The Elective use of a Transtracheal Jet Ventilation Catheter and the LMA Unique
for the Management of a Tracheal Stoma Repair in an Ambulatory Surgery Center
Damion Sanchez, MD, Allan Goldman, MD, Reinette Robbertze, MD.
University of Washington Medical Center, Seattle, Washington.

Introduction:
Surgery on patients with complicated medical histories, severe disease, and difficult airways are usually not performed in an ambulatory surgery center (ASC). We present a case of airway management in a 72-year old woman with hypertension, emphysema, and stomal stenosis, after a total laryngectomy, that presented to our ambulatory surgery center for a brief stoma revision.
Case:
A 72-year-old Vietnamese woman with a history of pharyngeal laryngectomy was admitted to our ASC for revision of her tracheostomy stoma secondary to stenosis. Her stomal stenosis, likely exacerbated by radiation therapy, was refractory to office dilatation.
The patient had the customary pre-op IV and antibiotics and was brought to the operating room where standard ASA monitoring was placed. Pre-oxygenation was performed with an oxygen mask placed loosely over the patient’s stoma. Remifentanyl (0.25 mcg/kg/min) and Propofol (50 mcg/kg/min) infusions were begun. After the patient was adequately sedated, and during spontaneous ventilation, the airway (stoma and trachea) was topicalized using 4% lidocaine gel and 4% lidocaine via an LTA. Placement of a 5.0 cuffed endotracheal tube was attempted. This was found to be too large for the stoma. The surgeons then decided that a smaller tube would distort their operative field. A 6.0Fr Cook Emergency Transtracheal Airway Catheter was then placed through the stoma in a caudal direction. Oxygen flow (2L/min) through the catheter was begun. A stopcock had been attached to the end of the Cook catheter and connected to a capnograph so that ETCO2 could be verified intermittently during the procedure. Verifying the ETCO2 during the procedure required brief cessation of O2 flow.
The procedure began after local anesthetic infiltration by the surgeon. The patient continued to breathe spontaneously through her stoma with the Cook catheter in place providing supplemental oxygen. Twice during the procedure the patient became apneic which required the Propofol and Remifentanyl infusions to be stopped and an LMA Unique #3 was placed over the stoma on both occasions to facilitate manual positive pressure ventilation until spontaneous breathing resumed. LMA assisted stomal ventilation was
brief (approx. 1-2 minutes) during both apneic periods. The LMA was an excellent fit without any leak, and we were able to provide adequate tidal volumes (approx 400-500cc). Oxygen saturation remained above 90% during the entire case, and was 100% during spontaneous ventilation.
She tolerated the procedure well. At the end of the 71-minute procedure a #4 cuffless Shiley tracheostomy tube was placed. The infusions were stopped and the Cook catheter was removed. The patient was taken to the PACU where she did well and was discharged home the same day.
Discussion:
This illustrates a case, first time reported, where a Cook Transtracheal Airway Catheter was used electively outside the emergency setting and without jet ventilation for the routine management of a surgical procedure. While trans-tracheal jet ventilation remained an option, it was felt to be an option of last resort because of the patient’s emphysema. This case also demonstrates an additional use of the LMA as a mask for ventilation via a tracheal stoma. The LMA Unique provided a good fit over a tracheostomy stoma
facilitating manual ventilation with adequate tidal volumes and without any leak. Through flexible innovation we were able to simplify a complicated airway case and maintain the patient’s “outpatient” status.
Note: Photos are available that follow the above case description

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