Apnoeic oxygenation using transnasal humidified rapid-insufflation ventilatory exchange during rigid bronchoscopy: a report of four cases

General anaesthesia with a muscle relaxant is usually performed for rigid bronchoscopy (RB), but ventilation is challenging due to large amounts of leakage. Optiflow™ supplies 100% humidified, warmed oxygen at a rate of up to 70 l/min and this high flow rate may overcome the leakage problem. This case report describes four patients that were scheduled for RB. The lung lesions were all located below the carina, so a bronchial tube was inserted under general anaesthesia. Once a large amount of leakage was confirmed by manual ventilation, Optiflow™ was connected to the bronchial tube (flow rate, 70 l/min). All of the ports of the bronchoscopy were left open to prevent the risk of outlet obstruction. Oxygenation was well maintained with stable vital signs throughout the procedures, which took up to 34 min without airway intervention. There were no occurrences of cardiac arrhythmia or changes in the electrocardiograms. Respiratory acidosis recovered after emergence, which was confirmed by arterial blood gas analysis in all cases. Apnoeic oxygenation using Optiflow™ was applied successfully during RB. Applying Optiflow™ could make cases of difficult ventilation during RB much easier for the anaesthetist. Larger studies need to demonstrate the efficacy and safety of this technique.

DIAGNOSTIC BRONCHOSCOPY FOR EVALUATION OF CONGENITAL STRIDOR:A CASE SERIES

Introduction: Stridor is a noise mechanically produced through partially occluded airway. Airway obstruction may be extrathoracic or intrathoracic. Stridor may be congenital or acquired. Timing in respiratory cycle determines anatomic location of lesion – inspiratory, biphasic, or expiratory. Gold standard for diagnosis is bronchoscopy which requires general anaesthesia in infants and small children. Major anaesthetic concerns are – possible difficult airway, sharing of an already compromised airway, airway oedema. Case Description: 40 infants, 0 - 6 months age, with history of noisy breathing suggestive of congenital stridor, planned for diagnostic rigid bronchoscopy with or without therapeutic procedure, over one year period. Preoperative treatment – humidified oxygen, nebulization, dexamethasone, antibiotics, anti-reflux medication. Not premedicated, standard monitors applied. Induction of anaesthesia with inhalational oxygen and sevoflurane or intravenous propofol, fentanyl 1 mcg/kg, dexamethasone 0.5 mg/kg. Topical lidocaine 2% sprayed at vocal cords. 100% oxygen with propofol infusion for maintenance with spontaneous ventilation via nasopharyngeal airway. Patients requiring surgical intervention intubated using microcuffed endotracheal tube. Patients observed post-operatively. If ventilation was inadequate, intubated to control airway during recovery, extubated on restoration of spontaneous ventilation. After surgical intervention, babies shifted to ICU for elective ventilation for 48 hours. Discussion: On bronchoscopy, laryngomalacia was the finding in majority of cases. Others had subglottic stenosis, tracheomalacia, vocal-cord paresis, laryngeal cyst. Out of 40 patients, 9 underwent therapeutic procedure and were electively ventilated, 26 resumed spontaneous breathing, 2 patients had delayed recovery and 2 had severe chest retractions and desaturations and they were managed accordingly. One baby aged 6 months diagnosed with grade III subglottic stenosis desaturatedand tracheostomy had to be done. Conclusion:Anaesthesia for rigid diagnostic bronchoscopy is a significant challenge. Rigid bronchoscopy under general anaesthesia requires multidisciplinary approach and close cooperation between all team members.

Airway Management and Anesthesia for Tracheal Resection in a 68-Year-Old: 3 Airways for the Price of 1

Subglottic tracheal stenosis can occur after prolonged intubation or tracheostomy. This stenosis can become severe and causes symptoms refractory to endoscopic interventions that require tracheal resection. This surgery presents unique anesthetic issues due to the airway anatomy, physiology, and shared airway management with the surgical team. We present the case of a 68-year-old patient who underwent cervical tracheal resection and reconstruction due to persistent symptoms despite balloon dilation and medical management with oxygen and heliox. Our anesthesia management involved several techniques that allowed the safe completion of this procedure. Firstly, we started the airway management with a combined size 4 Ambu® AuraStraight™ (Denmark) supraglottic airway device and flexible bronchoscopy to allow localization of the stenosis and dilation before endotracheal tube (ETT) placement. The conventional approach for this endoscopic evaluation phase is to use rigid bronchoscopy. Secondly, we used prior CT images to help guide our ETT tube size selection. Thirdly, we used total intravenous anesthesia during most of the procedure because of the intermittent apnea necessary to complete the tracheal resection. Lastly, extubation had to be done very carefully to minimize excessive patient neck movement and avoid any reintubation. Both could lead to a catastrophe with the newly reconstructed trachea.

Rigid Bronchoscopy in Foreign Body Aspiration Diagnosis and Treatment in Children

Foreign body aspiration in children is a common condition and can bring about serious undesired results. Fast and accurate diagnosis and foreign body extraction from airways are essential. We performed a retrospective study on rigid bronchoscopy outcomes due to suspected foreign body aspiration. A total of 66 children were admitted to the Chair and Department of Pediatric Otolaryngology, Phoniatrics and Audiology, Medical University of Lublin between 2015 and 2020 and underwent rigid bronchoscopy in general anesthesia due to suspected foreign body aspiration. We analyzed the data, including patients age and sex, reported complaints, and bronchoscopy findings. Analyzed children were aged from 8 months to 17 years old; 74.24% of them were under 3 years old during the procedure, and most of the operated patients were males. In 36.36% cases, no foreign body was identified, and 57.14% foreign bodies were located in right main bronchus. A total of 80.95% of foreign bodies extracted from airways were organic, mostly nuts. Diagnosis and treatment of suspected foreign body aspiration requires consistent cooperation between pediatricians, pulmonologists, anesthesiologists, and otolaryngologists.

A Case of Whistle as Foreign Body in Trachea

Background. Most of foreign body aspiration cases are found in children under the age of fifteen. Pediatric patients often presents with non-food foreign body aspiration, such as toys. The most common clinical manifestation are history of choking following foreign object insertion into the mouth (85%), paroxysmal cough (59%), wheezing (57%) and airway obstruction (5%). Case presentation. Main principle of airway foreign body extraction is to do it immediately in the most optimal condition with slightest possible trauma. Rigid bronchoscopy is a suitable choice for tracheal foreign body extraction. We reported a case of seven years old male with tracheal foreign body presented with history of whistle ingestion five hours prior to admission. This patient was discharged from hospital after third days of rigid bronchoscopy procedure. Conclusion. History of foreign body aspiration in children should be suspected as a tracheobronchial foreign body. Rigid bronchoscopy is preferred to extract foreign bodies present in the trachea. The prognosis for tracheobronchial foreign body aspiration is good if the foreign body is treated early and without complications.

A challenging case of tracheal foreign body retrieval following COVID-19 swabbing

The COVID-19 pandemic has resulted in a significant increase in the number of tracheostomised patients in hospitals requiring ventilatory support. These patients require highly specialist care, but overwhelmed hospital systems with stretched human resources potentially leave these patients cared for by undertrained healthcare professionals. We describe a rare complication where a routine COVID-19 swab done incorrectly via a tracheostomy tube, resulted in a snapped-off swab in the trachea. We outline the events and our method of removal using rigid bronchoscopy through the tracheostomy stoma as endo-tracheal bronchoscopy was impossible due to significant sub-glottic stenosis. This case highlights the paramount importance of the unique care needed to safely manage tracheostomies during this ongoing pandemic.