Dear Editor, We present the case of a 24-year-old female with tracheal stenosis postcolopharyngoplasty at the T1-T2 segment, posted for balloon mechanical dilatation. Written informed consent was obtained from the patient for the publication of this case report. She had a history of corrosive consumption 2 years ago and developed dysphagia. She was operated on for colopharyngoplasty 8 months ago. Subsequently, she developed tracheal stenosis and required a tracheostomy. Now, she presented with stridor and dyspnoea with a tracheostomy tube (TT) in situ. On contrast-enhanced computerised tomography of the neck, a tracheal stenosis was noted at the T1-T2 segment with an opening of approximately 3.8 mm. The patient was shifted to the operating theatre, and routine non-invasive monitors were attached. Initially, sedation was given with midazolam 1 mg and fentanyl 50 mcg intravenously (IV). On screening, flexible bronchoscopy at two sites with stenosis – one at subglottic area around the TT and one below the TT were noted Figure 1a. The pulmonologist planned a rigid bronchoscopy-guided balloon dilatation under general anaesthesia. The patient received 50 mcg fentanyl, 100 mg propofol and vecuronium 6 mg IV after confirming adequacy of ventilation via cuffed TT. A size 7.5 TT was kept as a backup.Figure 1: The stricture below the tracheostomy tube, before (a) and after (b) dilatationFirst, the balloon dilatation of the subglottic stricture was done uneventfully. For the rigid bronchoscopy of the stricture below the TT, we removed the TT and ventilated the patient via the ventilating channel of the rigid bronchoscope. The tracheostomy stoma was covered with a sterile gauge and packed with a Tegaderm sterile dressing. A 7 mm rigid bronchoscope was advanced beyond the TT site and close to the stenosed segment. However, we were not able to ventilate the patient due to stenosis distal to the bronchoscope and a large amount of leak. The pulmonologist tried to pass the bronchoscope beyond the stenosed segment, but it did not go through. In spite of repeated oxygen flushing, the patient’s oxygen saturation dropped to 58%. The rigid bronchoscope was immediately removed, a 7.5 mm cuffed TT was reinserted, and positive pressure ventilation was restored. However, the pulmonologist was unable to pass the bronchoscope with the TT cuff deflated due to subglottic stenosis. We attempted to ventilate the patient via rigid bronchoscope, but our attempts were futile. Due to constriction present distal to the bronchoscope, the patient required positive pressure, which was not possible through the accessory channel of the bronchoscope. Hence, the TT was replaced by an endotracheal tube (ETT) of 5.0 mm. The ETT cuff was inflated, and the ventilation was re-established. For the rigid bronchoscopy, the ETT cuff was deflated, and the pulmonologist was able to pass the bronchoscope to reach close to the stenosed segment, and the balloon dilatation was done. Intermittent ventilation via the ETT was continued, in between the sessions of balloon dilatation, until 3 balloon dilatations were done Figure 1b, and the pulmonologist was able to pass a 9 mm rigid bronchoscope through the stenosed segment. After the procedure, adequate suctioning was done and a 7.5 mm TT was inserted. The muscle relaxation was reversed, and spontaneous respiration was restored. There was no obstruction in breathing after the procedure. Subglottic or tracheal stenosis is the narrowing of the airway that could be congenital, traumatic or after airway manipulation such as surgery, prolonged endotracheal intubation or tracheostomy. The symptoms include hoarseness, stridor and respiratory distress. In severe cases, complete obstruction may happen, needing continued intubation or tracheostomy. Rigid bronchoscope-guided balloon dilatation is recommended as an initial therapeutic option.1 For a fibrous stenotic lesion, dilatation can also be done. In this process, a rigid bronchoscope is passed beyond the lesion with a corkscrew motion. The ventilation can be done through the rigid bronchoscope. Bleeding can occur but can be controlled with pressure from the advancing bronchoscope.2 Maintaining adequate ventilation could be challenging during rigid bronchoscopy, especially in patients with tracheal stenosis due to the difficulty in providing positive pressure across the narrow opening in the airway, without a proper seal. Various approaches had been described in the literature, including the use of conscious sedation with or without regional anaesthesia, apnoeic oxygenation using high-flow nasal cannulas, spontaneous assisted ventilation, controlled ventilation via face mask, supraglottic airway, ETT or TT, manual jet ventilation or high-frequency jet ventilation. In our case, since a rigid bronchoscopy was planned, general anaesthesia with adequate muscle relaxation was required. After failed ventilation through rigid bronchoscope and inability to pass the rigid bronchoscope beyond the constriction, we performed intermittent ventilation via a cuffed ETT. Some cases reported in the past have highlighted this issue. In a patient with Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) syndrome and foreign-body aspiration, the anaesthesiologist had to pass a smaller-sized TT (4.5 mm ID) alongside a rigid bronchoscope, for positive pressure ventilation.3 In another case report, a 14-year-old female child with critical posttracheostomy tracheal stenosis presented with severe respiratory distress. Balloon tracheoplasty was done under general anaesthesia with LMA insertion to provide positive pressure ventilation.4 Other modalities, such as jet ventilation, could potentially have been used in our case if the cannula had been successfully passed beyond the stricture. However, the risks of hypercapnia and barotrauma remained significant concerns, as previously reported in the literature.5 We can therefore conclude that anaesthesiologists may encounter complete ventilation failure situations even during airway interventions such as rigid bronchoscopy, for which no dedicated airway management algorithms currently exist. Successful restoration of positive-pressure ventilation in such scenarios demands a thorough understanding of the compromised airway anatomy and a judicious selection of appropriate airway equipment. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Author contributions Dr Deepak Singla: drafting the article or revising it critically for important intellectual content, final approval of the version to be submitted. Dr Livleen Mann, Dr Jyoti Suthar, Dr Shreya Singh, Dr Arvinth VS: acquisition of data, and drafting the article Disclosure of use of artificial intelligence (AI)-assistive or generative tools No artificial intelligence (AI)-assistive or generative tools were used for writing this case report. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Singla et al. (Thu,) studied this question.