Download Respiratory failure after tracheal extubation in a patient

Mercer
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Foster JMG, Jones RM. The anaesthetic management of the
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Hall RI, Murphy JT, Mof®tt EA, Landymore R, Pollak PT, Poole L.
A comparison of the myocardial metabolic and haemodynamic
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bypass graft surgery. Can J Anaesth 1991; 38: 996±1004
10 Lumley J, Whitwam JG, Morgan M. General anesthesia in the
presence of Eisenmenger's syndrome. Anesth Analg 1977; 56:
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11 Goto T, Suwa K, Uezono S, Ichinose F, Uchyiama M, Morita S.
The blood-gas partition coef®cient of xenon may be lower than
generally accepted. Br J Anaesth 1998; 80: 255±6
12 Tenbrinck R, Reyle Hahn M, GuÈltuna I et al. The ®rst clinical
experiences with xenon. Int Anesthesiol Clin in press.
British Journal of Anaesthesia 86 (6): 886±91 (2001)
Respiratory failure after tracheal extubation in a patient with
halo frame cervical spine immobilizationÐrescue therapy using
the Combitube airway
M. Mercer
Department of Anaesthesia, Frenchay Hospital, Bristol BS16 1LE, UK
A 78-yr-old man, with halo frame cervical spine immobilization, suffered rapid respiratory
deterioration after tracheal extubation in the intensive care unit. Control of the airway was dif®cult as bag-valve-mask ventilation was ineffective, tracheal intubation was known to be dif®cult
from management of a previous episode of respiratory failure on the ward, and laryngeal
mask insertion proved impossible. Rescue therapy using a Combitube airway is described and
discussed.
Br J Anaesth 2001; 86: 886±91
Keywords: complications, cardiorespiratory arrest; equipment, combitube; complications,
cervical spine immobilization
Accepted for publication: January 29, 2001
In the most recent guidelines from the European
Resuscitation Council, oral tracheal intubation remains the
method of choice to secure the emergency airway.1 The
Combitube airway (Kendall Ltd, Gosport, UK) is included
in these guidelines as an adjunct, along with the laryngeal
mask airway (LMA)1², if tracheal intubation fails.
The Combitube (Fig. 1) is a twin lumen device that is
inserted blindly into the oropharynx. Each lumen is named
to correspond to the position it will be in when used for
ventilation of the lungs. One lumen (the `tracheal' lumen)
opens distally, the second (the `oesophageal' lumen) opens
²
LMAâ is the property of Intavent Limited.
at more proximally placed side ports. A large in¯atable cuff
(85±100 ml) is sited proximal to the side ports, whilst a
small in¯atable cuff (12±15 ml) is sited distally. It is usually
positioned with the smaller cuff in the oesophagus,2 3 such
that ventilation of the lungs occurs through the proximal
side ports, with the larger cuff sealing the hypopharynx.
This case describes two episodes of emergency airway
management in the same patient who had halo frame
cervical spine immobilization in place. The ®rst occurred
during the patient's initial respiratory decompensation when
ventilation was secured with a LMA. The second episode
occurred following tracheal extubation towards the end of
the patient's stay in the intensive care unit, when rescue
Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2001
Emergency airway control using Combitube airway
Fig 1 The Combitube airway (photograph). 1, Oesophageal lumen; 2, tracheal lumen; 3, ring markings to coincide with teeth; 4, pilot balloon for
proximal, large cuff; 5, pilot balloon for distal, small cuff; 6, large cuff; 7, small cuff; 8, side port openings of oesophageal (proximal) lumen;
9, opening of tracheal (distal) lumen.
therapy using the Combitube airway was lifesaving as all
other techniques had failed.
Case report
A 78-yr-old man, weighing 76 kg, was referred to the
regional neurosurgical centre (day 1) for care of a transverse
fracture through the base of the odontoid peg (Fig. 2), which
was accompanied by posterior displacement of the ®rst
cervical vertebra (C1) and the obontoid peg in relation to the
second cervical vertebra (C2). He had suffered neck pain for
3 days after tripping over a cobble stone and falling forward
onto his forehead, so causing an extension injury at the
craniovertebral junction. During this time, his wife reported
his oral intake of food and ¯uids had been poor. A lateral
cervical spine x-ray requested at this stage by his general
practitioner revealed the injury. Halo frame cervical spine
immobilization was applied at the referring hospital,
comprising a thoracic vest supporting a halo ring attached
to the skull.
His past medical history was complicated. In 1982, he
had undergone Starr-Edwards aortic valve replacement and
had been fully anticoagulated with warfarin ever since. He
had breathlessness at rest, and was chronically in atrial
®brillation and biventricular cardiac failure. An echocardio-
gram in 1998 had revealed a dilated, severely impaired left
ventricle with moderate mitral regurgitation.
His medications were warfarin 5 mg daily, amiodarone
100 mg daily, bumetanide 2 mg daily, enalapril 20 mg daily,
bendro¯uazide 2.5 mg daily and temazepam 10±20 mg at
night. He was a non-smoker.
On examination at the referring hospital, he was dehydrated, with an arterial pressure of 100/60 mm Hg, and pulse
of 80 beats min±1 in atrial ®brillation. There was a mitral
regurgitant murmur and the jugular venous pressure was
5 cm. Neurological examination was normal. INR was 4.4
(normal range 0.9±1.3), plasma urea 31.8 mmol litre±1, and
creatinine 380 mmol litre±1.
At the neurosurgical centre the warfarin was stopped, and
cautious i.v. rehydration commenced. An early decision was
taken to adopt conservative, non-surgical, therapy for this
man in view of his debilitating intercurrent morbidities.
On day 2, x-rays revealed the cervical alignment to be
inadequate warranting further manipulation of the craniocervical junction into ¯exion of approximately 5±10 degrees
in the halo frame, such that the odontoid peg and body of C1
would be moved anteriorly on C2. The patient was kept nilby-mouth for 6 h. On the ward during the procedure, he
became increasingly tachypnoeic with peripheral oxygen
saturation decreasing to 60% despite administration of a
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Mercer
Fig 2 Lateral cervical spine x-ray with arrow indicating fracture through the base of the odontoid peg.
high ¯ow of oxygen by Hudson mask. This was followed by
a deterioration in conscious level and obstruction of the
airway.
Anaesthetic assistance was urgently requested and the
ward emergency airway trolley immediately made available. Bag-valve-mask ventilation was found to be impossible. A good mask to face seal was possible, but the airway
remained obstructed despite the use of oro- and nasopharyngeal airways, and oral suctioning. The patient was
noted to have unrestricted mouth opening and full dentition.
I.v. propofol 20 mg followed by succinylcholine 100 mg
was given. With a Macintosh 3 blade, the epiglottis was not
visible (Cormack and Lehane grade 4) but nothing was seen
that could have caused airway obstruction. As other
laryngoscope blades were not contained in the emergency
trolley, the procedure was abandoned. A size 4 LMA was
then successfully placed at the ®rst attempt. With restoration
of the airway, and bag-valve ventilation of the lungs through
the LMA with 100% oxygen, peripheral resaturation to
100% occurred. Cardiac output was not lost at any stage. I.v.
vecuronium 10 mg was given, and manual ventilation
continued. The patient was transferred to the intensive care
unit for arti®cial ventilation of the lungs. Sedation was
maintained with a 1% propofol i.v. infusion at 10±20 ml h±1.
Fibreoptic visualization of the vocal cords and trachea was
possible through the LMA, enabling a size 6-cuffed tracheal
tube to be passed over the ®brescope to secure the airway.
This tube was then removed over a gum elastic bougie and
replaced by a size 9-cuffed tracheal tube. At this stage, the
patient was seen to move all four limbs.
The morning of the following day (day 3), further
¯uoroscopic reduction of the cervical spine involving 5±10
degrees of craniocervical ¯exion in the halo frame, was
undertaken in the operating theatre. Again, all limbs were
seen to move after the procedure.
The patient was now breathing spontaneously on the
Siemens Servo 300 ventilator at a rate of 18 bpm with
triggered pressure support/positive end-expiratory pressure
assistance of 12/5 cm H2O, generating tidal volumes of 7±
8 ml kg±1. With an inspired oxygen concentration of 40%,
peripheral oxygen saturation was 99% and arterial carbon
dioxide partial pressures less than 6.6 kPa. He was obeying
commands with open eyes, and was coughing on the
tracheal tube. Arterial pressure was 140/80 mm Hg.
Following pre-oxygenation for 3 min, and oral and tracheal
suctioning, he was extubated and given high ¯ow oxygen by
reservoir bag mask. Tachypnoea immediately followed,
with peripheral oxygen saturations decreasing to 70%. His
conscious level deteriorated. As before, bag-valve-mask
ventilation was unsuccessful as the airway was obstructed.
This was unrelieved by oral or by nasal airways, and
suctioning. Tracheal intubation was not attempted in view
888
Emergency airway control using Combitube airway
Fig 3 (A) Patent airway of supine patient before craniocervical ¯exion (diagrammatic). Halo frame not shown. (B) After second episode of
craniocervical ¯exion. Obstructed airway of extubated patient sat up in bed (diagrammatic). Halo frame shown. Angle A2 is greater than A1 in (A).
of the previous dif®culties, and unlikelihood of rapid control
of the airway. Despite the gag response now being absent,
attempts to insert a size 4 and 3 LMA, with and without
digital guidance, were on this occasion unsuccessful.
The LMAs would not pass beyond the oropharynx.
Further peripheral desaturation to 60% occurred
accompanied by a decrease in invasive arterial systolic
pressure to 60 mm Hg, and electrocardiography showing a
broad complex tachycardia of 140 beats min±1. Peripheral
i.v. methoxamine 20 mg was quickly followed by
epinephrine 1 mg as the systolic pressure decreased further.
Respiratory effort was now diminishing. At this stage, a
small adult size Combitube was inserted without dif®culty
into the oesophagus and the cuffs in¯ated to the manufacturer's guidelines (small cuff 12 ml, large cuff 85 ml).
Manual ventilation of the lungs was immediately possible
using a high-¯ow oxygen, bag-valve system through the
proximal side ported, oesophageal lumen of the Combitube.
This was con®rmed by bilateral chest expansion, auscultation of the lungs and an improvement in the peripheral
saturation to 98%. After control of the airway and breathing,
infusions of epinephrine 0.15 mg kg±1 min±1 and norepinephrine 0.05 mg kg±1 min±1 were commenced via a central
vein to maintain arterial pressure at 95/50 mm Hg. After 1 h
of i.v. 1% propofol sedation, mandatory pressure control
ventilation with 100% oxygen, and no spontaneous respiratory efforts, arterial blood gas analysis showed pH 7.22,
PCO2 6.9 kPa, PO2 64 kPa, and base excess ±6.8 mmol
litre±1.
At this stage, detailed discussions regarding patient
prognosis took place between all the relevant physicians
and the patients' family. In view of the patient's age,
premorbid state and presenting pathology, and the systemic
insult of two episodes of hypoxia, the decision was taken not
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Mercer
to escalate treatment further. Over the following 10 h, lung
ventilation through the Combitube was continued, but the
patient became progressively hypotensive and died.
Discussion
If the airway needs to be secured and tracheal intubation has
failed, then the use of adjuncts may be life saving. The
Combitube and LMA are included in the European
Resuscitation Council guidelines for the management of
the emergency airway.1 Previous studies have con®rmed the
effectiveness of the Combitube in hospital-based cardiopulmonary resuscitation,3 4 in the management of the
trauma patient,5 and in ventilation of the lungs both during
routine surgery,6 and on the intensive care unit.7 Many
dif®cult airway situations have been managed using the
Combitube airway,8±12 and it compares favourably with the
LMA when used by unskilled staff.13±16
Management of the airway of a patient with halo frame
cervical spine immobilization in place is dif®cult. The halo
frame immobilizes the head and neck, and prevents `snif®ng
the morning air' positioning for intubation, where the
cervical spine is ¯exed and the craniocervical junction
extended. Undue force used during laryngoscopy and
tracheal intubation may move the cervical vertebrae and
jeopardize the spinal cord. For these reasons, preference
over direct laryngoscopy is usually given to awake ®breoptic tracheal intubation, or use of the intubating LMA. In
this case, as discussed below, only the contents of the ward
emergency airway trolley as described were immediately
available. The author became involved during the second
airway episode, at which point the Combitube was available
from his personal supply.
The Combitube is designed for insertion in the neutral
position, with the occiput on the ¯at surface on which the
patient is positioned. Supine patients with Halo frame
immobilization approach this position. Successful use of the
Combitube in the elective anaesthetic airway management
of a patient with Halo frame cervical spine ®xation has been
described.17 The natural curve and rigidity of the Combitube
facilitates its passage around the angle between the axis of
the oral cavity and larynx. It, therefore, proved ideal in this
case.
The recommended position for insertion of the LMA is
`snif®ng the morning air'.18 This is clearly not possible with
a halo frame in place.
The LMA was successful in the ®rst instance of
emergency airway control, but failed after further craniocervical ¯exion during the second episode.
This is the ®rst case described using the Combitube in the
emergency management of the airway of a patient with halo
frame cervical spine immobilization in place. It is also the
®rst case of emergency airway management described
where other airway techniques, including the use of the
LMA, have failed and the Combitube succeeded. Moreover,
airway obstruction caused by placement of a halo frame has
not been reported. Pathology associated with the initial
trauma, such as retropharyngeal haematoma, can cause
obstruction, although in this case, no such abnormality was
seen at initial laryngoscopy, and the post-mortem reported
the upper airways as normal.
The cause of both acute deteriorations was airway
obstruction following craniocervical junction ¯exion, the
¯exion being greater in the second instance (Fig. 3).
However, this only became apparent after extubation on
the ICU. The differential diagnosis initially included acute
pulmonary oedema (although this was not evident clinically), cervical cord damage (although the patient moved all
limbs throughout and no external cord abnormalities were
seen at post-mortem examination), and tracheal mucus
plugging (which was also not seen at post-mortem).
In hindsight, better equipment to manage the second
episode should have been available on the operating theatre
dif®cult airway trolley, which contained the intubating
LMA and intubating ®brescope. Additionally, at any stage
craniocervical de¯exion may have alleviated the airway
obstruction, but at the risk of compromising the cervical
spinal cord.
When resuscitating the unconscious patient, where the
`snif®ng the morning air' position is not achievable because
the cervical spine is, or must be, immobilized in the neutral
position, then the Combitube may be preferential to the
LMA as an adjunct device, or for use by those not skilled in
tracheal intubation. In this regard, inclusion of the
Combitube in the emergency airway trolley would be
bene®cial, although this does assume the operator has prior
experience of all of these airway techniques.
In conclusion, this case demonstrates the utility of the
Combitube in the management of the emergency airway in a
hitherto unreported setting. It has been demonstrated to be
effective where other airway techniques have failed, and its
inclusion in the European Resuscitation Council guidelines
has been reiterated.
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The esophageaaal tracheal Combitube: preliminary results with a
new airway for CPR. Ann Emerg Med 1987; 16: 768±72
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management during cardiopulmonary resuscitation ± a
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and combitube in a bench model. Resuscitation 1999; 41: 63±9
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British Journal of Anaesthesia 86 (6): 891±3 (2001)
Intramuscular ketamine in a parturient in whom pre-operative
intravenous access was not possible
W. C. Lum Hee* and V. F. Metias
Department of Anaesthesia, Barnsley District General Hospital NHS Trust, Gawber Road,
Barnsley S75 2EP, UK
*Corresponding author. Present address: Department of Anaesthesia, C Floor, Royal Hallamshire Hospital, Glossop
Road, Shef®eld S10 2SB, UK
We describe the management of a 23-yr-old woman with extreme needle and mask phobia,
presenting for an emergency Caesarean section for fetal distress. She also suffered from spina
bi®da cystica with no sensation from mid thigh. Regional anaesthesia, rapid sequence induction,
and gaseous induction were not possible. She was managed successfully with i.m. ketamine
followed by a more conventional anaesthetic technique.
Br J Anaesth 2001; 86: 891±3
Keywords: anaesthesia, obstetric; anaesthetic techniques, intramuscular, ketamine;
complications, spina bi®da
Accepted for publication: January 26, 2001
Patients with an aversion to either needles or masks are not
uncommon, but those with a marked phobia to both are
more rare, and can present an anaesthetic dilemma.
However, in general, they can be persuaded to undergo
either an i.v. induction, following the use of a topical local
anaesthetic for cannulation, or a gaseous induction, with the
promise of a pleasant smelling agent and a clear mask. In
this case, we were presented with a patient who was
Ó The Board of Management and Trustees of the British Journal of Anaesthesia 2001