Sir,
A 63-year-old female, weighing 84 kg, was operated for left temporo-parietal glioma.
In the postoperative period, she developed infarction in the left temporo-parietal
region and had poor Glasgow Coma Score (E2VETM3). Since the patient required prolonged mechanical ventilation, the decision for tracheostomy
was taken. However, as the patient had a short neck along with large submandibular
fatty tissues, an elective surgical tracheostomy in the operating room was planned.
The procedure was carried out under local anaesthesia with continuous monitoring of
heart rate, blood pressure, oxygen saturation and end-tidal carbon dioxide (ETCO2). Following skin incision, retractors were applied, and dissection of soft tissue
was completed. The trachea was identified, and an opening was made on the tracheal
wall. After suctioning of the oral cavity and oropharynx, the endotracheal (ET) tube
cuff was deflated and ET tube was withdrawn slowly (while watching the ET tube through
the opening made in the tracheal wall), till its lower end passed just proximal to
the opening made in the tracheal wall. However, before passing the tracheostomy tube
into the trachea through the tracheal wall opening, the retractors slipped and got
displaced and thus the tracheostomy tract was lost. In spite of repeated efforts,
the tracheal opening could not be relocated. Meanwhile, sliding of the ET tube back
to its position into the trachea was attempted but was unsuccessful though ventilation
of the patient through the ET tube with circuit and reservoir bag was possible (though
not satisfactory). While ventilating the patient with 100% oxygen using bag and circuit,
we observed visible gas leak through the dissected neck tissue. Suctioning was done
through the probable tracheostomy tract and to locate the trachea we attempted to
pass a 4.0 mm size ET tube through the point of the gas leak and succeeded. The ET
tube was then connected to the ETCO2 monitor, and the CO2 trace confirmed the placement of ET tube in the trachea. Then, a well lubricated
7.5 mm tracheostomy tube was railroaded over the 4.0 mm ET tube into the trachea after
removing the tube connector. Finally, the ET tube was removed, and the tracheostomy
tube was connected to the ETCO2 monitor. A sustained ETCO2 curve and visible chest rise confirmed the correct position of the tracheostomy tube
and the tracheostomy tube was secured.
Loss of tracheostomy tract can occur while performing tracheostomy and sometimes may
be difficult to relocate especially in patients with short neck and a large amount
of submandibular fat. Coleman et al.,[1] has demonstrated the usefulness of ETCO2 during percutaneous dilatational tracheostomy. In this case, we could locate the
lost tracheal opening by using 4.0 mm ET tube and confirmed it with ETCO2 trace. In addition to detection of the tracheal opening the ET tube helped us to
railroad the tracheostomy tube. Our case highlights how a simple technique using ET
tube and ETCO2 monitor could be used to avert a catastrophe.
Conflicts of interest
There are no conflicts of interest.
