Case 45: Airway Obstruction in an Anesthetized Prone Patient

Abstract

Today you are anesthetizing a 58-year-old man (82 kg and 5′11″) with a cerebellar tumor. He is otherwise healthy and classified as an ASA 2. General anesthesia is induced uneventfully, and the patient is turned prone after having been placed in a Mayfield pin holder. The patient’s head is 180 degrees away from the anesthesia machine. His neck is flexed so that there is a one finger gap between the mentum of the mandible and the sternal notch. You would prefer to have two finger gap. A BiteGard (Hudson RCI, Teleflex Medical, Research Triangle Park, NC 27709) has been placed between the upper and lower molar on the right side. The operation proceeds uneventfully for 6 h, when there is an increase in the peak inspired pressure from 24 cm H20 to 42 cm H2O over a 2–4-min period. All the other parameters are unchanged. You call for help and one of your colleagues comes to your aid. With his help you confirm bilateral air entry with no adventitious sounds. You inspect the endotracheal tube at the mouth and confirm that it has not moved and is still taped at 22 cm H20. Your colleague places the patient on 100% oxygen, and after a few minutes you attempt to pass a suction catheter through the endotracheal tube (ETT), but it only goes in 15–20 cm. You manipulate the ETT, but there is no improvement. Your colleague suggests you let the endotracheal cuff down as the cuff could have herniated into the lumen. You do so, but you are still unable to pass the suction catheter all the way through the ETT. You diagnose a partial kink in the ETT. The vital signs are still within normal limits but the peak airway pressure has gone to 48 cm H2O. You are concerned. At the moment you can ventilate the patient, but should the kink be total, this could have serious consequences for the patient. There are 30–45 min left, and the surgeon is unhappy to reposition the patient’s neck before the end of the surgery. Nor is he happy about your request to turn the patient supine and reintubate the trachea. You get an LMA ready in case you are unable to ventilate the patient.