Airway management in an adult with subglottic stenosis: Overcoming ventilation challenges with a small endotracheal tube

Vinothkumar1, Saravanakumar2, Santhosham3, Ramu4

1MEM/CCTEM, Kauvery Hospital, Cantonment, Trichy

2HOD Critical Care, Kauvery Hospital, Cantonment, Trichy

3Critical Care Specialist, Kauvery Hospital, Cantonment, Trichy

4Emergency Physicist, Kauvery Hospital, Cantonment, Trichy

Introduction

Subglottic stenosis is narrowing of the trachea between the inferior margin of vocal cords and lower border of cricoid cartilage .It can be due to variety of causes with injury following tracheal intubation or tracheostomy being the most common cause.

Case Presentation

A 61-year-old male patient with a history of left malignant MCA infarct s/p decompressed craniotomy, underwent tracheostomy in view of prolonged weaning; decannulation done.

After 2 weeks post decannulation, patient had noisy breathing for which he was evaluated and diagnosed as subglottic stenosis for which balloon dilation was done and shifted to rehabilitation center for further care.

Patient developed CO2 retention due to inadequate ventilation through a smaller tube. To overcome this difficulty, ventilatory settings are optimized by increasing the respiratory rate and decreasing the tidal volume. Subsequent ABG values improved. Patient underwent balloon dilatation and then planned for elective tracheostomy in OT. Airway secured with 8-size Tracheostomy tube. On (5/10/24) after 20 days of ballon dilation patient came to ER with complaints of breathing difficulty and noisy breathing.

Examination

On examination, patient had stridor, RR-48/min, SPO2 – 97% on NRBM, HR – 142/min, BP – 110/70mmmhg, GCS E4V1M6 with right hemiparesis.

Clinical Course and Intervention

Initially managed with nebulization and steroids which did not relieve the symptoms hence planned for emergency intervention. Since patient had a previous history of subglottic stenosis, endotracheal intubation was deferred and planned for Emergency Tracheostomy. ENT surgeon was involved during the procedure and patient underwent cardiac arrest.

CPR initiated according to ACLS protocol, definitive airway with tracheostomy tube 8 attempted and failed hence airway was secured with smaller size ET tube size 5 through tracheostomy port and ROSC obtained. Patient had a complete neurological recovery.

Ventilation Challenging

Patient developed CO2 retention due to inadequate ventilation through a smaller tube. To overcome this difficulty, ventilatory settings optimized by increasing the respiratory rate and decreasing the tidal volume. Subsequent ABG values improved. Patient underwent balloon dilatation and then planned for elective tracheostomy in OT. The airway secured with 8-size Tracheostomy tube.

Conclusion

Subglottic stenosis poses significant airway management challenge. Swift thinking and efficient management of available resources in an unprepared emergency condition can be lifesaving. A patient who needs a definitive airway with a high suspicion of subglottic stenosis needs to have multiple ET and TT tube sizes ready.

Reference


Dr. Vinothkumar
MEM/CCTEM – Resident

Dr. P. Saravana Kumar

Dr. Saravanakumar
HOD Critical Care

Dr Santhosam

Dr. C. M. Santhosam
Critical Care Specialist

Dr Ramu

Dr. V. Ramu
Emergency Physicist

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