Difficult Airway Management for Traumatic Tracheal Injury

An 18-year-old female presented s/p MVC with seatbelt injury to the neck. Patient was awake and alert but complained of neck pain, hoarseness, and difficulty breathing. CT C-spine and chest revealed an irregularity of the... [ view full abstract ]

An 18-year-old female presented s/p MVC with seatbelt injury to the neck. Patient was awake and alert but complained of neck pain, hoarseness, and difficulty breathing. CT C-spine and chest revealed an irregularity of the right anterolateral trachea concerning for tracheal injury versus rupture, extensive retropharyngeal and paravertebral subcutaneous emphysema, and pneumomediastinum.  Patient was brought to the OR on 100% non-rebreather mask with 96% O2 saturation .  The surgical team prepped the patient’s neck and the difficult airway cart with fiberoptic bronchoscope (FOB) was set up prior to induction of anesthesia. General anesthesia was induced via inhalational of sevoflurane and 100% O2 with maintenance of spontaneous respiration.

After induction, endotracheal intubation was performed via video laryngoscopy.  No injury was visualized above the vocal cords.  However, the endotracheal tube (ETT) met resistance a short distance below the vocal cords preventing further advancement.  ETT cuff was inflated and positive pressure ventilation (PPV) attempted without success.  FOB was then inserted through the ETT and tissue noted to be occluding the tip of the ETT.  The decision was made to withdraw the ETT and resume spontaneous mask ventilation.  A surgical airway was obtained via neck incision below the site of tracheal injury, followed by placement of an ETT through the incision.  Capnography confirmed tracheal placement of ETT.  FOB was then advanced through the oropharynx into the trachea until the surgically placed ETT was visualized.  ETT was removed, FOB advanced past the point of tracheal injury, and a new ETT advanced over the FOB to secure the airway past the point of tracheal tear.  Trachea was repaired around the ETT and the patient was transferred to ICU, intubated and sedated.  She was extubated on postoperative day (POD) 1 and discharged on POD 3. Emergency airway management in the setting of acute airway trauma is a challenge for anesthesiologists.  This scenario is infrequently encountered.  Previous studies show that up to 78% of patients with tracheal or bronchial injuries are dead on arrival to the hospital¹.  The American Society of Anesthesiologists (ASA) modified trauma algorithm that pertains to tracheal tears is a great resource².  As recommended by the guideline, we were able to maintain spontaneous respirations during induction and securing the airway.  This was important because we were unable to initially provide PPV despite placement of the ETT below the level of vocal cords.  We were also able, with surgical team assistance, place the ETT below the level of the tracheal tear as recommended by the algorithm.  In hindsight, on our first intubation attempt, we might have considered confirming placement of ETT past the level of the tracheal tear before attempting positive pressure ventilation.  This is because there is a concern that PPV, with ETT placed above the level of the tear, could worsen subcutaneous emphysema and pneumomediastinum. This case and others such as described by Barrett³ highlight the importance of coordination with the surgical team and preparation for a variety of possible airway management scenarios by having the difficult airway cart and FOB available.