|LETTER TO EDITOR
|Year : 2023 | Volume
| Issue : 1 | Page : 32-33
Unanticipated difficult intubation due to tracheal stenosis in an adult patient posted for Whipple's surgery
Pooja K Subbiah1, Jitendra S Bapat1, Manju T Butani1, Arpit P Sharma2
1 Department of Anaesthesiology, P. D. Hinduja Hospital, Mumbai, Maharashtra, India
2 Department of ENT, P. D. Hinduja Hospital, Mumbai, Maharashtra, India
|Date of Submission||29-Dec-2022|
|Date of Acceptance||15-Feb-2023|
|Date of Web Publication||20-Apr-2023|
Dr. Pooja K Subbiah
Department of Anaesthesiology, P. D. Hinduja Hospital, Mahim, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Subbiah PK, Bapat JS, Butani MT, Sharma AP. Unanticipated difficult intubation due to tracheal stenosis in an adult patient posted for Whipple's surgery. Airway 2023;6:32-3
|How to cite this URL:|
Subbiah PK, Bapat JS, Butani MT, Sharma AP. Unanticipated difficult intubation due to tracheal stenosis in an adult patient posted for Whipple's surgery. Airway [serial online] 2023 [cited 2023 Jun 4];6:32-3. Available from: https://www.arwy.org/text.asp?2023/6/1/32/374371
We report a 59-year-old male patient scheduled for Whipple's procedure. The patient had a history of septic shock and ventilatory support. The patient complained of slight breathlessness on rest, which was attributed to general weakness preoperatively secondary to septic shock. After adequate preoxygenation and premedication, general anaesthesia was induced with injection propofol 100 mg intravenous (IV). Mask ventilation was easy, and therefore, injection atracurium 40 mg IV was given. After adequate relaxation, laryngoscopy was done and vocal cords were easily visualised with Cormack − Lehane Grade 1. An endotracheal tube (ET) size 8.0 mm was negotiated through the vocal cords, but the tube could not be advanced further below the cords. Thereafter, smaller ET sizes up to 6.0 mm were tried sequentially without success. Finally, a 5.5-mm cuffed tube was introduced without inflation of the cuff. It too did not pass beyond the vocal cords, but good EtCO2 trace was obtained. In view of suspected subglottic stenosis, specialist consultation was requested in the operation theatre. After adequate counselling of the relatives, it was decided to do rigid bronchoscopy, microlaryngoscopy, tracheal dilatation and if required emergency tracheostomy. Rigid bronchoscopy revealed stenosis which was approximately 3 cm below the vocal cords [Figure 1].
This explained the difficulty in the passage of the ET. Serial balloon dilatation was done two times after which a 7.0 cuffed ET could be incorporated with good respiratory and ventilatory parameters. Since the patient was vitally stable throughout the procedure and at the end of the procedure was generating adequate tidal volume spontaneously, it was decided to extubate the trachea. Surgery was deferred in view of multiple attempts at intubation and serial elective dilatation, which may have led to immediate postoperative oedema, eventually leading to delayed weaning. Adequacy of dilatation was assessed by decreased breathlessness in the postoperative period and also serial steam inhalation and steroid nebulisation was administered. After one week, bronchoscopy was repeated to document the absence of re-stenosis and the planned surgery was carried on with 7.0 cuffed tube. Postintubation tracheal stenosis remains an important cause of acquired tracheal stenosis. The reported rate of stenosis after intubation is between 1% and 9.7%. Due to mucosal ischaemia and ulceration, healing takes place with the formation of fibrous scar tissue resulting in stenosis. In one prospective study of critically ill patients, 11% of patients who had been intubated with high-volume, low-pressure ET tubes developed tracheal stenosis that were 10%–50% of their tracheal diameter at the cuff site. Patients can be asymptomatic for many months before they develop symptoms such as breathlessness, which can be seen immediately in some cases and sometimes can occur after many days which can go unrecognised as it happened in our case. It can also be misdiagnosed as asthma and diagnosis is not suggested in 44% of patients at initial presentation.
A high index of suspicion along with coordination with surgeons is imperative to manage these cases.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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