Ann Thorac Surg 2011;92:710-713. doi:10.1016/j.athoracsur.2011.03.004
© 2011 The Society of Thoracic Surgeons
New Technology
Sheath-Assisted Tracheal Intubation: A Further Treatment Option for Patients With Acute Dyspnea or Asphyxia Caused by Severe Stenosis of the Larynx or Trachea
Gang Wu, MDa,*,
Yong-Dong Li, MD, PhDa,*,
Xin-Wei Han, MD, PhDa,*,
Wei Zhang, MDb,
Xue-Ping Han, MDb,
Peng-Xu Ding, MDa
a Department of Interventional Radiology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, Henan Province, China
b Department of Anesthesiology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, Henan Province, China
Accepted for publication March 7, 2011.
* Address correspondence to Dr X-W Han, No.1, East Jian She Rd, Zhengzhou, Henan Province, 450052 China (Email: hanxinwei{at}tom.com).
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Abstract
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Purpose: This report details our preliminary results for sheath-assisted tracheal intubation (SATI) for patients with acute dyspnea caused by severe stenoses in the larynx or trachea.
Description: Of 289 patients with acute dyspnea who required tracheal intubation in the emergency department of our hospital, 21 who experienced intubation difficulty or failure were entered into this study. Data on technical success, clinical outcome, and complications related to SATI were collected and analyzed retrospectively.
Evaluation: Sheath-assisted tracheal intubation was successful in all patients. Clinical success was observed in all patients 1 to 7 days after the procedure. Tracheal stents or incisions, or both, were performed 1 to 3 days after SATI for all patients, once their general physical condition had improved. During follow-up, acute dyspnea had resolved in all patients. At the time of this report, 18 patients were well, with no dyspnea, but 3 patients had died, 2 of lung cancer and 1 of carcinoma of the larynx.
Conclusions: Shealth-assisted tracheal intubation is a safe and feasible procedure, and may serve as an additional treatment option for patients with acute dyspnea caused by severe stenoses of the larynx or trachea.
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Introduction
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Airway stent insertion is an effective and widely used method in the management of airway stenoses [1], but the appropriate stents for patients with airway stenosis are often not available in the emergency department. Therefore, tracheal intubation is still needed temporarily as a life-saving procedure or as a bridge until further curative treatment can be initiated.
Although tracheal intubation is the accepted gold standard for patients who require a definitive airway, and is a critical and often life-saving, procedure [2], it may be difficult or fail completely, with a rate of 0.2% to 7% [2, 3], and may require more than two attempts in some patients [3]. For patients who present with severe stenosis of the larynx or trachea, the difficulty and failure rate of airway intubation are even higher, which may often result in severe complications that include serious hypoxia, brain damage, and even death after multiple failures of intubation.
To overcome these disadvantages, in October 2008 we devised a technique for sheath-assisted tracheal intubation (SATI), a remedial measure used after failure of routine tracheal intubation, that is specifically intended for patients with acute dyspnea that results from severe stenoses of the airway. This report details our preliminary results of SATI for patients with acute dyspnea or asphyxia caused by severe stenoses of the larynx or trachea.
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Technology
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The study was approved by our Institutional Review Board, and written informed consent was obtained from all patients or their immediate relatives if the patients were unable to give consent themselves.
Patients
From October 2008 to October 2010, 289 patients presented to the emergency department of our hospital with acute, severe dyspnea or asphyxia that required treatment with immediate tracheal intubation to maintain airway patency. During this period, routine tracheal intubation failed in 21 patients (9 men, 12 women) due to severe stenosis of the trachea or the main bronchus. These patients were managed with SATI under fluoroscopic guidance and were entered into the study. The patients were a mean age of 55.05 ± 13.78 years (range, 34 to 87 years). Demographic data from these patients are summarized in Table 1. All patients presented with severe symptoms of dyspnea and preoperative oxygen saturation levels measured by pulse oximetry (SpO
2) were below 90%, even with the administration of high-flow oxygen.
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Table 1 Characteristics of the Patients With Severe Acute Dyspnea Who Were Managed With Sheath-Assisted Tracheal Intubation
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Technique
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SATI Procedure
The SATI system consists of 2 parts: a 10Fr to 16Fr introducer sheath with a dilator (60 to 80 cm long) and a tracheal cannula (Fig 1
) that is mounted over the introducer sheath. All of the procedures were performed with the use of local anesthetic by two interventional radiologists. The blood pressure, heart rate, SpO
2, and other vital signs were monitored throughout the procedure.
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Fig 1. The sheath-assisted tracheal intubation system consists of (A) the tracheal cannula, (B) a 16Fr introducer sheath with a dilator, and (C) the entire sheath-assisted tracheal intubation system. The tracheal cannula is mounted over the 16Fr introducer sheath.
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The patient was placed in a right anterior oblique or supine position with the neck extended, and the stenosis was identified by injection of 3 to 5 mL of 30% diluted nonionic Ultravist 300 contrast medium (Schering, Guangzhou, China). After topical anesthesia (lidocaine 2%) was administered, a 0.035-inch Radiofocus M guidewire (Terumo, Tokyo, Japan) with a 5Fr Torcon NB catheter (Cook, Bloomington, IN) was advanced into the trachea or bronchus orally or nasally with fluoroscopic guidance.
The initial guidewire was exchanged for a 0.035-inch super-stiff guidewire (Boston Scientific/Medi-Tech, Watertown, MA), and the SATI system was advanced over the guidewire and slowly passed through the stenosis until the tip reached the left or right main bronchus. After the tracheal cannula had been passed across the stenosis, the introducer sheath and the dilator were pulled back and withdrawn, with the tracheal cannula retained in the trachea (Fig 2
). It usually took less than 5 minutes to complete the SATI procedure.
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Fig 2. Diagrams show the technical steps involved in the sheath-assisted tracheal intubation procedure. (A) A 0.035-inch super-stiff guidewire is inserted into the bronchus. (B) The sheath-assisted tracheal intubation system is advanced over the guidewire and slowly passed through the stenosis. (C) The tracheal cannula is retained in the trachea after the introducer sheath and the dilator are withdrawn. (D) A roentgenogram shows the tracheal cannula placed in the trachea (arrow).
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After the physical condition of the patient had been allowed to recover for 1 to 3 days, a tracheal stent or incision was performed to maintain the long-term patency of the airway.
Postoperative Outcome Evaluation
All patients underwent chest roentgenogram and clinical examination at 1 to 3 days, 1 month, and then every 3 months after the procedure to evaluate respiratory function and the status of the stent. In the event the clinical examination could not be performed, patients or their families were contacted by telephone every 3 months to ascertain the patient's respiratory status.
Data on technical success, SpO
2, Hugh-Jones classification, complications, and clinical success were evaluated at each follow-up and at the time of death. All data were obtained prospectively by completion of clinical surveys by the authors. Technical success was defined as successful insertion of the stent into the tracheal carina without any major complications. Clinical success was defined as an improvement of more than one grade on the Hugh-Jones classification scale at 1 to 7 days after SATI and any subsequent treatment.
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Clinical Experience
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Technical and Initial Results
SATI was technically successful and well tolerated in all patients, with no procedure-related complications. The severe dyspnea was relieved in all patients, and postoperative SpO
2 levels rose to 95% to 99%. Clinical success was observed in all patients at 1 to 7 days after the procedure. The improvement between preoperative and postoperative Hugh-Jones classification grade was statistically significant (Table 1).
Successive Treatment
Further successive treatments were performed for all patients 1 to 3 days after SATI, once their general physical condition had improved. Tracheal stents were placed in 15 patients, and tracheal incisions were performed in 5 to achieve long-term patency of the airway. Patient 4 was managed with tracheal stent and incision due to multiple stenoses of the trachea caused by recurrent polychondritis.
Follow-Up Data
During 11.38 ± 4.86 months (range, 3 to 21 months) of follow-up, the general physical condition of the 21 patents showed improvement, with no obvious dyspnea. At the last follow-up, 3 patients had died, at a mean of 6.33 ± 1.53 months (range, 6 to 8 months) after the procedure: 2 of lung cancer and 1 of carcinoma of the larynx. The remaining 18 patients were well and showed no evidence of dyspnea at the time of this report. Mean survival was 12.39 ± 1.06 months, and median survival was 12.00 ± 1.66 months.
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Comment
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This study evaluated the feasibility of SATI for patients with acute, severe dyspnea or asphyxia caused by severe airway stenoses. Initial results were positive. Acute, severe dyspnea or asphyxia resolved completely in all study patients, and follow-up revealed that no complications had occurred and that the patients were generally healthy. These results suggest that SATI can be considered a viable and effective treatment for patients with acute, severe dyspnea or asphyxia.
The high overall success rate of SATI in this study may be attributed to the following factors: Firstly, it was largely dependent on the use of the guidewire (0.89 mm in outer diameter with a J-tip), which once past the laryngeal or tracheal stenosis, almost always resulted in a successful procedure.
Secondly, all procedures were monitored fluoroscopically, which helped negotiate the guidewire easily through the stenosis and lessened complications.
Thirdly, the taper tip of the dilator made it easy to pass through the stenosis along the guidewire.
Many risk factors have been identified as causes of intubation difficulty, including poor mouth opening, a large tongue, prominent teeth, receding jaw, limited neck mobility, airway edema, airway malformation, laryngeal or tracheal stenosis, and tumor compression [4]. Patients with a severe laryngeal or tracheal stenosis often present with severe life-threatening respiratory distress that requires immediate life-saving intervention, such as tracheal intubation or mask ventilation. Otherwise, severe complications, which include serious hypoxia, brain damage, and death, can occur due to lack of oxygen or to carbon dioxide accumulation.
Management of the airway in patients with acute, severe dyspnea or asphyxia due to laryngeal or tracheal stenosis remains a formidable challenge for surgeons and anesthesiologists due to the high incidence of difficult or failed tracheal intubation. Various methods to control the acute dyspnea, including fiberoptic intubation with the patient awake [5], rigid bronchoscopy [6], fibrobronchoscopy, retrograde tracheal intubation [7], and Airtraq (Prodol Meditec S.A., Vizcaya, Spain) or Macintosh laryngoscope [8], have been established to solve this problem. On the basis of the available treatment options for the patients in our study, these methods were chosen as the optimal strategy but were delayed with efforts to pass through the laryngeal or tracheal stenosis. After multiple attempts with these methods failed, the general physical condition and symptoms of dyspnea of the patients had quickly deteriorated.
Failure of multiple attempts at intubation led us to use SATI to maintain the patency of the airways and prolong the lives of these patients. SATI helped solve the problem of unpredictable, difficult intubation and provided reliable patency of the respiratory airways in these patients with latent stenosis of the larynx or trachea. Compared with tracheal intubation, SATI has two distinct advantages: (1) a higher technical success rate because the sheath easily passes through the tracheal stenosis, and (2) a lower complication rate because it is a relatively simple and rapid procedure with fewer complications.
In recent reports, guidewires, Aintree Intubating Catheter (Cook) [9], airway exchange catheters [6], and a long, semirigid catheter [10] have been used to facilitate tracheal intubation with the aid of a rigid Glidescope bronchoscope (Verathon Medical Bothell, WA) or fiberoptic bronchoscope. Compared with these methods, SATI has certain unique advantages, including a high technical success rate with fewer complications, it is easily performed, and less time is required.
This study has some limitations. Firstly, it is not a comparative study; the patient population was small and no control group was included. The small sample prevents the results from being generalized.
Secondly, application of SATI was not possible in some patients when the trachea was completely obstructed and difficult to recanalize with the guidewire and the catheter.
Lastly, asphyxia, bleeding, and migration of the tracheal intubation might occur with the application of SATI. In addition, the SATI procedure needs multidisciplinary coordination and cooperation, which may confine its application in some centers.
Although further clinical trials are needed, our preliminary study indicates that the use of SATI for patients with acute dyspnea caused by severe airway stenoses of the larynx or trachea is a simple, safe, and feasible procedure that may serve as an additional treatment option for such patients.
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Disclosure and Freedom of Investigation
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We have performed a free and independent evaluation of this new technology and have no financial relationship with any manufactures in China. In addition, the new method of treatment is our original contribution. We had full control of the design of the study, methods used, outcome variables, analysis of the data, and production of the written report.
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Footnotes
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Disclaimer The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.
* These authors share first authorship. 
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References
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Abstract
Introduction
