Emergency Percutaneous Tracheostomy after Unsuccessful Orotracheal Intubation in a Patient with an Acute Myocardial Infarction

Abstract

A 41-year-old woman had acute respiratory failure related to a myocardial infarction. Attempts at orotracheal intubation were unsuccessful; therefore, an emergency percutaneous tracheostomy was performed. The patient was then taken to the cardiac catheterization laboratory for myocardial revascularization. After the tracheostomy cannula was removed, the patient recovered successfully and was discharged from the hospital. The percutaneous tracheostomy technique may be useful in similar patients who need emergency airway access.

The percutaneous tracheostomy is an accepted means of accessing the airway to provide mechanical ventilation. First described in 1985 by Ciaglia and coworkers,¹ this technique has become widely used in the intensive care unit, where it can be performed quickly at the patient's bedside. It is primarily used for ventilator-dependent patients in whom a tracheostomy can facilitate clearing of secretions and weaning from the ventilator. In the emergency setting, however, the role of the percutaneous tracheostomy is less clear. Schachner and associates² described a rapid percutaneous tracheostomy technique for use in mass casualty and emergency situations; however, the use of this technique raises concerns about safety and spine stabilization. Many physicians advise against a percutaneous tracheostomy in the emergency setting and recommend a cricothyroidotomy instead. Others resort to the percutaneous technique only after orotracheal intubation fails.^3,4 We describe a case of respiratory failure related to an acute myocardial infarction in which an emergency percutaneous tracheostomy was used to salvage the patient.

Case Report

While hospitalized at another institution, an obese, 41-year-old woman had an acute myocardial infarction, followed by pulmonary edema and respiratory failure necessitating emergency airway access. Four unsuccessful attempts at orotracheal intubation were complicated by a glottal hemorrhage, which resulted in a lingual hematoma; therefore, this approach was abandoned. The patient was given tissue plasminogen activator and heparin to treat her myocardial infarction and was transferred to our hospital.

On admission to our coronary care unit in March 2003, the patient was semiconscious and in respiratory distress. Airway examination revealed a short neck with a limited range of motion, as well as a decreased thyromental distance, small mouth, and prominent incisors. Further examination revealed a swollen tongue and blood in the posterior pharynx. Despite some nasal hemorrhage, the patient was able to maintain an airway through a nasal trumpet. An ambulatory breathing unit and mask were applied, and 100 mg of succinylcholine was administered. The patient was ventilated with the breathing unit, and the oxygen saturation as measured by pulse oximetry (SpO₂) was maintained in the 90% to 93% range. On laryngoscopy, no glottal structures were visible. The supraglottal tissues were edematous, and hemorrhage was noted with gross blood in the pharynx, presumably from previous intubation attempts. Use of a laryngeal mask airway was not deemed possible. Because of the patient's obesity, a cricothyroidotomy or conventional tracheostomy would have been difficult in this anticoagulated patient and would have prevented further definitive emergency cardiac intervention. She was hemodynamically unstable, so an intra-aortic balloon pump (IABP) was inserted. During IABP placement, a percutaneous sequential dilational tracheostomy was performed (Per-fit™ percutaneous tracheostomy kit, Portex, Inc.; Keene, NH). After completion of the procedure, the carina was visible on bronchoscopic examination, and satisfactory mechanical ventilation was provided.

The patient was taken to the cardiac catheterization laboratory, where blood flow was reestablished through her occluded left anterior descending artery. Her hemodynamic condition improved, and she was transferred to the intensive care unit later the same night. During the next week, she recovered smoothly and was weaned from the IABP and mechanical ventilator. Her tracheostomy was sequentially downsized, and decannulation was performed before she was discharged on the 14th postoperative day. She had no airway complications and was able to tolerate a normal diet.

Comments

An open tracheostomy is the gold standard for establishing long-term airway access. Because this procedure is time-consuming and often difficult in an emergency setting, however, it is not generally recommended for emergency cases. A cricothyroidotomy can provide rapid airway access in an emergency and remains the standard treatment, but ventilation may be difficult, particularly in patients who have pulmonary edema with decreased pulmonary compliance.

The percutaneous tracheostomy is normally safe and efficacious; however, it can result in cannula dislodgment, airway obstruction, tracheal stenosis, or other complications and therefore is not generally recommended for emergencies. In fact, the manufacturer of the Per-fit tracheostomy tube warns that its use is contraindicated for airway insufficiency requiring emergency access. Nevertheless, a few case reports^3,4 have shown the efficacy of this approach for rapid tracheal access. Our case confirms that—under these special circumstances, when application of standard management techniques for a difficult airway⁵ were not possible—a percutaneous tracheostomy can be valuable in an emergency situation to establish airway access for further procedures and ventilator management. Whether or not this technique will supplant cricothyroidotomy in an emergency setting is unknown and is dependent upon the availability of the equipment and the familiarity of the operator with the technique.