Page 15 - CASA Bulletin of Anesthesiology 2020 Issue 2

Vol.7, No.2, 2020

Airway Manipulation of a Pneumonia Patient with Suspected

Coronavirus Infection

Guozhang Cheng, MD
Department of Anesthesiology, Sinai Hospital of Baltimore, USA

One evening, I was called emergently to the ICU to help inves-
tigate an existing ventilation problem of an intubated patient as an
on-call-anesthesiologist of a large community hospital .

The patient, a sixty year old male, was intubated for his hypoxic re-
spiratory distress two days ago . He had severe pneumonia with a pro-
file of acute respiratory distress syndrome, but all common test results
were negative for etiology . Special tests have been sent out due to the
concerns of potential COVID-19 infection, with the result pending .

The patient was a nursing home resident who had a significant past
medical history of HTN, CAD, CVA, liver cirrhosis, ascites, esopha-
geal varices, thrombocytopenia, hypothyroidism, dementia, and para-
noid schizophrenia . He was transferred from his nursing home to the
ER for a hypoxia evaluation . He was found to have a SpO2 of 81 on
room air and a tachypneic of up to 40 breath per minute . After a short period of a BiPAP trial, the patient was
intubated with no difficulty. A portable chest x-ray (CXR) showed extensive bilateral pulmonary infiltrates,
bilateral patchy opacities, and a endotracheal tube (ETT) tip 4.5 cm above carina.

Two days later, I was called to the ICU because the ICU team was unable to pass a suction tube through
the patient’s ETT . They suspected his ETT was kinked and they wanted an anesthesiologist to help with the
ETT exchange . The patient was kept in a negatively pressurized room due to the concerns of disease trans-
mission. After reviewing all relevant information, we discovered that his CXR showed that his trachea was
pushed to the right at the clavicle level with a sharp curve. His ETT tip was 8.5 cm above carina (Fig 1).

His ventilation had a reasonable tidal volume, but every ventilation came with a strange noise at his throat
area . Realizing that this might not be a simple ETT exchange due to the suspected COVID-19 infection and
deviated trachea and possible loss of airway, the surgical team was called to standby for a possible surgical
airway . Despite the recent recommendation by the APSF to not use a fiber optic bronchoscope (FOB) unless
(1)
necessary for COVID-19 infected patients, we still felt that a FOB through his ETT was the safest approach to
find the cause of obstruction and reposition his ETT. We passed the FOB beyond ETT tip but not too far into
trachea due to an apparent sharp curvature . A pulmonologist was called in and he found that the tip of the
ETT was against the tracheal mucosa . He could advance the bronchoscope past the tip of the ETT . The airway
was significantly deviated to the right, causing a barrier for further advancement of the ETT. After maneuver-
ing the FOB through the airway to the right, then back to the left, we could see the carina which was sharp
and without any lesions . Findings were suggestive of extrinsic cause of tracheal deviation which had caused
a significant shift of the tracheal to the right and prevented further advancement of ETT passing the airway
deviation. We were, unfortunately, not able to accomplish our job even though we had the pulmonary expert’s
help on site .

15