Two cases of tracheoinnominate artery fistula following tracheostomy treated successfully by endovascular embolization of the innominate artery

Prevention of Tracheo-Innominate Artery Fistula Formation as a Complication of Tracheostomy: Two Case Reports

Tracheo-innominate artery fistula (TIF) is a rare complication of tracheostomy and refers to the formation of a fistula between the trachea and innominate artery. Because TIF is fatal, prevention rather than treatment is very important. Here we report the cases of two high-risk patients who underwent tracheostomy, and in whose cases attempts were made to lower the risk of TIF. In the first patient who developed a chest deformity with Duchenne muscular dystrophy, a tracheostomy was performed with a high-level (cricothyroid level) approach compared with the standard tracheostomy. In the second patient, the thoracic cage was relatively small due to a giant omphalocele, and the risk of a fistula forming was decreased by wrapping the innominate artery with an opened polytetrafluoroethylene vascular graft after resolving crowding of the intrathoracic cavity by total thymectomy. There was no TIF occurrence at the outpatient follow-up in either case. We expect that our approaches may be effective intervention measures for preventing TIF.

Successful management of a tracheomalacia patient with active endotracheal bleeding due to intraoperative innominate artery injury: A case report

RATIONALE

Intraoperative innominate artery injury is life-threatening in tracheomalacia patients with prolonged tracheostomy. Anesthetic management is challenging in cases with massive hemorrhage into the endotracheal tube. We report a case in which we successfully managed a tracheomalacia patient with acute endotracheal bleeding due to innominate artery injury.

PATIENT CONCERNS

A 24-year-old patient with tracheomalacia was scheduled to undergo exploratory thoracotomy for the treatment of intermittent bleeding at the tracheostomy site. During exploration, sudden active bleeding due to innominate artery injury was observed in the endotracheal lumen.

DIAGNOSES

The patient was diagnosed with tracheomalacia.

INTERVENTIONS

We immediately used the bronchoscope to place the tip of the endotracheal tube at the bleeding site and hyperinflated the cuff.

OUTCOMES

The ballooned cuff compressed the active bleeding site, so no additional bleeding was detected by bronchoscopy, and no additional massive bleeding was observed in the operative field.

LESSONS

Immediate and appropriate overinflation of the endotracheal tube cuff by an anesthesiologist may provide improved surgical field visibility and time for critical surgical procedures in cases of massive hemorrhaging.

Construction of a detachable artificial trachea model for three age groups for use in an endotracheal suctioning training environment simulator

Tracheal suctioning is an important procedure to maintain airway patency by removing secretions. Today, suctioning operators include not only medical staff, but also family caregivers. The use of a simulation system has been noted to be the most effective way to learn the tracheal suctioning technique for operators. While the size of the trachea varies across different age groups, the artificial trachea model in the simulation system has only one fixed model. Thus, this study aimed to construct multiple removable trachea models according to different age groups. We enrolled 20 patients who had previously received proton beam therapy in our institution and acquired the treatment planning computed tomography (CT) image data. To construct the artificial trachea model for three age groups (children, adolescents and young adults, and adults), we analyzed the three-dimensional coordinates of the entire trachea, tracheal carina, and the end of the main bronchus. We also analyzed the diameter of the trachea and main bronchus. Finally, we evaluated the accuracy of the model by analyzing the difference between the constructed model and actual measurements. The trachea model was 8 cm long for children and 12 cm for adolescents and young adults, and for adults. The angle between the trachea and bed was about 20 degrees, regardless of age. The mean model accuracy was less than 0.4 cm. We constructed detachable artificial trachea models for three age groups for implementation in the endotracheal suctioning training environment simulator (ESTE-SIM) based on the treatment planning CT image. Our constructed artificial trachea models will be able to provide a simulation environment for various age groups in the ESTE-SIM.

Successful Management of a Life-threatening Endotracheal Bleed with Angiographic Stenting

Several operative and postoperative complications have been reported after tracheostomy, including fatal hemorrhage from erosion of a major vessel. We present here a case of hemorrhage after a surgical tracheostomy. This case is being reported on account of the unusual etiology of the hemorrhage and associated high fatality rates. All concerned need to be aware of this complication and its emergency management.

How to cite this article: Joseph MM, Benjamin R, Padmanabhan A, Bal D, Nair S. Successful Management of a Life-threatening Endotracheal Bleed with Angiographic Stenting. Indian J Crit Care Med 2020;24(3):210–211.

Managing Otolaryngologic Complications in Cardiothoracic Surgery

BACKGROUND

Cardiothoracic procedures are often lifesaving operations, and because of their complexity they are not without complications. Although major complications are often recognized and treated immediately, there are many less commonly identified complications that can and frequently should be addressed by otolaryngology colleagues during a patient's hospital course.

METHODS

This comprehensive review describes otolaryngologic complications of cardiac and thoracic surgery.

RESULTS

Dysphonia, dysphagia, stridor, tracheotomy hemorrhage, and pharyngeal tear are all complications of cardiothoracic procedures. Indications for treatment and treatment options are reviewed. The impact on quality of life and long-term morbidity is also discussed.

CONCLUSIONS

Otolaryngologic complications are common after cardiothoracic procedures. An otolaryngologist should be asked to evaluate a patient with dysphonia, dysphagia, or stridor while the patient is an inpatient. Patients experiencing persistent or nonacute problems should be referred to otolaryngologists to discuss more long-term interventions.

[Surgical treatment of tracheoarterial fistulas]

BACKGROUND

A tracheoarterial fistula (TAF) is an uncommon but life-threatening complication after tracheostomy. Only an immediate and targeted treatment provides a chance to survive.

OBJECTIVE

Surgical treatment of TAF.

METHODS

Selective review of the literature and case description.

RESULTS

A TAF leads to an acute bleeding complication with displacement of the respiratory tract. The mortality rate is nearly 100% without a surgical intervention. In the literature various interventional and surgical treatment procedures are described. Rapid control of bleeding via manual compression and overinflation of the tracheal cuff are the most important steps of treatment. Subsequent emergency surgery with ligation or resection of the TAF and covering of the tracheal lesion should be performed. Extracorporeal membrane oxygenation (ECMO) and a heart-lung machine can sometimes be necessary.

CONCLUSION

Despite all treatment options the mortality rate of TAF remains high. The critical steps are a quick diagnosis of TAF, securing the airway and immediate bleeding control.

Tracheo-innominate fistula in children: A systematic review of literature

OBJECTIVE

Tracheo-innominate fistula (TIF) is a rare but fatal complication of tracheotomy. To date, there is a paucity of literature regarding pediatric TIFs. The objectives of this study were to conduct a systematic review of literature on pediatric TIF following tracheotomy and describe three demonstrative cases from our institutional experience.

METHODS

We conducted a systematic review using MEDLINE, Embase, Cochrane Database of Systematic Reviews, Web of Science, and CINAHL. All studies with pediatric patients (under 18 years of age) who developed TIF following tracheotomy were included.

RESULTS

Fifty-four publications met inclusion criteria, reporting on 77 cases. The most common indication for tracheotomy was prolonged intubation and the need for ventilatory support (38.6%), with neurological comorbidities being the most common indication (72.7%). The mean time to TIF was 395.7 days (95% confidence interval, 225.9-565.5). Fifty-four patients (70.1%) presented with massive hemorrhage, whereas 18 patients (23.3%) presented with a sentinel bleeding event. The most common diagnostic interventions were computed tomography scan with or without contrast and bronchoscopy (55.8%). A substantial number of patients did not have any investigations (41.6%). Surgical management occurred in 70.1% of patients. Mortality was 38.6% in reported cases with variable follow-up periods.

CONCLUSION

TIF may occur in long-term tracheostomy-dependent children, contrary to the conventionally described 3-week postoperative period. The mortality may not be as high as previously reported with timely intervention. Our results are limited by inherent risks of bias. Further research including well-designed cohort studies are needed to guide an evidence-based approach to TIF.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:217-224, 2020.

Resuscitating the tracheostomy patient in the ED

BACKGROUND

Emergency physicians must be masters of the airway. The patient with tracheostomy can present with complications, and because of anatomy, airway and resuscitation measures can present several unique challenges. Understanding tracheostomy basics, features, and complications will assist in the emergency medicine management of these patients.

OBJECTIVE OF REVIEW

The aim of this review is to provide an overview of the basics and features of the tracheostomy, along with an approach to managing tracheostomy complications.

DISCUSSION

This review provides background on the reasons for tracheostomy placement, basics of tracheostomy, and tracheostomy tube features. Emergency physicians will be faced with complications from these airway devices, including tracheostomy obstruction, decannulation or tube dislodgement, stenosis, tracheoinnominate fistula, and tracheoesophageal fistula. Critical patients should be evaluated in the resuscitation bay, and consultation with ENT should be completed while the patient is in the department. This review provides several algorithms for management of complications. Understanding these complications and an approach to airway management during cardiac arrest resuscitation is essential to optimizing patient care.

CONCLUSION

Tracheostomy patients can present unique challenges for emergency physicians. Knowledge of the basics and features of tracheostomy tubes can assist physicians in managing life-threatening complications including tube obstruction, decannulation, bleeding, stenosis, and fistula.

Tracheostomy care and complications in the intensive care unit

Tracheotomy is a common procedure in intensive care units, and nurses must provide proper care to tracheostomy patients to prevent complications. One of the most important considerations is effective mobilization of secretions, and a suction catheter is the most important tool for that purpose. Each bedside should be equipped with a functional suctioning system, an oxygen source, a manual resuscitation bag, and a complete tracheostomy kit, which should accompany patients wherever they go in the hospital. Complications include infection, tracheomalacia, skin breakdown, and tracheoesophageal fistula. Tracheostomy emergencies include hemorrhage, tube dislodgement and loss of airway, and tube obstruction; such emergencies are managed more effectively when all necessary supplies are readily available at the bedside. This article describes how to provide proper care in the intensive care unit, strategies for preventing complications, and management of tracheostomy emergencies.

Successful treatment of tracheoinnominate artery fistula following tracheostomy in a patient with cerebrovascular disease

Tracheoinnominate artery fistula is a critical complication of tracheostomy. The most important factors influencing patient outcome are prompt diagnosis, immediate control of bleeding with a patent airway, and emergency operation with or without interruption of the innominate artery. Here, we report a case of tracheoinnominate artery fistula in a 40-year-old woman with cerebrovascular accident who was successfully managed with an aorta-axillary artery bypass.