Abstract

Upper airway obstruction, although uncommon, is an urgent situation demanding quick access to the trachea. Cricothyroidotomy is considered to be the gold standard method to secure the airway is these cases. However, emergency tracheostomy is a prompt alternative. A case of a 55-year-old suffering from upper airway obstruction is described. The patient was transferred to the Emergency Department unconscious and he was rapidly deteriorating. Percutaneous tracheostomy was immediately performed successfully. Further investigation revealed squamous cell carcinoma of the larynx and total laryngectomy was performed a few days later. Tracheostomy is not recommended for emergency airway management, but it is a life saving technique that should be taught to all emergency medicine physicians.

Citation: Apostolopoulou A, Zouka M, Gkinas D, Gkarmiri S, Nano A, et al. A case of percutaneous tracheostomy in the emergency department. J Clin Images Med Case Rep. 2024; 5(6): 3096

Background

Cricothyroidotomy stands as the rescue technique of choice for gaining emergency access to the airway in cases of failed airway in adults. However, there are some cases where this approach may not be feasible. Tracheostomy is typically a planned procedure for long-term airway management. Due to time-intensive nature of airway issues, tracheostomy is not considered an emergency procedure and therefore is not recommended for emergency airway management. However, several cases of airway obstruction have been documented in the literature, where emergency tracheostomy was successfully employed [1-3].

Case presentation

A 55-year old man was transferred to the Emergency Department (ED) unconscious, as he had collapsed a few minutes ago at home. Possible upper airway obstruction was suspended, as the patient had signs of acute respiratory failure: inspiratory stridor with rapid shallow breathing and SpO₂ of 60%. The auscultation revealed silent chest. Patient was hemodynamically stable with mild sinus tachycardia 130 beats/minute and blood pressure 170/68 mmHg. Evaluation of his neurological status showed GCS (Glascow Coma Scale) 2-1-5. According to his medical history he suffered from deep venous thrombosis at the lower left limb and he was receiving 5 mg apixaban daily.

A face mask was placed and 100% oxygen was immediately delivered to the patient. Intramuscular administration of 0.5 mg adrenaline was decided in case of anaphylactic shock. Direct endoscopy performed by an otolaryngologist revealed loose swelling of the false vocal cords, and possible hypoglottic swelling. However, identification of cricoid cartilage was impossible and patient was deteriorating rapidly. Therefore, Percutaneous Tracheotomy (PT) was immediately decided and performed without any complications. Immediately thereafter, patient was ventilated with mask and AMBU (artificial manual breathing unit). Patient showed rapid clinical improvement both with regard to respiration parameters (SpO₂ increased to 100%, respiratory pattern and auscultation findings improved) and regarding his level of consciousness (GCS 15/15). Patient was then connected to the ventilator on spontaneous mode.

Patient was transferred to the ENT (Ear-Nose-Throat) Department where he was diagnosed with squamous cell carcinoma of the larynx, stage T4N0M0 and total laryngectomy with bilateral lymph node dissection was scheduled and performed a few days later.

Discussion

Upper airway obstruction necessitating swift access to the trachea is rare; however, when it does arise, it poses a life-threatening situation requiring immediate intervention. The algorithm of difficult airway management recommends a step by step approach with gradual escalation and use of various aids such as supraglottic devices which serve as alternatives to tracheal intubation [4]. However, when confronted with supraglottic or glottic obstruction, rapid access to the tracheal lumen becomes imperative.

At present, percutaneous tracheostomy is not recommended as first choice for emergency airway management, because tracheostomy is not an emergency procedure and might result in delayed resolution of acute airway challenges. Surgical cricothyroidotomy should be prioritized as the preferred technique, particularly in instances of hypoxemia [5]. Nevertheless, impossible visual or digital identification of the cricoid cartilage or cases of tumor masses in the region and/or anatomical abnormalities require alertness for an alternative method. Emergency tracheostomy may be then the sole option to ensure airway security facilitating ventilation, suctioning, and bronchoscopy, minimizing damage to the vocal cords, and obviating the need for conversion to a more stable airway [6].

Malignancies are the most common cause of airway obstruction [7,8]. Squamous cell carcinoma arising from the mucosal layer is the most common histology identified in 95% of the cases of hypopharyngeal cancer. Advanced tumors may invade the larynx, leading to possible airway obstruction and increased risk of aspiration [9], but acute respiratory failure is not commonly the preceding symptom in laryngeal tumors.

In the case described above, the first option would be approaching the airway quickly by cricothyroidotomy. However, since identification of cricoid cartilage was impossible and our patient was deteriorating rapidly, percutaneous tracheostomy was immediately decided as an alternative method to secure patient’s airway. Transcutaneous tracheostomy technique should be an arrow in the quiver of the emergency medicine physician. Appropriate training can potentially prevent serious adverse events in cases of upper airway obstruction.

References

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