British Journal of Anaesthesia, 2001, Vol. 86, No. 6 886-891
© 2001 The Board of Management and Trustees of the British Journal of Anaesthesia
Respiratory failure after tracheal extubation in a patient with halo frame cervical spine immobilization—rescue therapy using the Combitube airway
Department of Anaesthesia, Frenchay Hospital, Bristol BS16 1LE, UK
LMA® is the property of Intavent Limited.
Accepted for publication: January 29, 2001
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Abstract |
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A 78-yr-old man, with halo frame cervical spine immobilization, suffered rapid respiratory deterioration after tracheal extubation in the intensive care unit. Control of the airway was difficult as bag-valve-mask ventilation was ineffective, tracheal intubation was known to be difficult from management of a previous episode of respiratory failure on the ward, and laryngeal mask insertion proved impossible. Rescue therapy using a Combitube airway is described and discussed.
Br J Anaesth 2001; 86: 886–91
Keywords: complications, cardiorespiratory arrest; equipment, combitube; complications, cervical spine immobilization
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Introduction |
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In the most recent guidelines from the European Resuscitation Council, oral tracheal intubation remains the method of choice to secure the emergency airway.1 The Combitube airway (Kendall Ltd, Gosport, UK) is included in these guidelines as an adjunct, along with the laryngeal mask airway (LMA)
, if tracheal intubation fails. The Combitube (Fig. 1) is a twin lumen device that is inserted blindly into the oropharynx. Each lumen is named to correspond to the position it will be in when used for ventilation of the lungs. One lumen (the ‘tracheal’ lumen) opens distally, the second (the ‘oesophageal’ lumen) opens at more proximally placed side ports. A large inflatable cuff (85–100 ml) is sited proximal to the side ports, whilst a small inflatable cuff (12–15 ml) is sited distally. It is usually positioned with the smaller cuff in the oesophagus,2 3 such that ventilation of the lungs occurs through the proximal side ports, with the larger cuff sealing the hypopharynx.
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This case describes two episodes of emergency airway management in the same patient who had halo frame cervical spine immobilization in place. The first occurred during the patient’s initial respiratory decompensation when ventilation was secured with a LMA. The second episode occurred following tracheal extubation towards the end of the patient’s stay in the intensive care unit, when rescue therapy using the Combitube airway was lifesaving as all other techniques had failed.
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Case report |
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A 78-yr-old man, weighing 76 kg, was referred to the regional neurosurgical centre (day 1) for care of a transverse fracture through the base of the odontoid peg (Fig. 2), which was accompanied by posterior displacement of the first cervical vertebra (C1) and the obontoid peg in relation to the second cervical vertebra (C2). He had suffered neck pain for 3 days after tripping over a cobble stone and falling forward onto his forehead, so causing an extension injury at the craniovertebral junction. During this time, his wife reported his oral intake of food and fluids had been poor. A lateral cervical spine x-ray requested at this stage by his general practitioner revealed the injury. Halo frame cervical spine immobilization was applied at the referring hospital, comprising a thoracic vest supporting a halo ring attached to the skull.
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His past medical history was complicated. In 1982, he had undergone Starr-Edwards aortic valve replacement and had been fully anticoagulated with warfarin ever since. He had breathlessness at rest, and was chronically in atrial fibrillation and biventricular cardiac failure. An echocardiogram in 1998 had revealed a dilated, severely impaired left ventricle with moderate mitral regurgitation.
His medications were warfarin 5 mg daily, amiodarone 100 mg daily, bumetanide 2 mg daily, enalapril 20 mg daily, bendrofluazide 2.5 mg daily and temazepam 10–20 mg at night. He was a non-smoker.
On examination at the referring hospital, he was dehydrated, with an arterial pressure of 100/60 mm Hg, and pulse of 80 beats min–1 in atrial fibrillation. There was a mitral regurgitant murmur and the jugular venous pressure was 5 cm. Neurological examination was normal. INR was 4.4 (normal range 0.9–1.3), plasma urea 31.8 mmol litre–1, and creatinine 380 mmol litre–1.
At the neurosurgical centre the warfarin was stopped, and cautious i.v. rehydration commenced. An early decision was taken to adopt conservative, non-surgical, therapy for this man in view of his debilitating intercurrent morbidities.
On day 2, x-rays revealed the cervical alignment to be inadequate warranting further manipulation of the craniocervical junction into flexion of approximately 5–10 degrees in the halo frame, such that the odontoid peg and body of C1 would be moved anteriorly on C2. The patient was kept nil-by-mouth for 6 h. On the ward during the procedure, he became increasingly tachypnoeic with peripheral oxygen saturation decreasing to 60% despite administration of a high flow of oxygen by Hudson mask. This was followed by a deterioration in conscious level and obstruction of the airway.
Anaesthetic assistance was urgently requested and the ward emergency airway trolley immediately made available. Bag-valve-mask ventilation was found to be impossible. A good mask to face seal was possible, but the airway remained obstructed despite the use of oro- and naso-pharyngeal airways, and oral suctioning. The patient was noted to have unrestricted mouth opening and full dentition. I.v. propofol 20 mg followed by succinylcholine 100 mg was given. With a Macintosh 3 blade, the epiglottis was not visible (Cormack and Lehane grade 4) but nothing was seen that could have caused airway obstruction. As other laryngoscope blades were not contained in the emergency trolley, the procedure was abandoned. A size 4 LMA was then successfully placed at the first attempt. With restoration of the airway, and bag-valve ventilation of the lungs through the LMA with 100% oxygen, peripheral resaturation to 100% occurred. Cardiac output was not lost at any stage. I.v. vecuronium 10 mg was given, and manual ventilation continued. The patient was transferred to the intensive care unit for artificial ventilation of the lungs. Sedation was maintained with a 1% propofol i.v. infusion at 10–20 ml h–1. Fibreoptic visualization of the vocal cords and trachea was possible through the LMA, enabling a size 6-cuffed tracheal tube to be passed over the fibrescope to secure the airway. This tube was then removed over a gum elastic bougie and replaced by a size 9-cuffed tracheal tube. At this stage, the patient was seen to move all four limbs.
The morning of the following day (day 3), further fluoroscopic reduction of the cervical spine involving 5–10 degrees of craniocervical flexion in the halo frame, was undertaken in the operating theatre. Again, all limbs were seen to move after the procedure.
The patient was now breathing spontaneously on the Siemens Servo 300 ventilator at a rate of 18 bpm with triggered pressure support/positive end-expiratory pressure assistance of 12/5 cm H2O, generating tidal volumes of 7– 8 ml kg–1. With an inspired oxygen concentration of 40%, peripheral oxygen saturation was 99% and arterial carbon dioxide partial pressures less than 6.6 kPa. He was obeying commands with open eyes, and was coughing on the tracheal tube. Arterial pressure was 140/80 mm Hg. Following pre-oxygenation for 3 min, and oral and tracheal suctioning, he was extubated and given high flow oxygen by reservoir bag mask. Tachypnoea immediately followed, with peripheral oxygen saturations decreasing to 70%. His conscious level deteriorated. As before, bag-valve-mask ventilation was unsuccessful as the airway was obstructed. This was unrelieved by oral or by nasal airways, and suctioning. Tracheal intubation was not attempted in view of the previous difficulties, and unlikelihood of rapid control of the airway. Despite the gag response now being absent, attempts to insert a size 4 and 3 LMA, with and without digital guidance, were on this occasion unsuccessful. The LMAs would not pass beyond the oropharynx. Further peripheral desaturation to 60% occurred accompanied by a decrease in invasive arterial systolic pressure to 60 mm Hg, and electrocardiography showing a broad complex tachycardia of 140 beats min–1. Peripheral i.v. methoxamine 20 mg was quickly followed by epinephrine 1 mg as the systolic pressure decreased further. Respiratory effort was now diminishing. At this stage, a small adult size Combitube was inserted without difficulty into the oesophagus and the cuffs inflated to the manufacturer’s guidelines (small cuff 12 ml, large cuff 85 ml). Manual ventilation of the lungs was immediately possible using a high-flow oxygen, bag-valve system through the proximal side ported, oesophageal lumen of the Combitube. This was confirmed by bilateral chest expansion, auscultation of the lungs and an improvement in the peripheral saturation to 98%. After control of the airway and breathing, infusions of epinephrine 0.15 µg kg–1 min–1 and norepinephrine 0.05 µg kg–1 min–1 were commenced via a central vein to maintain arterial pressure at 95/50 mm Hg. After 1 h of i.v. 1% propofol sedation, mandatory pressure control ventilation with 100% oxygen, and no spontaneous respiratory efforts, arterial blood gas analysis showed pH 7.22, PCO2 6.9 kPa, PO2 64 kPa, and base excess –6.8 mmol litre–1.
At this stage, detailed discussions regarding patient prognosis took place between all the relevant physicians and the patients’ family. In view of the patient’s age, premorbid state and presenting pathology, and the systemic insult of two episodes of hypoxia, the decision was taken not to escalate treatment further. Over the following 10 h, lung ventilation through the Combitube was continued, but the patient became progressively hypotensive and died.
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Discussion |
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TopAbstractIntroductionCase reportDiscussionReferences |
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If the airway needs to be secured and tracheal intubation has failed, then the use of adjuncts may be life saving. The Combitube and LMA are included in the European Resuscitation Council guidelines for the management of the emergency airway.1 Previous studies have confirmed the effectiveness of the Combitube in hospital-based cardiopulmonary resuscitation,3 4 in the management of the trauma patient,5 and in ventilation of the lungs both during routine surgery,6 and on the intensive care unit.7 Many difficult airway situations have been managed using the Combitube airway,8–12 and it compares favourably with the LMA when used by unskilled staff.13–16
Management of the airway of a patient with halo frame cervical spine immobilization in place is difficult. The halo frame immobilizes the head and neck, and prevents ‘sniffing the morning air’ positioning for intubation, where the cervical spine is flexed and the craniocervical junction extended. Undue force used during laryngoscopy and tracheal intubation may move the cervical vertebrae and jeopardize the spinal cord. For these reasons, preference over direct laryngoscopy is usually given to awake fibre-optic tracheal intubation, or use of the intubating LMA. In this case, as discussed below, only the contents of the ward emergency airway trolley as described were immediately available. The author became involved during the second airway episode, at which point the Combitube was available from his personal supply.
The Combitube is designed for insertion in the neutral position, with the occiput on the flat surface on which the patient is positioned. Supine patients with Halo frame immobilization approach this position. Successful use of the Combitube in the elective anaesthetic airway management of a patient with Halo frame cervical spine fixation has been described.17 The natural curve and rigidity of the Combitube facilitates its passage around the angle between the axis of the oral cavity and larynx. It, therefore, proved ideal in this case.
The recommended position for insertion of the LMA is ‘sniffing the morning air’.18 This is clearly not possible with a halo frame in place.
The LMA was successful in the first instance of emergency airway control, but failed after further craniocervical flexion during the second episode.
This is the first case described using the Combitube in the emergency management of the airway of a patient with halo frame cervical spine immobilization in place. It is also the first case of emergency airway management described where other airway techniques, including the use of the LMA, have failed and the Combitube succeeded. Moreover, airway obstruction caused by placement of a halo frame has not been reported. Pathology associated with the initial trauma, such as retropharyngeal haematoma, can cause obstruction, although in this case, no such abnormality was seen at initial laryngoscopy, and the post-mortem reported the upper airways as normal.
The cause of both acute deteriorations was airway obstruction following craniocervical junction flexion, the flexion being greater in the second instance (Fig. 3). However, this only became apparent after extubation on the ICU. The differential diagnosis initially included acute pulmonary oedema (although this was not evident clinically), cervical cord damage (although the patient moved all limbs throughout and no external cord abnormalities were seen at post-mortem examination), and tracheal mucus plugging (which was also not seen at post-mortem).
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In hindsight, better equipment to manage the second episode should have been available on the operating theatre difficult airway trolley, which contained the intubating LMA and intubating fibrescope. Additionally, at any stage craniocervical deflexion may have alleviated the airway obstruction, but at the risk of compromising the cervical spinal cord.
When resuscitating the unconscious patient, where the ‘sniffing the morning air’ position is not achievable because the cervical spine is, or must be, immobilized in the neutral position, then the Combitube may be preferential to the LMA as an adjunct device, or for use by those not skilled in tracheal intubation. In this regard, inclusion of the Combitube in the emergency airway trolley would be beneficial, although this does assume the operator has prior experience of all of these airway techniques.
In conclusion, this case demonstrates the utility of the Combitube in the management of the emergency airway in a hitherto unreported setting. It has been demonstrated to be effective where other airway techniques have failed, and its inclusion in the European Resuscitation Council guidelines has been reiterated.
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References |
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