Acute airway obstruction, hypertension and kyphoscoliosis

An elderly woman developed acute respiratory obstruction after choking on a bolus of food. On rigid bronchoscopy no foreign body, or anatomical obstruction was seen, but airway obstruction recurred during emergence from general anaesthesia, and was thought to be functional in nature. A recurring airway obstruction followed, relieved by induction of anaesthesia and by sedation. This was subsequently demonstrated to be caused by a tortuous aorta which impinged intermittently on the anterior tracheal wall, as a result of kyphoscoliosis of the thoracic spine. We attribute the relief of airway obstruction by general anaesthesia to a reduction in arterial blood pressure.     

Airway obstruction during general anaesthesia in a child with congenital tracheomalacia

Fibreoptic bronchoscopy is often used to diagnose tracheomalacia under local anaesthesia. However, in children, general anaesthesia may be required due to difficulty in obtaining co-operation. A 1-yr-old girl with a suspected congenital tracheomalacia was scheduled for diagnostic fibreoptic bronchoscopy. During induction of anaesthesia by inhalation of increasing concentration of sevoflurane, spontaneous breathing became irregular and a partial airway obstruction occurred. Because vecuronium relieved the airway obstruction, the airway was managed using a laryngeal mask. No further airway obstruction occurred during fibrescopy under controlled ventilation, but when spontaneous breathing resumed, marked airway obstruction occurred. The trachea was intubated immediately. Caution is required to manage the airway without tracheal intubation during general anaesthesia in the patient with tracheomalacia.     

Compression trachéale par une masse médiastinale chez l’enfant: Intérêt de la fibroscopie trachéobronchique pour la prise en charge anesthésique

Due to the action of the drugs and the position of the patient, general anaesthesia in a child with a mediastinal tumor can complete the obstruction of the trachea and/or the main bronchi and possibly result in irreversible respiratory failure. The risk is directly Iinked to the degree of lumen amputation of the trachea, usually evaluated by CT-scan: there is a risk of accident if the degree of lumen amputation is greater than 30 %. The case reports underline the value of the flexible fibreoptic bronchoscopy under local anaesthesia. This examination, as weil as the CT-scan, allows to evaluate the degree of tracheal compression. Moreover, it carries a lower risk than the CT-scan which requires, in a small child, either general anaesthesia or heavy premedication which could lead to asphyxia. Total obstruction most often occurs with anterior mediastinal tumors. However, even posterior or lateral tumors can extend to an anterior position, especially in the young child. If the obstruction of the lumen is greater than 30 % and if general anaesthesia is required, the fibreoptic bronchoscopy allows endotracheal intubation under local anaesthesia before general anaesthesia. We report 5 cases which illustrate the risk of tracheal compression during general anaesthesia in patients with a mediastinal tumor and substantiate the advantages of a flexible fibreoptic bronchoscope in the management of these patients before and during general anaesthesia.     

Temporary extracorporeal jugulosaphenous bypass for the peri-operative management of patients with superior vena caval obstruction: a report of three cases

Superior vena caval obstruction from a mediastinal mass presents a significant risk to patients requiring general anaesthesia, with reports of sudden death on induction of anaesthesia, during intubation and on initiation of positive pressure ventilation. We describe the first reported use of temporary extracorporeal jugulosaphenous bypass in three cases of superior vena caval obstruction and extrinsic tracheal compression caused by massive retrosternal multinodular goitre. The bypass was performed before induction of general anaesthesia with consequent reduction in upper body venous pressure and avoidance of complications.     

Redistribution of halothane and sevoflurane under simulated conditions of acute airway obstruction

Forty patients having surgery requiring muscle paralysis and tracheal intubation were randomly allocated to receive either halothane (n = 20) or sevoflurane (n = 20). Following intravenous anaesthesia and tracheal intubation, inhalation induction of anaesthesia was simulated. After attaining an end-tidal anaesthetic concentration of 2 MAC for the respective agent, the airway was obstructed for 3 min. The end-tidal anaesthetic concentration was measured for the first three breaths following the period of airway obstruction. The decrease in alveolar concentration of sevoflurane following 3 min of airway obstruction was found to be significantly greater than that of halothane. We conclude that even if the airway obstructs completely during inhalational induction of general anaesthesia, awakening would be faster with sevoflurane than with halothane.     

Spannungspneumothorax nach akuter Atemwegsverlegung bei pulmonaler Aspergillose

Acute lymphoblastic leukaemia is the most common malignancy in childhood. This disease and its associated therapy may lead to specific life-threatening complications if general anaesthesia has to be carried out. The case of a 14-year-old boy suffering from aspergillosis because of immunosuppression in the course of chemotherapy is reported. Due to a cerebral round lesion an open biopsy was required. After induction of anaesthesia, severe pulmonary obstruction developed. After exchange of the endotracheal tube a coagulum-like foreign body interspersed with Aspergillus hyphae obstructing the distal aperture in a valve-like manner could be recovered. The resulting unilateral tension pneumothorax had to be relieved with a closed pleural drainage. With reference to this as yet unreported life-threatening complication of pulmonary aspergillosis, the appropriate preparation and conduction of general anaesthesia are discussed.     

Airway obstruction due to arytenoid prolapse in a child

In paediatric patients, obstruction of the upper airway is still a common problem during general anaesthesia. This case report documents the susceptibility of arytenoids to prolapse in paediatric patients during halothane anaesthesia. The use of video endoscopy provides an excellent tool for visualizing this type of airway obstruction; and continuous positive airway pressure is an effective treatment for clearing the airway.     

Preoperative marijuana inhalation — An airway concern

Purpose

Cannabis Sativa (marijuana) may cause a variety of respiratory disorders including uvular oedema. This case illustrates that uvular oedema secondary to marijuana inhalation may cause a potentially serious postoperative clinical problem.

Clinical features

A healthy 17-yr-old man who inhaled marijuana prior to general anaesthesia. In the recovery room, after an uneventful general anaesthetic, acute uvular oedema resulted in post operative airway obstruction and admission to hospital. The uvular oedema was treated successfully with dexamethasone.

Conclusion

Recent inhalation of marijuana before general anaesthesia may cause acute uvular oedema and post operative airway obstruction. The uvular oedema can be easily diagnosed and treated.     

General anaesthesia may improve the success rate of hydrostatic reductions of intussusception

Intussusception is the most common cause of intestinal obstruction in young children. Hydrostatic enemas result in a successful reduction of intussusception in 50% to 80% of patients. Failure to achieve reduction with hydrostatic enema results in laparotomy, although a frequent finding upon exploration is complete reduction of the intussusception, presumably due to induction of general anaesthesia. Recent paediatric literature suggests that induction of general anaesthesia may improve the success rate of therapeutic hydrostatic enema. We report a difficult case of recurrent intussusception where the induction of general anaesthesia alone did not result in reduction of intussusception, but successful reduction by enema was achieved while the patient was anaesthetized.     

The airways and anaesthesia II

We pointed out in the first of these two articles [1] that the commonest cause of an anaesthetic disaster in young healthy patients is a loss of airway patency then a failure to intubate occurring unexpectedly in the absence of head or neck pathology. Upper airway obstruction is a very common complication of general anaesthesia and all anaesthetists must be trained in the management of this problem. Less obvious are the changes that can occur in the lower airways which can impair gas exchange by increasing ventilalion-perfusion mismatch. This article is concerned with these pathophysiological changes that occur during general anaesthesia.     

Endoscopy and intubation in cancer of the upper aerodigestive tract

The pathogenesis of upper airway obstruction from cancer arising in the larynx, pyriform fossa and oropharynx is discussed. Endotracheal intubation for general anaesthesia can be a hazardous procedure and alternatives are presented.     

Flexible bronchoscopy via the laryngeal mask: a new technique.

Malignant tracheal tumours often cause airway obstruction and this may be aggravated by vocal cord paralysis due to invasion of the recurrent laryngeal nerve. Conventional endoscopic techniques performed under general anaesthesia do not give a simultaneous view of vocal cord function and the distal airways. The technique of bronchoscopy via the laryngeal mask allowed full assessment of the cause of stridor in a patient with a malignant tracheal tumour that was causing airways obstruction and vocal cord paralysis.     

Œdème pulmonaire aigu par inhalation du cale-dents au réveil d’une anesthésie avec un masque laryngéPulmonary oedema due to the inhalation of the LMA bite-block during recovery.

We report a case of acute pulmonary oedema, consecutive to upper airway obstruction due to the inhalation of the laryngeal mask airway (LMA) bite block during recovery. The LMA was used for general anaesthesia with the bite-block provided in France. No trouble occurred during LMA insertion and anaesthesia. Symptomatic treatment provided complete resolution within a few days.     

Acute pulmonary edema from inhalation of the bite-block after anesthesia with a laryngeal mask]

We report a case of acute pulmonary oedema, consecutive to upper airway obstruction due to the inhalation of the laryngeal mask airway (LMA) bite block during recovery. The LMA was used for general anaesthesia with the bite-block provided in France. No trouble occurred during LMA insertion and anaesthesia. Symptomatic treatment provided complete resolution within a few days.     

Obstruction respiratoire au cours de l''anesthésie chez des enfants ayant un lymphome malin médiastinal

In children with a malignant mediastinal lymphoma, acute respiratory occlusion can be a life-threatening complication during general anaesthesia. 26 cases have been reported since 1973, with five deaths. There were 23 boys for 3 girls, aged between 13 months and 18 years. The hazards of anaesthesia in these children are described. The risk of airway obstruction should be assessed preoperatively. General anaesthesia, carried out with the patient half-sitting, should be aimed at maintaining spontaneous breathing, and therefore muscle relaxants should be avoided. The anaesthetist should also be prepared to change the patient rapidly to a lateral or prone position; a rigid bronchoscope should always be at hand. Preoperative awareness of the risk of respiratory occlusion in these patients is essential so that the correct anaesthetic technique can be chosen and the postoperative course prepared.     

Rapidly developing airway obstruction resulting from achalasia of the oesophagus

Megaoesophagus resulting from achalasia is a rare but serious cause of airway obstruction. The exact aetiology remains unclear. Although 29 cases have previously been reported, the potential need for urgent treatment has not been sufficiently emphasized. Some forms of treatment with drugs or decompression with a fine tube have been advocated but emergency tracheal intubation may become necessary. A 90-year-old lady had a bolus of food lodged in her oesophagus but with no respiratory symptoms. The bolus was removed under anaesthesia. Six weeks later she suffered similar symptoms after eating but developed severe airway obstruction over 10 min. Emergency intubation of the trachea was necessary before removing the food bolus under general anaesthesia. This case demonstrates the urgency with which these patients may need to be treated. The condition can rapidly worsen due to swallowing of air and saliva.     

Angina bullosa haemorrhagica presenting as acute upper airway obstruction

We report a case of acute upper airway obstruction caused bya rapidly expanding blood-filled bulla in the oropharynx (anginabullosa haemorrhagica), requiring tracheal intubation. The larynxcould not be visualized by either awake fibreoptic laryngoscopyor direct laryngoscopy under anaesthesia. Surgical tracheostomywas therefore performed under general anaesthesia. Br J Anaesth 2004; 92: 283–6     

An unexpected functional cause of upper airway obstruction

A case of acute respiratory obstruction in the immediate postoperative period is described in a young woman who emerged from general anaesthesia after a Caesarean section for fetal distress. She had a pregnancy complicated by disabling polyhydramnios and anxiously anticipated the birth of a child with a diaphragmatic hernia, diagnosed antenatally. The cause of the airway obstruction was functional in nature as confirmed by flexible fibreoptic laryngoscopy. The diagnosis, paradoxical vocal cord motion, has to be considered as an infrequent cause of postoperative airway obstruction; its recognition and treatment are discussed. The patient did not have a history which might have indicated its possible occurrence. It is suggested that paradoxical vocal cord movement in a more mild form may be overlooked as cause for postoperative stridor and airway obstruction.     

Obstructive respiration disorders. An aneurysm of the ventilator tubing during general anesthesia]

Technical problems during anaesthesia are important causes of anaesthesia-related deaths and brain damage. During general endotracheal anaesthesia for ophthalmic surgery (41-year-old man, ASA 1) we observed an increase in inspiratory pressure without other clinical changes. Disconnection and ventilation with a resuscitation bag showed normal inspiratory pressures. Inspection demonstrated an obstruction due to an aneurysm of the inner layer of the inspiratory tubing. The classification of this rare blockage of ventilation differs in the literature (pressure, hypoventilation, hypercarbia). In addition, it demonstrates the principal problem of clinical decision-making during anaesthesia based on monitoring information. Strategies for responding to alarms indicating hazards of ventilation must be based on immediate restoration of sufficient ventilation, and not primarily on detecting the cause.     

Anaesthesia for surgery of the trachea and main bronchi

The anaesthetic challenges of major tracheobronchial surgery relate to airway control, ventilation management, maintaining optimal surgical exposure and appropriate patient selection. Although such surgery is generally performed in specialist centres, the strategies for dealing with central airway obstruction and bronchoscopy under general anaesthesia are of broader importance. Furthermore, an intra-thoracic airway obstruction presents difficulties that require a different mindset to the more familiar scenario of an extra-thoracic airway obstruction. Tracheal stenosis following a period of prolonged tracheal intubation is now the leading indication for tracheal resection. A standard approach involves total intravenous anaesthesia, a right-sided arterial line, epidural analgesia and early extubation. Usually, a sterile armoured cuffed endotracheal tube is placed under direct surgical vision for the period of segmental resection followed by reintroduction of the native orotracheal tube under bronchoscopic vision for the primary end-to-end anastomotic reconstruction.