Emergency percutaneous tracheostomy in two cancer patients with difficult airway: An alternative to cricothyroidotomy?
A 48-year-old male, a known case of carcinoma buccal mucosa stage III and had already undergone commando procedure followed by chemotherapy and concurrent radiotherapy 3 months back, presented to triage with complaints of breathlessness, cough, difficulty in speaking of 1 day duration. On evaluation, there was an inspiratory stridor and labored respiration along with hypoxemia on room air (oxygen saturation (SpO2) 77% and PaO254 mm Hg). After an initial stabilization, he was immediately shifted to the hemato-oncology intensive care unit (ICU).\nHe was managed conservatively on the lines of laryngeal edema with adrenaline nebulization, steroids, antibiotics, and urgent surgical consultation. However, in next few minutes, patient’s condition worsened with increasing stridor, respiratory distress, and hypoxemia. He went into cardio-respiratory arrest, and resuscitation was started as per Advanced Cardiac Life Support (ACLS) protocol.\nThe call for definitive airway protection was taken as there was no improvement with the primary resuscitation. Orotracheal intubation was tried thrice by senior intensivist, however, it was unsuccessful. A rapid decision for PCT was taken by the critical care team along with on-call surgeon and was performed by Ciaglia technique using Blue Rhino PCT kit (Cook Critical Care Inc, Bloomington, IN) with size 7.0 tracheostomy tube. The time taken to secure an airway was less than 2 minutes, and position was confirmed with capnography. After tracheostomy, there was improvement in ventilation and SpO2. He was successfully resuscitated with the return of spontaneous circulation in approximately 11-12 minutes. Hypothermia protocol was initiated as per our hospital protocol.\nPatient showed gradual recovery, vasopressors and ventilatory support were subsequently tapered off, and the patient was transferred out, neurologically alert and oriented, with T-piece on day 5 [Figures and ].