Undiagnosed tracheomalacia accompanied with accidental expiratory central airway collapse after tracheal intubation

Abstract

Background A patient with undiagnosed tracheomalacia undergoing surgery experienced accidental expiratory central airway collapse after tracheal intubation. Here, we aimed to diagnose tracheomalacia from the preoperative data. Case Presentation A 73‐year‐old man, scheduled for abdominal surgery, had a clinical history of chronic obstructive pulmonary disease. Preoperative chest computed tomography revealed a lateral narrowing of the tracheal shape. After tracheal intubation, we could not manually ventilate the inflated lung. Emergent bronchoscopy findings, including severe expiratory tracheal collapse, indicated a diagnosis of tracheomalacia. We could fully ventilate the patient by moving the endotracheal tube near the tracheal carina and finally changing it to a double‐lumen tube. Airway collapse did not occur under spontaneous breathing. Conclusion Accidental expiratory central airway collapse could occur in patients with undiagnosed tracheomalacia during surgery. A diagnosis of tracheomalacia should be presumed from a deformed trachea on preoperative imaging and history of chronic obstructive pulmonary disease.

Expiratory Central Airway Collapse and Dynamic Hyperinflation During Peroral Endoscopic Myotomy: A Case Report

“…Other strategies include avoiding muscle relaxants and maintaining spontaneous ventilation during general anesthesia, utilizing regional techniques, if appropriate, and postponing elective procedures until corrective treatment such as stenting for ECAC is sought. 6 Emergency equipment, including fiberoptic bronchoscope, ETT, DLT, and rigid bronchoscope 6,13 to manage dynamic airway collapse should be available in patients with severe ECAC. The resolution of ECAC may sometimes be promptly achieved by removing the endoscope or other instruments that may be contributing to or directly causing a physical obstruction.…”

“…Placement of the ETT beyond the level of the obstruction to stent the airway open is the goal. 13 If the obstruction is at, or just above the carina, a double-lumen tube (DLT) may be preferred despite its higher invasiveness. 13 Providing 1-lung ventilation by maneuvering a single-lumen ETT past the carina may be useful to provide emergency management of EDAC; however, maintaining this technique throughout the procedure may result in hypoxia and hypercarbia, particularly with the use of carbon dioxide insufflation.…”

“…13 If the obstruction is at, or just above the carina, a double-lumen tube (DLT) may be preferred despite its higher invasiveness. 13 Providing 1-lung ventilation by maneuvering a single-lumen ETT past the carina may be useful to provide emergency management of EDAC; however, maintaining this technique throughout the procedure may result in hypoxia and hypercarbia, particularly with the use of carbon dioxide insufflation. In our case, ECAC occurred near the carina during submucosal tunneling; however, more invasive airway measures were unnecessary given the prompt airway obstruction resolution after endoscope removal.…”