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Name of Journal: World Journal of Clinical CasesManuscript Type: CASE REPORT
Unexpected intraoperative airway obstruction in a patient with ascending aortic and arch aneurysm: A case report
Running title: Unexpected airway obstruction in TAA
Jian-Ming Yue, Leng Zhou, Peng Liang
Jian-Ming Yue, Leng Zhou, Peng Liang, Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, China
ORCID numbersJian-Ming Yue: 0000-0002-1826-4931Leng Zhou: 0000-0003-3374-7007Peng Liang: 0000-0001-8485-1694
Author contributions: All the authors participated in the management of this patient and provided suggestion for the manuscript. Jian-Ming Yue followed up the patient closely, collected the data and written the manuscript. Leng Zhou provided some suggestions about the manuscript and management of this patient. Peng Liang was the attending anesthesiologist for the patient.
Supported by none.
Corresponding author: Peng Liang, PhD, Department of Anesthesiology, West China Hospital of Sichuan University,
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AbstractBACKGROUNDUpper airway compression is one of the clinical manifestations of thoracic aortic aneurysm (TAA), which is associated with poor prognosis and high mortality from TAA.
CASE SUMMARYA 44-year-old patient with ascending aortic and arch aneurysm who was scheduled for Bentall surgery and total arch replacement under cardiopulmonary bypass suffered difficult ventilation after endotracheal intubation. The patient did not exhibit any positional dyspnea or orthopnea, did not show any difficulties in the supine position, and had no noteworthy medical history. However, we encountered unexpected hypoventilation after intubation, and the SBP exceeded 200 mmHg when the patient was treated with epinephrine. Pneumatorexis occurred for nearly 20 minutes and developed hypoxic-ischemic encephalopathy eventually. Fiberoptic bronchoscopy revealed complete obstruction of the carina and confirmed the supracarinal position of the SLT. The patient was transferred to another hospital for rehabilitation after surgery for week and she had not yet recovered two weeks after treatment, although her circulation level was stable.
CONCLUSIONThe choice of anesthesia induction should be individualized based on the character of disease and the level of obstruction. Comprehensive preoperative assessment, a well-developed airway management plan, and responses to possible emergencies are essential to reduce unnecessary events or complications.
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Key words: Thoracic aneurysm; Compression; Airway management; Anesthesia; Cardiopulmonary bypass; Case report
Core tip: It is extremely rare that asymptomatic airway compression caused by thoracic aortic aneurysm, which may lead to anesthesiologist's misjudgment of the condition and increase the risks and challenges of airway management. Here, we report a 44-year-old woman with ascending aorta/aortic aneurysm and Marfan syndrome, who suffered a difficult ventilation after anesthesia induction. Complete airway obstruction can occur for patient with preoperative compression due to the aneurysm and a well-developed airway management plan is essential to reduce unnecessary events or complications.
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INTRODUCTIONThe prevalence of thoracic aortic aneurysm in Western countries is about 0.3% and mostly in men [1]. TAA is a cardiovascular disease with three-layer thoracic aortic stenosis and dilation, high mortality and poor prognosis[2]. TAA has a variety of clinical manifestations, which involve compression of adjacent organs, especially upper airway compression. Symptoms of aortic aneurysm-related tracheal compression include dyspnea, cough, expectoration, and even pneumonia, which are rare complications of aortic arch aneurysms and descending aortic aneurysms. DeBakey et al. reported an 8% incidence of airway injury associated with aortic aneurysm [3]. It is extremely rare that asymptomatic tracheal and bronchial compression caused by TAA. Several cases have been reported on tracheal or bronchial compression by TAA which requires surgical treatment and are usually undiagnosed unless the symptoms appear [4, 5]. This may lead to doctor's misjudgment of the condition and increase the risks and challenges of airway management. If airway obstruction occurs, it is very likely to be life-threatening [6, 7]. For cases where the airway is compromised, a direct or fiberoptic intubation is an option, but we recently encountered an unexpected difficult ventilation after endotracheal intubation due to vascular tracheal compression syndrome by a large ascending aortic and arch aneurysm.
CASE PRESENTATIONChief complaints
The patient complained of palpitations, fatigue and accelerated breathing after physical activity for more than 2 years, and these symptoms were aggravated in the last 11 months before
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hospitalization.
History of present illness
A 44-year-old woman (height, 175 cm; weight, 56 kg) was admitted to the Department of Cardiac Surgery, West China Hospital of Sichuan University on April 9, 2020. The patient complained of palpitations, fatigue and accelerated breathing after physical activity for more than 2 years, and these symptoms were aggravated in the last 11 months before hospitalization. She felt tired and short of breath when climbing stairs. But she did not experience any symptoms at rest and had steady breathing (no inspiratory dyspnea, wheezing and coughing). The patient went to the local hospital first, and was diagnosed as “thoracic aortic aneurysm, moderate aortic valve regurgitation, and Marfan syndrome” after color Doppler ultrasound examination.
History of past illness
The patient had a history of appendectomy and uterine cysts, and denied any other history of disease, surgery, trauma, blood transfusion, or food or drug allergy.
Personal and family history
The patient had no noteworthy family medical history.
Physical examination upon admission
The patient walked to the ward. Physical examination showed that the body temperature was 36.3°C, pulse rate was 78 beats/min, respiration rate was 18 breaths/min, blood pressure was 112/59 mmHg, and blood oxygen saturation was 96%. Aortic valve diastolic murmur could be auscultated.
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Laboratory examinations
The main laboratory examinations were normal, including routine blood tests, blood biochemistry and conventional coagulation function test.
Imaging examinations
Re-examination of the cardiac color Doppler ultrasound in our hospital revealed “aortic aneurysm-like widening (ascending aorta diameter, 49 mm), with severe aortic regurgitation and ejection fraction of 70% (Figure 1).” Considering aortic aneurysm, computed tomography angiography (CTA) of the dissecting aneurysm revealed a large aneurysm of the ascending aorta and arch with the maximum cross-section measuring 8.4 × 7.3 cm2. Compression and narrowing of the trachea were observed with a minimum diameter of 0.51 cm (Figure 2). There was no obvious abnormality in the preoperative head CT.
FINAL DIAGNOSISCombined with the symptoms and imaging examinations, the patient was diagnosed with ascending aorta/aortic aneurysm, heart function level III and Marfan syndrome.
TREATMENTBentall surgery and total arch replacement under cardiopulmonary bypass (CPB) was considered to treat this patient. During the preanesthetic assessment, the patient exhibited no typical symptoms of airway compression such as cough, hoarseness, and postural dyspnea in the resting state. In addition, upper airway evaluation and all laboratory investigations were normal, with a
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blood pressure of 108/52 mmHg, heart rate of 68 beats/min, pulse oxygen saturation of 96% and respiratory rate of 20 breaths/min in operation room. Therefore, the symptoms and chief complaints of patient were thought to be mainly related to heart function.On April 11, 2020, she underwent surgery. Intraoperatively, standard monitors and arterial blood pressure were attached and oxygen supplementation was performed at 6 L/min using a mask. Regular general anesthesia was induced by administration of propofol, midazolam, sufentanil, and cisatracurium, following which the trachea was intubated with a 7.0-mm ID cuffed single-lumen tube (SLT) at the 21-cm mark under a Glidescope®. Controlled ventilation was difficult after the intubation, and the anesthesiologist considered it to be a severe bronchospasm. The patient has no history of wheezing and other medical conditions and regular backup drugs such as salbutamol for bronchospasm in the operating room were unavailable. Moreover, epinephrine can also be used for patients with severe bronchospasm during surgery. Considering these factors, epinephrine and hydrocortisone were used for the treatment. After epinephrine administration, the systolic blood pressure (SBP) increased to over 200 mmHg and ventilation could not be applied. Brain protective strategy was performed while emergency cardiopulmonary bypass (CPB) was established through cannulation of the femoral vein and the femoral artery. Fiberoptic bronchoscopy (FOB) revealed complete obstruction of the carina (Figure 3), and confirmed the supracarinal position of the SLT. After interposition for dacron graft anastomosis of the thoracic aorta, mechanical ventilation returned to normal.Postoperatively, the patient's circulation was stable and ventilator was used to maintain breathing. The patient was transferred to the
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ICU for observation and treatment. However, she was not awake, and her pupils were the same regular size, while she showed poor responsiveness to light. And the limbs continued to convulse. Head CT results showed that the brain tissue was slightly swollen. Based on the results of the neurological examination and medical history, hypoxia and hypoxic encephalopathy were considered. The patient was administered 40–56 mg/h sodium valproate and a 50-mL solution made of 50 mg promethazine hydrochloride, 50 mg chlorpromazine, and 100 mg dolantin, which was administered by pumping at the rate of 5 mL/h. The patient was transferred to another hospital on April 16, 2020, for rehabilitation treatment, including hyperbaric oxygen therapy.
OUTCOME AND FOLLOW-UPUnfortunately, because pneumatorexis occurred for nearly 20 minutes, the patient developed hypoxic-ischemic encephalopathy. The patient has not yet recovered after 2 weeks of treatment postoperatively, but the circulation level has been stable. At the follow-up attempt at 1 month after surgery, the patient could not be contacted.
DISCUSSIONThis case describes a patient with a large ascending aortic aneurysm involving the aortic arch, in which concomitant Bentall operation and total arch replacement surgery was performed. The patient had difficulty ventilating after general anesthesia. FOB revealed complete obstruction of the carina. Mechanical ventilation returned to normal after interposition of the thoracic aorta graft and anastomosis, but the outcome was unfortunate.
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Most patients with TAA are often asymptomatic [8]. However, when it is significantly enlarged, due to compression of the adjacent structures, symptoms may appear [8]. These symptoms may vary based on the size, location, and changes in the aneurysm [9]. Tracheobronchial compression is a well-documented complication of aneurysms of the ascending aorta and/or the aortic arch [7, 10]. Owing to the strong anatomic relationship of the aortic arch to the trachea and the left main stem bronchus, a compression may occur[9]. Patients with tracheobronchial compression usually present with chest, back, and abdominal pain. Aneurysmal expansion of the ascending aorta is the consequence of aortic reflux, which can cause congestive heart failure and progressive dyspnea [11]. Bronchial obstruction caused by aortic expansion may present as postural dyspnea, wheezing, chest pain, cough, hemoptysis, breathlessness, stridor, hoarseness, and/or pneumonia [6]. Hoarseness may indicate vagus or left recurrent laryngeal nerve compression, while wheezing, dyspnea, or cough are suggestive of tracheal compression. Hemoptysis may signify aneurysmal erosion into the trachea.Most airway obstructions/complications are unanticipated and are associated with airway incidents during induction of general anesthesia, a large part of which may lead to significant morbidity, or even death [12]. Airway compression poses significant risks and challenges in airway management. Assessment of airway compression using chest X-rays utilizes lateral views. In addition, neck or chest CT/ MRI scans can reveal the structures compressing the airway. Murayama H et al. reported that multi-slice spiral CT with 3D image reconstruction aids in the effective evaluation of airway obstruction caused by mediastinal masses, including TAA [13]. In this
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case, although the preoperative CT scan clearly revealed tracheal compression, the patient lacked symptoms suggestive of compression or erosion. Therefore, the routine anesthesia was administered by anesthesiologist. and tracheal intubation was carried out by utilizing a single-lumen endotracheal tube. Subsequently, when the patient had difficult ventilation, epinephrine and hydrocortisone were infused and FOB revealed a complete obstruction of the carina. The dynamic increase in airway compression following the infusion of epinephrine may be attributed to further dilation of the TAA owing to increased SBP. Therefore, it is crucial to maintain hemodynamic stability during induction of anesthesia. Airway obstruction caused by general anesthesia can be relieved by sternotomy, repositioning the patient or lowering blood pressure [11]. Of note, previous studies have highlighted the effectiveness of Cook® airway exchange catheter in laryngeal mask airway-guided fiberoptic intubation in neonates [14]. However, the relevance and feasibility of Cook® airway exchange catheter under the guidance of the FOB, which allows the controlled passage of a long, armored tube into the distal trachea or carina, needs to be validated in cases of tracheal obstruction. For these cases, flexible bronchoscope facilitates the inspection of all the accessible airway portions, assessment of endoluminal tissue properties of the airway wall, and effective direct clearing of retained secretions after decompression. However, it may not be suitable for patients with severe positional dyspnea and could be hazardous when there is a risk of rupture. Slow and careful induction with short-acting or inhaled agents accompanied by local anesthesia while maintaining spontaneous breathing until the airway is secured is beneficial when it is deemed necessary, as loss of tissue tone with increasing depth
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of anesthesia may exacerbate extrinsic compression [8].
CONCLUSIONIn conclusion, patients with a large TAA may develop an airway compression and even a complete obstruction. Following a complete airway evaluation in every patient, a rational decision should be taken regarding the implementation of an awake approach to tracheal intubation to maximize patient safety after induction of general anesthesia. Further, an individualized approach regarding the choice of anesthetic induction may be employed based on the nature of disease and extent of obstruction. This case report highlights the importance of a comprehensive preoperative assessment, well-developed airway management plan, and possible emergency response measures to avoid unnecessary events or complications.
ACKNOWLEDGEMENTSWe thank the patient for allowing us to publish the case report and to use the images taken.
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Cook® airway exchange catheter in laryngeal mask airway-guided fiberoptic intubation in a neonate with Pierre Robin syndrome -A case report. Korean J Anesthesiol 2013; 64: 168-171 [PMID: 23458916 DOI: 10.4097/kjae.2013.64.2.168].
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FootnotesInformed consent statement: Informed written consent was obtained fromthe patient's relatives for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflictof interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist(2016), and the manuscript was prepared and revised according to the CAREChecklist (2016).
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Figure Legends
Figure 1 Preoperative echocardiography. (A): Aneurysmal dilation of the ascending aorta. Dimension of the aortic root is 54 mm and 49 mm in the ascending aorta. (B): Severe aortic valve regurgitation (white arrow).
Figure 2 Computed tomography angiography (CTA) of the aneurysm. The maximum cross-section of the aneurysm is 8.4 × 7.3 cm2 (blue arrow) and the minimum diameter of the trachea is only 0.51 cm (red mark). (A): Three-dimensional reconstruction view.
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(B): Transverse plane of the narrow trachea. (C): Sagittal plane of the narrow trachea. (D): Transverse plane of the normal carina.
Figure 3 Complete compression of the carina (red arrow) after anesthesia induction revealed by fiberoptic bronchoscopy after femoro-femoral bypass.
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Supplementary Materials
Video 1 Enhanced computed tomography (CT) of the dissecting aneurysm.
Video 2 Discovery of tracheal carina through fiberoptic bronchoscopy after femoro-femoral bypass.
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