“Cannot Intubate_Cannot Ventilate” Emergency: Airway Management of Difficult Airway in a Patient; A Case Report
AbstractThe present study reports a 42 years old male patient with modular thyroid cancer. The patient became candidate for direct laryngoscopy (DL) in order to observe the condition of the lesion in the trachea and probable biopsy, and subsequent surgery. After a few moments, it was observed that the patient cannot be ventilated. Immediately, the patient was tried to be intubated but was not successful and thus, quick track was put for the patient rapidly and he was connected to the jet ventilation machine. But after a short time, suddenly the patient got bradycardia and respiratory interruption and drop in saturation that the patient underwent CPR operation which continued for 30 seconds which resulted finally in the patient’s heart rate reaching 100 and spontaneous breathing began. After auscultation of lungs, bilateral pneumothorax was diagnosed that according to previous studies, is probably a complication resulting from trans tracheal jet ventilation (TTJV). This complication was resolved through needle aspiration. After 4 hours, the surgery was over and the patient, with stable vital signs and spontaneous breathing, was sent to the intensive care unit.In some previous studies, the researchers have suggested using open surgical technique in order to reduce the complications resulting from cannot intubate, cannot ventilate (CICV), and the present study also supports this suggestion and recommends it to other anesthesiologists when facing CICV situation, in order to reduce the complications resulting from jet ventilation and its subsequent damages.
Danlon JV, Doyle J, et al. Anesthesia for eye, ear, nose, and throat surgery. In: Miller RD. Miller's Anesthesia. 6th edition; Philadelphia, Churchill Living stone 2002; 2527-2570.
Rosenblatt WH. Airway management. In: Barash PG, Cullen BF, Stoelting RK, eds. Clinical anesthesia. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2001:614 –5.
Caplan RA, Posner KL, WARD RJ. Adverse respiratory events in Anesthesia. Anesthesiology 1990; 72(5):828-33.
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG. et al. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013; 118(2):251– 270.
Brock-Utue JG, Goeta RR. Otolaryngology, Heart, Neck surgery. In: Anesthesiologist's manual of surgical procedures. 2th edition; Philadelphia; Lippincott Williams & Wilkins, 1999; 119-620.
Wong DT, Lai K, Chung FF, Ho RY. Cannot intubate–cannot ventilate and difficult intubation strategies: results of a Canadian national survey. Anesthesia & Analgesia. 2005; 100(5):1439-46.
Duggan LV, Ballantyne Scott B, Law JA, Morris IR, Murphy MF, Griesdale DE. Transtracheal jet ventilation in the ‘can't intubate can't oxygenate’emergency: a systematic review. BJA: British Journal of Anaesthesia. 2016; 117(suppl_1):i28-38.
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. 2013; 118(2): 251–70.
Heard AMB, Green RJ, Eakins P. The formulation and introduction of a ‘can’t intubate, can’t ventilate’ algorithm into clinical practice. Anaesthesia. 2009; 64(6): 601–8.
Cook T,Woodall N, Frerk C. 4th National Audit Project (NAP4): Major complications of airway management in the UK. 2011. https://rcoa.ac.uk/nap4
Peterson G, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway. Anesthesiology. 2005; 103(1):33–9.
Liu EH, Asai T. Cannot intubate cannot ventilate—focus on the 'ventilate'. J Anesth. 2015; 29(3):323-325.
hadadi S, salmani A. Management of the difficult Airway. J Holist Nurs Midwifery. 2008; 18(1):51-54 [In Persian].
Frerk C, Mitchell V, McNarry A, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 delines for management of the unanticipated difficult intubation in adults. Br J Anaesth. 2015; 115(6):827-48.
Black A, Flynn P, Popat M, Smith H, Thomas M, Wilkinson K. APA DAS Cannot intubate and cannot ventilate (CICV) in a paralysed anaesthetised child aged 1-8 years. http://www.das.uk.com/files/APA3-CICV-FINAL.pdf
Love S, Oti C, Kakar V. Transtracheal jet ventilation in failed intubation; not just a rescue intervention. In: Difficult Airway Society Annual Meeting Abstracts. 2014; 117(1): 28-38.
Smith RB, Schaer WB, Pfaeffle H. Percutaneous Transtracheal ventilation for anaesthesia and resuscitation: A review and report of complications. Can Anaesth Soc J. 1975; 22(5):607-12.
Weymuller EAJ, Pavlin EG, Paugh D, Cummings CW. Management of difficult airway problems with percutaneous transtracheal ventilation. Ann Otol Rhinol Laryngol. 1987; 96(1 Pt 1):34-7.
McHugh R, Kumar M, Sprung J, Bourke D. Case Reports: Transtracheal jet ventilation in management of the difficult airway. Anaesth Intensive Care Med. 2007; 35(3):406–8
Patel RG. Percutaneous Transtracheal Jet Ventilation* A Safe, Quick, and TemporaryWay To Provide Oxygenation and Ventilation When Conventional Methods Are Unsuccessful. Chest J. 1999; 116(6): 1689–94.