ventilate the lungs again, after the initial period of TTJV given through the cannula, before dilatation of the trachea with the guide wire dilating forceps.
In this patient, the use of TTJV was potentially hazardous, and the risk of barotrauma was extremely high because of upper airway obstruction by the tumor. 8However, during the unsuccessful attempts at intubation, some air bubbles expelled from the larynx could be seen with every expiration, indicating that the airway was at least partially patent. During spontaneous respiration, tumors in the neck produce dynamic airway obstruction that is more pronounced during inspiration than during expiration. An added advantage of TTJV is that blood and secretions are blown away from the laryngeal inlet during inspiration by upward flow of gas though the larynx as the pressure increases in the chest, and during expiration, when all the gas flow is upward through the larynx. 9
In this patient, other potential problems included bleeding during tracheal puncture and malplacement of the guide wire and tracheostomy tube. Problems related to malplacement can be avoided by fiberoptic bronchoscopic guidance during percutaneous tracheostomy. 10,11While this was clearly impossible in this patient, it can increase the safety of the procedure in other situations where the airway is not obstructed and the oropharynx is not contaminated.
We believe this is the first report on the combined use of TTJV and percutaneous tracheostomy in a cannot-intubate, cannot-ventilate situation. This concept is useful and should be considered in the management of failed intubation, especially when neck anatomy is better preserved and there is no upper airway obstruction. Percutaneous tracheostomy should be included in every failed intubation drill or difficult airway algorithm, and anesthesiologists must acquire the necessary training and skills to be able to perform percutaneous tracheostomy.