Failed intubation in congenital tracheal stenosis

Abstract

Key wordsTrachea; stenosis. Intubation, tracheal; complications Case historyA healthy 16-year-old girl who weighed 56 kg presented for planned surgical correction of an idiopathic thoracic scoliosis by internal fixation. The deformity was first noted at the age of fifteen and apart from a congenital reduction deformity of her left arm she was physically fit. However on further questioning she did admit to occasional wheezy episodes and routine pre-operative pulmonary function tests confirmed mild obstructive airways disease.Premedication was papaveretum (10 mg) and hyoscine (0.2 mg) given one hour pre-operatively. Anaesthesia was induced with thiopentone (250 mg) followed by pancuronium (6 mg) to facilitate orotracheal intubation. The vocal cords were sprayed with 4% lignocaine and intubation was attempted with an 8.5 mm cuffed armoured latex orotracheal tube. The tip passed easily through the cords but was held up about 2 cm lower down the trachea. The size of the tube for tracheal intubation was progrcssivcly reduced until a 5.0 mm one passed the obstruction. However ventilation of the lungs was unsatisfactory because the tube was relatively short. It was decided to assist ventilation using a Guedel airway, face mask and Bain system and ventilation was easy and unobstructed. The patient's condition remained stable and residual curarisation was reversed using neostigmine (5.0 mg) and atropine (1.2 mg) when slight muscle movements were noted 35 minutes after induction. The patient made a complete and uneventful recovery. In view of the difficulties encountered it was felt that major surgery could not be considered at this stage.At a later date an ENT examination with indirect laryngoscopy revealed normal vocal

Unsuspected concentric tracheal rings in a 14-year-old with scoliosis

“…Pulmonary function testing also differed. Their patient had signs of ®xed extrathoracic airway obstruction, which was partially obscured by mild asthma, 7 whereas pulmonary function tests in our patient demonstrated normal¯ow-volume loops and FEV 1 98%, FEV 1 /FVC 86%, PEFR 93%, PEF 25±75s 83%, VC 101% and IC 107% of predicted values. Hence there was no evidence of ®xed extrathoracic airway obstruction.…”

“…We found only four reported cases of anaesthetic management of patients with concentric tracheal rings, 4±7 and only one of these patients was managed in the prone position. 7 Goddard and Hughes 7 describe a failed intubation in a 16-yr-old child who presented for surgical correction of idiopathic scoliosis. The narrow segment began at the level of the cricoid and extended to just above the carina.…”

Laryngotracheal Hypoplasia—A Rare Cause of Difficult Intubation

“…There are many case reports describing the anaesthetic management of patients with tracheal stenosis but all were elective cases and the management was planned after proper diagnosis and evaluation 1,2,10,11 . on the other hand, this was an emergency case, which could not have been postponed, and there was no time for investigations or assessment to make a diagnosis and plan accordingly.…”

“…Failure or difficulty to intubate the trachea can be either due to inability to visualize the glottis or some pathology at the level of or below the cords. Many cases of tracheal stenosis have been reported [1][2][3] , however only one report describes the presence of total laryngotracheal hypoplasia leading to difficult intubation in an adult patient 4 . We present a full-term pregnant patient undergoing emergency laparotomy for uterine rupture in which tracheal intubation was impossible with conventional sizes of tracheal tubes for that age.…”

Congenital Tracheal Stenosis in an Adult, Complicated by Asphyxial Pulmonary Oedema

“…Goddard and Hughes reported the case of a 16-year-old girl who could be intubated with difficulty with a 5 mm un cuffed tube. 5 Her surgery (for scoliosis) was delayed until detailed investigation of her airway had been completed. Again, attempts at intubation were not prolonged, and the patient was ventilated with a mask until her relaxants wore off.…”