Tracheal dilatation followed by stenosis in Mounier-Kuhn syndrome. A case report

Airway management for a patient with tracheobronchomegaly undergoing lobectomy: a case report

BACKGROUND

Tracheobronchomegaly (TBM) is a rare disorder mainly characterized by dilatation and malacia of the trachea and major bronchi with diverticularization. This will be a great challenge for airway management, especially in thoracic surgery requiring one-lung ventilation. Using a laryngeal mask airway and a modified double-lumen Foley catheter (DFC) as a "blocker" may achieve one-lung ventilation. This is the first report introducing this method in a patient with TBM.

CASE PRESENTATION

We present a 64-year-old man with TBM receiving left lower lobectomy. Preoperative chest computed tomography demonstrated a prominent tracheobronchial dilation and deformation with multiple diverticularization. The most commonly used double-lumen tube or bronchial blocker could not match the distorted airways. After general anesthesia induction, a 4# laryngeal mask was inserted, through which the modified DFC was positioned in the left main bronchus with the guidance of a fiberoptic bronchoscope. The DFC balloon was inflated with 10 ml air and lung isolation was achieved without any significant air leak during one-lung or two-lung ventilation. However, the collapse of the non-dependent lung was delayed and finally achieved by low-pressure artificial pneumothorax. The surgery was successful and the patient was extubated soon after the surgery.

CONCLUSIONS

Using a laryngeal mask airway with a modified double-lumen Foley catheter acted as a bronchial blocker could be an alternative method to achieve lung isolation.

Unexpected curious cause of serious air leakage after endotracheal intubation: A case report of tracheobronchomegaly and literature review

Purpose

Tracheobronchomegaly (TBM) is a rare disease with enlarged trachea and mainstem bronchi, which might not be diagnosed preoperatively because of patient’s nonsymptoms or clinicians’ overlook. These patients would be at fatal risk after general anesthesia endotracheal intubation due to severe peritubal leakage. This case may provide a helpful and informative resource for anesthesiologists and other clinicians, especially those managing patients’ airways.

Clinical feature

We presented a patient undergoing elective scoliosis orthopedics who was postoperatively diagnosed with TBM. After general anesthesia endotracheal intubation, difficulty in maintaining ventilation with obvious peri-cuff air leakage made this rare disease to be suspected. The peritubal leakage was resolved by relocating the endotracheal tube to the subglottic area. Fortunately, there were no air leakage and postoperative complications.

Conclusion

Anesthesiologists should keep the possibility of the unpredicted anatomic abnormal respiratory tract in mind, such as TBM.

Airway management of a patient incidentally diagnosed with Mounier-Kuhn syndrome during general anesthesia

Mounier-Kuhn syndrome (MKS) is a disease characterized by dilation of the trachea and mainstem bronchi. Due to the risk of airway leakage, pulmonary aspiration, and tracheal damage, MKS can be fatal in patients undergoing tracheal intubation. Moreover, MKS may not be diagnosed preoperatively due to its rarity. In this case, a patient undergoing neurosurgery was incidentally diagnosed with MKS during general anesthesia. During anesthesia induction, difficulties in airway management led the anesthesiologist to suspect MKS. Airway leakage was resolved in this case using oropharyngeal gauze packing. Anesthesiologists should be aware of the possibility of MKS and appropriate management of the airways.

Mounier-Kuhn syndrome or congenital tracheobronchomegaly: a literature review

Mounier-Kuhn syndrome or congenital tracheobronchomegaly is a chronic airway condition which for currently unknown reasons mostly affects males. It is commonly overlooked on conventional chest X-rays, and is considered to be rare, but the prevalence might be higher as commonly assumed. The hallmark of it is a dilatation of the main airways which frequently, but not always, causes marked, mainly respiratory, symptoms, and patients usually present with varying degrees of recurrent infections, breathlessness, haemoptysis, dyspnoea. Although at least 200 case reports have been published, there have been only a few attempts to review them, and none in the last 20 years. Due to the lack of clinical trials and wide variability of case-report format, a systematic review was deemed not feasible, therefore PubMed and Medline databases were searched using terms "Mounier-Kuhn syndrome", "tracheobronchomegaly", "tracheomegaly", and "bronchomegaly", without any time restrictions, to summarize currently known facts about the syndrome. To the authors' best knowledge, the result is currently the most comprehensive review of previously published literature about the congenital tracheobronchomegaly, and summarizes what's known about symptoms, prevalence, disease associations, and treatment options for this syndrome.

Mounier-kuhn syndrome: anesthetic experience

Mounier Kuhn syndrome, or congenital tracheobronchomegaly, is an under diagnosed clinical entity with peculiar anatomical and physiological features making anesthetic care challenging. A 58-year-old chronic smoker with history of recurrent pneumonia and bronchiectasis presented for septoplasty. Thoracic imaging revealed a dilated trachea and main bronchi, tracheal and bronchial diverticuli, and chronic bronchiectasis with mediastinal lymphadenopathy. An 8.5 cuffed endotracheal tube (ETT) proved too big for his glottic aperture. An 8.0 cuffed ETT with wet gauze packing yielding an adequate seal. Postoperative continuous positive airway pressure to prevent airway collapse followed awake extubation. Anesthetic concerns include grossly enlarged and weakened airways, inefficient cough mechanisms, presence of tracheal diverticuli, and post operative tracheal collapse. Anesthetic planning includes management of endotracheal cuff size. Small size yields air leak and ineffective ventilation. Large size may lead to mucosal damage. Tube dislodgement, copious secretions, chance of expiratory collapse due to the abnormally dilated and thin airways, and post operative monitoring all must be considered.

Anesthetic management of a patient with Mounier-Kuhn syndrome undergoing off-pump coronary artery bypass graft surgery -A case report-

Mounier-Kuhn-syndrome patients have markedly dilated trachea and main bronchi due to an atrophy or absence of elastic fibers and thinning of smooth muscle layers in the tracheobronchial tree. Although this syndrome is rare, airway management is challenging and general anesthesia may produce fatal results. However, only a few cases have been reported and this condition is not widely known among anesthesiologists. We present the case of a tracheobronchomegaly patient undergoing an emergency off-pump coronary artery bypass. Although the trachea was markedly dilated with numerous tracheal diverticuli, there was an undilated 2 cm portion below the vocal cords found on the preoperative CT. Under a preparation of extracorporeal membrane oxygenation, we intubated and placed the balloon of an endotracheal tube (I.D. 9 mm) at this portion, and maintained ventilation during the operation. This case showed that a precise preoperative evaluation and anesthetic plan is essential for successful anesthetic management.

Anesthetic experience of a patient with tracheomegaly -A case report-

Tracheomegaly or tracheobronchomegaly is a rare syndrome that consists of marked dilatation of the trachea and the major bronchi, and this is usually due to a congenital defect of the elastic and muscle fibers of the tracheobroncheal tree. Physicians have had only limited experience with performing anesthesia in patients with this type of syndrome. This syndorme is diagnosed by roentenological investigation and this condition is frequently associated with chronic respiratory infection and partial airway obstruction. In this report, we present a case of performing tracheostomy for a patient with tracheomegaly, and this was probably secondary to mechanical ventilator therapy. The regular tracheostomy tube did not provided sufficient length to allow the cuff to lie properly in the trachea in this patient. Because of the peri-cuff air leakgae and hypercapnea after tracheostomy, we needed a longer tracheostomy tube. But we didn't have such a tube and we didn't know any other method, so we couldn't perform tracheostomy. Therefore, we introduced a method of reducing the length of the endotracheal tube to a suitable size until a longer tracheostomy tube can be obtained for those patients having tracheomegaly.

Mounier-Kuhn syndrome: report of 8 cases of tracheobronchomegaly with associated complications

Mounier-Kuhn syndrome is a rare congenital abnormality characterized by atrophy or absence of elastic fibers and thinning of smooth muscle layer in the trachea and main bronchi. These airways are thus flaccid and markedly dilated on inspiration and collapsed on expiration. First- to fourth-order bronchi are affected. There is an increase in dead space, tidal volume and diminished clearing of secretions. The usual presentation is recurrent respiratory tract infections with a broad spectrum of functional impairment ranging from minimal disease with preservation of lung function to severe disease in the form of bronchiectasis, emphysema and pulmonary fibrosis, ultimately culminating in respiratory failure and death. A congenital connective tissue weakness, in combination with inhalation of irritants like cigarette smoke and air pollution, are raised as possible factors in the development of this syndrome. Eight cases of tracheobronchomegaly with its associated complications are reported. Computed tomography scan of the chest was used for the diagnosis of tracheobronchomegaly. Treatment is mainly supportive with chest physiotherapy and antibiotics; however, there are a few reported cases where insertion of a tracheal stent resulted in some success.

Anaesthesia for a patient with tracheobronchomegaly (Mounier-Kuhn syndrome)

Tracheobronchomegaly is a rare condition in which anaesthetic experience is limited. Patients with tracheobronchomegaly are at risk of large airway collapse and obstruction, aspiration pneumonitis and tracheal trauma following airway instrumentation. We describe our anaesthetic technique and problems encountered during nephrectomy in a patient with this condition.

Effect of tracheal dilatation and rupture on mechanical ventilation using a low-pressure cuff tube

We report the case of a 36-year-old woman who suffered tracheal dilatation and rupture despite careful monitoring of intracuff pressure. Surgical manipulation, postoperative mediastinitis, and bacterial staphylococcal tracheitis may be involved in the development of this complication.

Tracheobronchiomegaly. The Mounier-Kuhn syndrome in a patient with the Kenny-Caffey syndrome

A 36-year-old woman with features of both the Mounier-Kuhn syndrome and the Kenny-Caffey syndrome is described. To our knowledge, this is the first reported case of these syndromes occurring together. Three-dimensional computed tomographic reconstruction of the upper airway revealed marked dilatation of the trachea and main-stem bronchi and several large diverticulae of the trachea.

Tracheobronchomegaly in association with ankylosing spondylitis

We present a case of tracheobronchomegaly seen in association with ankylosing spondylitis. To the authors' knowledge this combination has not been previously described. A review of the chest radiographs of 30 other patients with ankylosing spondylitis revealed no evidence of tracheal dilatation.