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In every anesthesiologist's career, there is a difficult airway that he will never forget
.
If handled well, it is a classic case that can be used for teaching; if handled poorly, it is a shadow and nightmare that will follow a lifetime
In every anesthesiologist's career, there is a difficult airway that he will never forget
If it is a difficult airway that has been predicted before anesthesia induction, the experienced anesthesiologist must have a variety of plans in mind, and can call enough companions to help minimize the risk of difficult ventilation
Today, I encountered another case of difficult airway.
case review
This is a 43 -year-old female patient.
At 18 weeks of pregnancy , she came to the hospital for examination due to poor breathing.
Through bronchoscopy, it was found that something grew in the trachea .
After biopsy, the diagnosis was tracheal adenoid cystic carcinoma ( ACC ) .
At 18 weeks of pregnancy , she came to the hospital for examination due to poor breathing.
Through bronchoscopy, it was found that something grew in the trachea .
The cancerous tissue located in the submucosa has extended to within 5mm of the elastic cone (a membranous structure located between the upper edge of the cricoid arch, behind the anterior horn of the thyroid cartilage and the vocal process of the arytenoid cartilage, mainly composed of elastic fibers, as shown in Figure 1 ) , Much above the plane of the cricoid cartilage, it grows more than 4 cm down the tracheal wall .
Due to pregnancy, other tests for the tumor can only be postponed .
1 Anesthesia surgery plan
1 Anesthesia surgery plan 1 Anesthesia surgery planIn the end, doctors decided to use betamethasone to promote fetal lung maturation, and planned to perform cesarean section at 34 weeks of gestation, and to perform tracheal tumor resection and tracheal reconstruction on the third postpartum day
.
.
The anaesthesia surgery plan assumes that the severity of the tracheal stenosis continues to worsen within 16 weeks after the initial bronchoscopy , without the typical symptoms of stridor or wheezing.
Epidural anesthesia was administered to the room, and cesarean section was performed in the presence of a thoracic surgeon
The anaesthesia surgery plan assumes that the severity of the tracheal stenosis continues to worsen within 16 weeks after the initial bronchoscopy , without the typical symptoms of stridor or wheezing.
Epidural anesthesia was administered to the room, and cesarean section was performed in the presence of a thoracic surgeon
In the event of obstetric or anesthesia complications requiring endotracheal intubation and general anesthesia, direct laryngoscope intubation will be used for the first attempt, and a small endotracheal tube may be used as there is no evidence of supraglottic involvement
If the severity of the stenosis prevents endotracheal intubation, the surgeon will ventilate with a rigid bronchoscope until labor is complete, then dilate the trachea
2 The process of performing anesthesia surgery 2 The process of performing anesthesia surgery
Finally, lumbar epidural anesthesia was used, and 0.
5% bupivacaine was slowly administered
.
The cesarean section was successful, the patient felt comfortable, and there was no respiratory distress, and a baby girl was delivered with an Apgar score of 9 . Finally, lumbar epidural anesthesia was used, and 0.
5% bupivacaine was slowly administered
Postoperative CT scan of the neck ( Fig.
2) showed a 4 cm diameter tumor encircling the trachea, involving the right posterolateral cricoid cartilage, esophagus, and thyroid gland, and extending to the right internal carotid artery, cervical vertebral body, and thoracic inlet .
The tracheal lumen was invaded by intraluminal tumors, with a diameter of only 0.
6 cm .
The patient ultimately refused laryngotracheal tumor resection, was discharged home for radiation therapy, and was subsequently lost to follow-up
.
Figure 2 : CT scan image of proximal trachea
Figure 2 : CT scan image of proximal tracheaNote: Small arrows delineate tumor boundaries, long arrows indicate tracheal lumen
Note: Small arrows delineate tumor boundaries, long arrows indicate tracheal lumenWhat is adenoid cystic carcinoma?
What is adenoid cystic carcinoma?About 0.
1% of the population had more complex malignancies during pregnancy , while primary tracheal tumors accounted for only 0.
2% of respiratory malignancies
.
Adenoid cystic carcinoma ( ACC ) is an aggressive adenocarcinoma that accounts for 10% of salivary gland tumors and 1 % of head and neck tumors .
It accounts for only 0.
2% of tracheal tumors , and cases are rare .
1% of the population had more complex malignancies during pregnancy , while primary tracheal tumors accounted for only 0.
2% of respiratory malignancies
.
Adenoid cystic carcinoma ( ACC ) is an aggressive adenocarcinoma that accounts for 10% of salivary gland tumors and 1 % of head and neck tumors .
It accounts for only 0.
2% of tracheal tumors , and cases are rare .
ACC hyperplasia originating from the epithelium of the tracheal salivary glands can lead to airway obstruction and invasion of adjacent structures, and symptoms may include dyspnea, wheezing, stridor, burning sensation, and hemoptysis due to main airway obstruction
.
.
According to incomplete estimates, 13 cases of primary tracheal tumors have been reported, of which only 4 cases were ACC , 3 of 4 cases were located in the distal trachea, and 1 case was located in the proximal part, but no complete anatomical description was available .
Final reflection and discussion
final reflection and discussion final reflection and discussionDue to pregnancy, the patient's difficult airway could not be surgically improved prior to caesarean section
.
The location of the tumor in the proximal trachea and its extent also did not allow resection by bronchoscopy or under cardiopulmonary bypass
.
.
The location of the tumor in the proximal trachea and its extent also did not allow resection by bronchoscopy or under cardiopulmonary bypass
.
The anesthesiologist's ability to control the airway in this case was limited
.
If positive pressure ventilation is required intraoperatively, it is unknown whether an endotracheal tube can be passed through a tracheal stenosis of unknown size to provide stable ventilation
.
.
If positive pressure ventilation is required intraoperatively, it is unknown whether an endotracheal tube can be passed through a tracheal stenosis of unknown size to provide stable ventilation
.
The ASA guidelines on difficult intubation state that invasive airway establishment including tracheostomy, cricothyroidotomy, jet ventilation, and retrograde intubation, all of which were not possible in this case
.
.
The experience from this case is that rigid bronchoscopy can be used as an adjunct to effective ventilation for extensive ACC in pregnancy with severe proximal tracheal stenosis .
In your anesthesia career, have you encountered those difficult airways that you will never forget?
In your anesthesia career, have you encountered those difficult airways that you will never forget?references
referencesRmp A ,Ler B.
Critical tracheal stenosis from adenoid cystic carcinoma during pregnancy: Case report[J].
Journal of Clinical Anesthesia, 2022.
Critical tracheal stenosis from adenoid cystic carcinoma during pregnancy: Case report[J].
Journal of Clinical Anesthesia, 2022.
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