Management of Unexpected Subglottic Stenosis in a Neonate With Congenital Tracheoesophageal Fistula

Abstract

Indian J Case Reports 336Letter to Editor Management of unexpected subglottic stenosis in a neonate with congenital tracheoesophageal fistula Sir, W e present a case of 4-day-old full-term female weighing 2 kg with tracheoesophageal fistula (TEF) posted for fistula ligation and repair. On examination, the child was crying, tachypneic with drooling of saliva, and receiving intravenous fluids. Her heart rate (HR) was 165 beats/ min and SpO 2 was 85% on room air which improved to 89 with oxygen. Coarse crepitations were auscultated, bilaterally. Her investigations were found to be within normal limits. Chest X-ray showed bilateral opacities and a PaO 2 of 60 mmHg (on oxygen) on arterial blood gas.After taking high-risk consent and arranging for post-operative ventilation, the patient was taken up for surgery. On attaching monitors, HR was 154/min, blood pressure was 68/40 mmHg, and SpO 2 83% on room air which increased to 95% with FiO 2 -1.0. Premedication with injection atropine 0.1 mg and injection fentanyl 2 µg was given. After inhalational induction with sevoflurane, mask ventilation was found to be adequate. Hence, injection atracurium 1 mg was given for the best intubating conditions [1]. After ventilating for 3 min, direct laryngoscopy (DL) was performed which showed Cormack-Lehane Grade 1. Intubation with uncuffed 3 mm endotracheal tube (ETT) was attempted; however, it was getting stuck beyond the vocal cords. The same was the case with 2.5 mm internal diameter (ID) ETT; therefore, the ventilation was resumed. Laryngoscopy was done again by more experienced anesthetist. DL findings remained the same. Intubation with stiletted 2.5 mm ID ETT and 2 mm ID ETT was also attempted but was unsuccessful. Ventilation was maintained with bag mask with FiO 2 -1.0. Provisional diagnosis of subglottic stenosis was made, and otolaryngologists were called for emergency tracheostomy. Appropriate size tracheostomy tubes (TTs) were kept. Meanwhile, I-gel 1.0 was inserted to maintain ventilation. However, ventilation deteriorated and mask ventilation resumed.After tracheostomy, an uncuffed 3.0 mm ID TT was inserted. Initially, the ventilation was adequate with EtCO 2 of 25-35 mmHg and saturation between 95% and 98%. However, within 3-4 min, saturation started falling and ventilation became suboptimal. Position of TT was reconfirmed and it was slightly withdrawn. Suctioning was also attempted, but there was resistance in passing smallest catheter (5 Fr) through TT. Ventilation did not improve. Suspecting that TT was blocked, it was replaced with cuffed 3.0 mmID TT and cuff inflated with 2 ml air. Subsequently, EtCO 2 rose to 40-50 mmHg and saturation picked up to 96%. The removed uncuffed 3.0 mm TT was not blocked. Hence, it was assumed that inflated cuff of the TT sealed the fistula and helped in improving ventilation. Only gastrostomy as a life-saving procedure was done.