W e report the combined use of a Fogarty catheter (FC), a 3.5-mm fiberoptic bronchoscope (FOB), and a 6.0 endotracheal tube (ETT) to intubate the lower trachea of a patient with a primary upper-and midtracheal tumor causing a 66% stenosis of the tracheal lumen at the level of the thoracic inlet. Initially, the 6.0 ETT, with the FOB and the FC fed to its tip, was placed above the tumor and rotated 90°c ounterclockwise. The FOB and the FC were advanced through the stenosis, and the FC cuff was inflated just above the carina. The ETT was advanced over the FOB toward the FC cuff, and the ETT cuff was inflated below the tumor and above the FC cuff. After inspection for blood and tumor debris through the FOB's eyepiece, the FC cuff was deflated, both the FOB and FC were withdrawn, and intermittent positive pressure ventilation (IPPV) was begun.
Case ReportA 53-yr-old, 68-kg, 153-cm, otherwise healthy woman presented for resection of a primary tracheal tumor. She reported progressive dyspnea and hoarseness over the last three months.Auscultation of the chest revealed bilateral, monophonic inspiratory and expiratory wheeze. Computerized tomography of the neck and thorax revealed a tumor extending between the third and eighth tracheal rings and causing a 66% stenosis of the tracheal lumen at the level of the first thoracic vertebra (Fig. 1). Pulmonary function tests (Table 1) revealed a peak expiratory flow rate of 2.4 L/s (43% of predicted) and a peak inspiratory flow rate of 1.7 L/s (27% of predicted). The greater decrease in inspiratory flow than expiratory flow indicated variable inspiratory obstruction, which is characteristic of extra-thoracic tracheal lesions (1).While the patient was inspiring room air, Pao 2 was 76 mm Hg, Paco 2 was 42 mm Hg, pHa was 7.42, and hemoglobin saturation was 95.3%.Preoperative fiberoptic bronchoscopy revealed an advanced intraluminal growth erupting through the posterior and left tracheal walls. There were areas of reddening on the mucosa of the proximal portion of the stenotic tracheal segment, and a few moderately engorged vessels were visible. However, there was no evidence of spontaneous bleeding and/or tumor-friability (e.g., areas of ulceration/ necrosis). The stenotic tracheal segment was narrowed by increased inspiratory effort and widened by increased expiratory effort. Fine needle tissue sampling (2) was performed, and subsequent cytology revealed cystic adenoid carcinoma with squamous metaplasia of the overlying epithelium.The airway was evaluated as Mallampati class I (3,4), maximal head extension was 45°(5), thyromental distance was 8.2 cm (5), and sternomental distance was 14.6 cm (6).Preoperative laser photoresection, radiotherapy, and chemotherapy were not performed as a result of reasons presented in the next section of this article.After obtaining institutional approval and informed, written patient consent, we applied a new and meticulously prepared technique of airway management. The patient lay supine in a 30°-head-up position; at this position, she reported minima...