Awake tracheostomy in a child with respiratory distress due to retropharyngeal abscess

Summary

Awake tracheostomy in a child with respiratory distress is an emergency life‐saving procedure when risk of airway loss after induction of general anaesthesia is greater due to difficult anatomy. A 10‐year‐old boy presented three days after removal of a foreign body in the throat under general anaesthesia. Over the subsequent days, the patient had a progressively increasing visible swelling in the neck, stridor and respiratory distress. An urgent X‐ray and computed tomography scan of the neck revealed a retropharyngeal abscess compressing the trachea. Due to anticipated difficulty in airway management under general anaesthesia, we decided to perform an awake tracheostomy. The child and the parents were counselled regarding steps of awake tracheostomy, as well as the benefits and possible risks associated with it. Topicalisation was achieved by administering glycopyrrolate, nebulisation with lidocaine 4%, and the skin was prepared with lidocaine 2% with 1:200,000 adrenaline. After the awake tracheostomy was successfully performed, general anaesthesia was induced and the retropharyngeal abscess was drained. Effective communication and building rapport is essential for safe awake tracheostomy in a child with respiratory distress when impending airway loss may occur at any moment.

Introduction

Retropharyngeal abscess is a potentially life‐threatening condition that can occur following trauma in children. Anatomically, retropharyngeal space extends from base of skull to the posterior mediastinum and is enclosed by buccopharyngeal and alar fascia. Trauma to posterior pharynx can cause retropharyngeal abscess [1]. Treatment of this condition includes airway management; oxygen therapy; and antibiotics. A rapidly developing retropharyngeal abscess can lead to airway obstruction and hypoxia, and potentially death [2]. Awake tracheostomy in a child with respiratory distress is an life‐saving procedure when risk of failed tracheal intubation is high due to difficult anatomy [3]. The challenges during awake tracheostomy in a child are unique due to difficult anatomy and challenges in cooperation [4]. The role of effective communication and rapport building with the child is the core component in counselling a child with respiratory distress due to impending airway loss [5].

Report

A 10‐year‐old, 35 kg, boy presented to the emergency room of a tertiary hospital with audible stridor and respiratory distress. The patient had a history of ingestion of a plastic toy three days previously which was atraumatically removed under general anaesthesia (GA). Over the subsequent days, the patient developed a progressively increasing visible swelling in the neck with audible stridor, orthopnea, dysphagia and neck swelling. An urgent X‐ray of the neck and computed tomography scan revealed a retropharyngeal abscess compressing the trachea in an hourglass appearance. The retropharyngeal abscess was large and occupied the oropharynx, laryngopharynx and the infra‐glottic part of trachea (Fig. 1). The child had a heart rate of 120 beats.min^‐1 and a respiratory rate of 30 beats.min^‐1, could not lie down, and S_pO₂ of 98 % on F_IO₂ of 0.6, therefore emergency drainage of the abcess was required. In the interim, supportive treatment included, intravenous (i.v.) ceftriaxone 1 g 12‐hourly, nebulisation with ipratropium bromide and salbutamol every 6‐hourly.

Figure 1.

Anteroposterior and lateral X‐ray view of‐neck showing narrowing of airway and subglottic tracheal compression.

Anaesthesia and airway management for surgery was expected to be challenging because of the potential difficulties in ventilation and the potential for rupture of the retropharyngeal Thus, an awake tracheostomy was decided as our initial airway management strategy. Should that technique fail, we had planned for a cricothyroidotomy with trans‐tracheal jet ventilation backup plan B. The child and the parents were counselled regarding steps of awake tracheostomy, benefits and possible risks. Premedication included i.v. glycopyrrolate 0.2 mg, pantoprazole 20 mg and nebulisation with lidocaine 4%. The child and his father of the child were brought into the operating room and the child was asked to position himself in the most comfortable sitting position to avoid respiratory distress. The patient was kept occupied by a resident who showed him a cartoon movie on the phone and also comforted him by continuously prompting the steps of the procedure, whilst standard monitoring was placed. The difficult airway cart and resuscitation trolley were kept ready. The patient was pre‐oxygenated via nasal prongs at 4 l.min^‐1. Generous local infiltration was given with lidocaine 2% with 1:200,000 adrenaline with a 26 G hypodermic needle. After ensuring adequate skin analgesia, the awake tracheostomy was performed in 3.5 min and a 6.0 mm tracheostomy tube was inserted. After ensuring correct placement of tracheostomy tube with capnography, general anaesthesia was instituted with i.v. fentanyl 70 µg and propofol 60 mg, with atracurium 20 mg administered for neuromuscular blockade. General anesthesia was maintained on oxygen in air and 1–2 % sevoflurane. Incision and drainage of retropharyngeal abscess was performed by otolaryngologist. A nasogastric tube was inserted for feeding at the end of the surgery after which neuromuscular blockade was reversed with i.v. neostigmine and glycopyrrolate. The patient was then kept in the ward on oxygen 8 l. min^‐1 delivered with a T‐piece initially and later transferred to room air. Intravenous acetaminophen 500 mg 6 hourly and psychological support was provided in postoperative period. The patient was decannulated after 7 days and is now able to breathe and swallow without any difficulty.

Discussion

Retropharyngeal abscess with potential life‐threatening dyspnoea requires rapid and definitive airway management. A ‘cannot intubate, cannot ventilate’ scenario can be detrimental for both patient and the anaesthetist. Airway management techniques including videolaryngoscope; supraglottic airway; and flexible bronchoscopic intubation were not feasible in the present case due to the supraglottic anatomical bottle neck and the risk of aspiration. This allowed only infraglottic intervention as definitive airway. Hence, an awake tracheostomy was planned in the present case. The use of periprocedural sedation was considered, but this could have decreased the respiratory effort of the child and may have caused hypoxia. The peri‐operative team decided to use lidocaine nebulisation; anti‐sialagogue; antiemetic; paraoxygenation; counselling; local anaesthetic infiltration; and awake tracheostomy. In an event of non‐cooperation and loss of airway preparation for front‐of‐neck airway (FONA) via cricothyroidotomy and trans‐tracheal jet ventilation were kept ready. Cricothyroidotomy is associated with high failure rate and should not be practiced by untrained anaesthetists [6]. According to Association of Paediatric Anesthetists (APA), Difficult Airway Society (DAS) guidelines and All India Difficult Airway Association, FONA was recommended if an otorhinolaryngologist was not available [7, 8]. We chose awake tracheostomy in the present case to maintain airway tone; allowed spontaneous ventilation; continue appropriate pre‐oxygenation; and reduce the risk of pulmonary aspiration.

Literature describes awake tracheostomy in a 7‐year‐old girl child with large supraglottic mass obstructing the laryngeal inlet [9]. The authors used periprocedural topical lidocaine cream; sedation with midazolam; ketamine; and a dexmedetomidine infusion. However, opted to avoid sedation to minimise the risk of patient non‐cooperation and loss of airway.

The importance of adequate counselling was critical in the management of our patient. There are a series of core principles of communication used by anaesthetists for paediatric patients [5]. Counselling played an important role in the management of this case as an awake procedure was performed in a paediatric patient.

To conclude, awake tracheostomy in a child requires meticulous planning of the airway, good counselling and team coordination for a successful outcome.

Acknowledgements

No external funding or competing interests declared. Published with the written consent of the patient's parents.