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 Table of Contents  
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 209-212

Failed airway despite securing the airway: A near-complete distal tracheal stenosis

1 Department of Emergency Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry, India
2 Department of Emergency Medicine and Trauma, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Department of Forensic Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission14-Aug-2021
Date of Acceptance03-Oct-2021
Date of Web Publication15-Nov-2021

Correspondence Address:
Dr. K NJ Prakash Raju
Department of Emergency Medicine, Mahatma Gandhi Medical College and Research Institute, Puducherry - 605 006
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/arwy.arwy_47_21

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Inability to ventilate or oxygenate can be catastrophic. Critical tracheal stenosis may present as a life-threatening airway emergency. We report a 25-year-male who presented to the Emergency Department in respiratory arrest. After endotracheal intubation, there was no tidal volume delivery despite generating high peak airway pressures. Unfortunately, even an emergency surgical airway did not succeed in providing adequate ventilation. Postmortem examination revealed near-total occlusion of the distal tracheal lumen. When a patient has refractory ventilatory failure due to possible airway obstruction, the acute care provider should consider distal tracheal stenosis as one among the differential diagnosis. Conventional approach to airway management, including surgical airway, may not be of help in the presence of distal tracheal stenosis. A skilled emergency physician should possess the ability to think out-of-the-box and be aware of novel techniques to achieve oxygenation and ventilation in a 'failed airway' of this nature. Though appropriate, fibreoptic intubation, extracorporeal membrane oxygenation or emergency thoracotomy may not be readily available or practically feasible options to manage a failed airway due to distal tracheal stenosis.

Keywords: Difficult airway, fibreoptic bronchoscopy, surgical airway, tracheal stenosis

How to cite this article:
Prakash Raju K N, Anandhi D, Ayyan S M, Ashok N, Naik BK. Failed airway despite securing the airway: A near-complete distal tracheal stenosis. Airway 2021;4:209-12

How to cite this URL:
Prakash Raju K N, Anandhi D, Ayyan S M, Ashok N, Naik BK. Failed airway despite securing the airway: A near-complete distal tracheal stenosis. Airway [serial online] 2021 [cited 2022 Aug 11];4:209-12. Available from: https://www.arwy.org/text.asp?2021/4/3/209/330491

  Introduction Top

Securing the airway is the first and foremost priority in critically ill patients. A difficult airway challenges the skills of the emergency physician because of the time constraint and emergent nature of any lifesaving intervention. An anticipated difficult airway gives the provider the opportunity to prepare ahead to have the equipment, personnel and a backup plan. An unanticipated difficult airway creates panic, thereby preventing an organised thought process.

The incidence of difficult airway in emergency medicine ranges from 2% to 14%, which also includes prehospital airway management. The incidence of a failed airway is <1%.[1] A 'cannot intubate-cannot ventilate' situation, though rare, is potentially fatal. Consequences of a failed airway include hypoxaemia, hypercapnoea, hypoxic brain injury and ultimately, death.

Adhering to difficult airway algorithms such as All India Difficult Airway Guidelines, Difficult Airway Society guidelines and American Society of Anesthesiologists guidelines may help to avoid such misadventures.[2],[3],[4] Such algorithms are designed for the operating room set-up. However, the Emergency Department is an uncontrolled environment with a large volume of patients arriving, often uninformed. Managing the airway is a dynamic process as difficulty may arise any moment. Prior airway assessment, adequate training and backup plans to use alternative airway devices are the cornerstones for successful airway management.[5] Critical lower tracheal stenosis is a rare life-threatening emergency for which surgery is the most effective treatment. Securing the airway in lower tracheal stenosis is a challenge even in a well-equipped Emergency Department. Traditional airway techniques may not be suitable or may even be catastrophic when attempted multiple times.[6]

  Case Report Top

A 25-year-old male was brought to the Emergency Department with a history of breathlessness for 4 h. He had agonal gasps, central cyanosis with a non-recordable saturation. Crash intubation was performed with an 8.0 mm ID endotracheal tube using a videolaryngoscope. Postintubation vital signs showed a pulse rate of 130/min, blood pressure of 110/80 mm Hg and saturation of 30% while breathing 100% oxygen. Severe resistance was encountered during attempted ventilation with a self-inflating bag. The chest was silent to auscultation with no chest rise or air entry. With an initial diagnosis of severe bronchospasm secondary to anaphylaxis, intramuscular adrenaline and nebulisation using adrenaline combined with salbutamol were provided. Ventilator waveforms revealed persistently elevated airway pressures and extremely low tidal volume being delivered [Figure 1].
Figure 1: Ventilator waveforms showing elevated airway pressures (arrows) with extremely low tidal volume delivery (asterisks)

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In spite of continuous nebulisation and frequent adjustments of ventilator settings, adequate tidal volume could not be delivered and desaturation persisted (SpO2 < 60% on 100% oxygen). Within a few minutes, subcutaneous emphysema developed all over the neck and chest. His chest and abdomen developed board-like rigidity and ventilation with a self-inflating bag proved impossible. He was paralysed, and bilateral chest tubes were placed in view of pneumothorax. However, there was persistent desaturation because of ineffective ventilation.

A healed scar was noted over his lower anterior neck. A brief history revealed severe head injury a month earlier for which he had received mechanical ventilation over 10 days through a tracheostomy. The tracheostomy tube had got expelled spontaneously a week prior, and the tracheostomy had closed completely. This led to the suspicion of tracheal stenosis at a distal site causing inability to ventilate. A fibreoptic bronchoscope was not available. We performed an emergency tracheostomy, but even a 6.0 mm ID endotracheal tube could not navigate the site of obstruction. With much difficulty, we could insert a 4.0 mm ID endotracheal tube through which ventilation was started. The patient sustained a cardiac arrest within minutes and could not be resuscitated.

Postmortem examination revealed a near-total obstruction of the tracheal lumen at 6th, 7th and 8th tracheal rings along with the formation of a constricting band externally [Figure 2] and [Figure 3]. The histopathological exam of tracheal tissue at the site of obstruction showed pseudostratified ciliated columnar epithelial lining. The subepithelial region showed oedema, haemorrhage with acute-on-chronic inflammatory infiltrates consisting of neutrophils and few lymphocytes.
Figure 2: Postmortem dissection of airway showing tongue (arrow), epiglottis (asterisk), tracheostomy site (dotted arrow) and stenosed part of trachea (curved arrow)

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Figure 3: Left image shows critical tracheal stenosis (dotted arrow) below the level of tracheostomy site (arrow). Right image shows dissected trachea with distorted rings (curved arrow)

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  Discussion Top

We present details of a case of an unanticipated failed airway in the Emergency Department where the currently existing difficult airway algorithms failed. Our patient was received in respiratory arrest and postintubation, there was persistent hypoxia and inability to ventilate. Even emergency tracheostomy proved ineffective. Postmortem examination revealed critical distal tracheal stenosis.

Most difficult airway algorithms originate from anaesthesia literature. They suggest several rescue plans in unanticipated difficult airways such as face mask ventilation, tracheal intubation, supraglottic airway devices and emergency cricothyrotomy.[2],[3],[7] None of these rescue plans addresses techniques to secure the airway in case of distal airway obstruction.

Our patient was unique in that he manifested a failed airway after successful endotracheal intubation, necessitating an emergency surgical airway. Failure to achieve a definitive airway prevailed despite securing a surgical airway (which is the final pivotal step to secure an airway as per all the current difficult airway algorithms). No guidelines throw light on how to approach a patient with a failed airway despite successful tracheal intubation. Securing the airway does not merely mean placement of a cuffed endotracheal tube below the glottis, because as exemplified in our patient, there is still a portion of the distal trachea which might still contribute to an obstructed airway. When emergency physicians face persistent difficulty in ventilation despite successful endotracheal intubation, placement of a supraglottic airway device or performance of emergency cricothyrotomy, the possibility of distal airway obstruction must be considered.

The most common causes of ventilatory failure despite successful tracheal intubation are distal tracheal obstruction, mediastinal tumours compressing the main bronchus or distal trachea, tracheal foreign bodies, endobronchial tuberculosis, aspirated teeth causing ventilatory failure, tracheal tumours and post-tracheostomy granulation.[8],[9] Suspecting tracheal stenosis in unstable patients is challenging. Patients with lesser degrees of tracheal stenosis are usually asymptomatic. Severe stenosis may present with stridor and wheezing. They are often mistaken to have bronchospasm due to acute asthma. The diagnosis is evident on bronchoscopy, although pulmonary function tests and computerised tomographic imaging may demonstrate it. Flow volume loops help to identify fixed airway obstruction.[10] Our patient presented to the Emergency Department in extremis due to significant stenosis of the distal trachea. We initially misdiagnosed him to be acute severe bronchospasm, angioedema or severe asthma. Availability of a fibreoptic bronchoscope in the Emergency Department might have helped in prompt diagnosis of this patient. Using a smaller size tube may sometimes help in negotiating the tube across the stenosed segment of the trachea. However, in critical tracheal stenosis, it may not be possible to pass even the smallest tube.

Zhou et al. reported a case of severe tracheal stenosis who presented with severe respiratory distress. An endotracheal tube was inserted above the stenosed part of the trachea in the operating room but ventilation was unsatisfactory, with severe hypercarbia and high airway pressures as in our case. Their patient was immediately started on extracorporeal circulation followed by emergency thoracotomy. The patient's airway was secured using a 6 mm ID tracheal tube passed into the left main bronchus.[11] Booka et al. reported a case of severe tracheal stenosis due to oesophageal neurofibroma where the patient was planned for elective surgery. They prepared a veno-venous extracorporeal membrane oxygenation (ECMO) as a backup plan in case tracheal intubation failed. However, they could intubate the patient successfully.[12]

These case reports highlight innovative ways of attaining oxygenation and ventilation by ECMO and emergency thoracotomy in failed airways due to distal tracheal narrowing. Emergency thoracotomy and bronchial intubation are the way forward in securing the airway in distal tracheal obstruction. The time has come for emergency physicians to familiarise themselves with ECMO and emergency thoracotomy. The failed airway guidelines should not stop with front-of-neck access or emergency cricothyrotomy as the final option. The importance of thoracotomy needs to be highlighted as an alternative. Emergency physicians should consider ECMO as a lifesaving bridge when tracheal intubation fails.

  Conclusion Top

Severe tracheal stenosis can present with stridor and wheezing. These patients are often misdiagnosed to have bronchospasm due to acute asthma. Distal tracheal stenosis should be considered as a possibility when ventilatory failure persists despite successful intubation. Securing the airway in the presence of distal tracheal obstruction is challenging. Most of the advanced airway techniques fail to provide ventilation. When securing airway fails, ECMO and emergency thoracotomy can be considered as advanced options for managing failed airway due to critical distal tracheal stenosis. Further vistas need to be created to manage the airway in the presence of distal tracheal obstruction.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The legal guardian understands that the name and initials of the patient will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.


We gratefully acknowledge the support of Balamurugan N and Vivekanandan M.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Wong E, Ng YY. The difficult airway in the emergency department. Int J Emerg Med 2008;1:107-11.  Back to cited text no. 1
Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al. All India difficult airway association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaesth 2016;60:885-98.  Back to cited text no. 2
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Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult airway society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015;115:827-48.  Back to cited text no. 3
Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: An updated report by the American society of anesthesiologists task force on management of the difficult airway. Anesthesiology 2013;118:251-70.  Back to cited text no. 4
Rajesh MC, Suvarna K, Indu S, Mohammed T, Krishnadas A, Pavithran P. Current practice of difficult airway management: A survey. Indian J Anaesth 2015;59:801-6.  Back to cited text no. 5
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Chiu CL, Teh BT, Wang CY. Temporary cardiopulmonary bypass and isolated lung ventilation for tracheal stenosis and reconstruction. Br J Anaesth 2003;91:742-4.  Back to cited text no. 6
Law JA, Broemling N, Cooper RM, Drolet P, Duggan LV, Griesdale DE, et al. The difficult airway with recommendations for management – Part 1 – Difficult tracheal intubation encountered in an unconscious/induced patient. Can J Anaesth 2013;60:1089-118.  Back to cited text no. 7
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Medrek SK, Lazarus DR, Zarrin-Khameh N, Mohyuddin N, Bandi V. Obstructive post-tracheotomy granulation tissue. Am J Respir Crit Care Med 2017;196:e12-3.  Back to cited text no. 9
Shenoy L, Nileshwar A. Postintubation tracheal stenosis: A devastating complication! Indian J Respir Care 2019;8:69-70.  Back to cited text no. 10
Zhou YF, Zhu SJ, Zhu SM, An X×. Anesthetic management of emergent critical tracheal stenosis. J Zhejiang Univ Sci B 2007;8:522-5.  Back to cited text no. 11
Booka E, Kitano M, Nakano Y, Mihara K, Nishiya S, Nishiyama R, et al. Life-threatening giant esophageal neurofibroma with severe tracheal stenosis: A case report. Surg Case Rep 2018;4:107.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3]


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