'Speaking valve' aspiration in a laryngectomy patient.
Our patient was a 73-year-old man who underwent a total laryngectomy, primary tracheo-oesophageal puncture and neck dissection followed by radiotherapy 18 years earlier for management of squamous cell carcinoma extending from the base of his tongue into his larynx. His previous history also included a large alcohol intake, hypertension, congestive cardiac failure, myocardial infarction, transient ischaemic attacks and iron deficiency anaemia. He usually became dyspnoeic on walking about 200 m.
Earlier on the night of the current presentation, having consumed some alcohol our patient coughed, dislodging his speaking valve. He then lost consciousness for a short period. When initially seen in the emergency department he was sitting upright, pale, distressed, had stridor and was unable to vocalise. His Glasgow coma score was 15/15, heart rate 160 /min, blood pressure 130/90 mmHg and respiratory rate 36 /min. His pulse oximetry indicated an oxygen saturation of 87% on air, which subsequently increased to 97% with supplementary oxygen via a Hudson mask over his stoma. An otolaryngologist examined his airway with a flexible fibreoptic nasoendoscope and saw the valve in the distal right main bronchus (RMB).
The patient was transported to the operating theatre for retrieval of the foreign body under controlled conditions. A Foley's catheter was passed into the TOF to maintain its patency and to prevent aspiration of secretions (Figure 1).
A preoperative anaesthetic assessment was unremarkable except for slightly decreased air entry on the right side, with no adventitious sounds. Glycopyrrolate 0.2 mg was given as premedication. The initial plan was to use a rigid ventilating bronchoscope (Model 10318D, Karl Storz, Tuttlingen, Germany) and if this failed, to consider a Negus rigid bronchoscope (Model LP-070-53-Q, Downs Surgical, Sheffield, UK) with modified jet ventilation or a non-ventilating endoscope (Hopkin's rod) and a grasper to retrieve the foreign body. The surgeon sprayed Cophenylcaine Forte[TM] (lignocaine 50 mg/ml and phenylephrine 5 mg/ml) into the trachea via the stoma. After commencement of monitoring, the Hudson mask was disconnected and the elbow catheter mount connector from the circuit was placed over the stoma to pre-oxygenate the patient. Some difficulty was experienced in attaining a good seal. As a result it took more than five minutes to attain an end-tidal oxygen of 85%; at this point a target-controlled infusion was commenced with propofol set to 4 [micro]g/ml. This was gradually increased up to 8 [micro]g/ml. The Storz bronchoscope was introduced and the speaking valve identified in the RMB. At the same time anaesthesia was supplemented by sevoflurane in oxygen through the side port of the bronchoscope.
[FIGURE 1 OMITTED]
Unfortunately, during bronchoscopy the patient was coughing and tachycardic and it was not possible to maintain adequate ventilation. Therefore, the Negus bronchoscope was used instead, with modified jet ventilation.
Suxamethonium 100 mg was given prior to introduction of the Negus bronchoscope and jet ventilation was commenced. The frequency and volume of air injected was controlled with a lock screw and chest wall movements were observed. Ventilation was tailored to avoid barotrauma. While the bronchoscope was in the RMB, the oxygen saturation declined rapidly from 100 to 89%. Fortunately, at that time the speaking valve was retrieved using the long grasping forceps, facilitated by appropriate neck positioning. Immediately following removal of the valve and bronchoscope from the RMB, ventilation was easy and the oxygen saturation improved to 94%. A postoperative chest X-ray did not show any complications related to the procedure (e.g. aspiration or pneumothorax) and the patient had an uneventful recovery. Figure 2 shows the retrieved valve.
[FIGURE 2 OMITTED]
In Australia, the incidence of laryngeal carcinoma is reported to be about 550 cases annually (1). It is the most common cause for a laryngectomy. There have been only 10 reported cases of various foreign bodies aspirated through the stoma in laryngectomy patients (2-11). The foreign bodies reported included a safety pin, nails, a wooden stick and speaking valve cleaning brushes (2-10). There has only been one previous case of a speaking valve aspiration (11). The techniques to extract these items included mostly flexible and rigid bronchoscopy, but requiring thoracotomy in some cases. Flexible bronchoscopy is generally the method of choice, but the overall success rate of foreign body removal with a flexible bronchoscope is only about 60%, compared to about 98% where rigid bronchoscopy has been used (12).
A case like this requires prompt action, but generally there is adequate time for assessment and planning before proceeding to surgery. In a patient who is unable to talk, poor communication will increase anxiety, leading to a short-term difficulty in co-operation and to increased sympathetic drive with its associated complications. The use of an anxiolytic should also be considered, if this would not increase the respiratory compromise. An anticholinergic agent, as used in our case, may help to reduce secretions and attenuate vagally-mediated bradycardias and possibly reflex bronchconstriction.
In several of the previous case reports, chest X-rays were the initial method for locating the foreign body; in one case flexible nasendoscopy was used. In this case we used the latter method, as we felt that it would be more reliable.
Discussion with the surgeon prior to attempting retrieval of the foreign body is essential to ensure adequate preparation and planning for a course of action. This should incorporate decisions including the type of bronchoscope to be used. For most flexible bronchoscopies, a neuroloept anaesthetic could be considered but for rigid bronchoscopy, general anaesthesia is mandatory. In a patient with a stoma, the challenges of airway endoscopy extend beyond ventilation issues to mechanical issues relating to endoscope introduction into the airway. Bronchoscopes are generally designed to be introduced via the mouth with atlanto-occipital extension and neck flexion and thus, the introduction of a bronchoscope via a neck stoma is challenging and sometimes impossible due to obstruction by the chin. These difficulties are exacerbated with co-existing obesity, unfavourable craniofacial and spinal anatomy, an inconveniently positioned stoma or limited neck extension and stoma stenosis, due to scarring and radiotherapy. In our case, there were several anatomical challenges including limited neck extension, most likely consequent to radiotherapy, obesity, co-existing arthritis and kyphosis. However, the major limiting factor was inadequate oxygenation with positive pressure ventilation provided by the Storz ventilating bronchoscope, requiring jet ventilation as an alternative.
In a laryngectomy patient, the only communication between the oral cavity and the trachea is the TOF, and the only airway is the permanent stoma in the neck. Due to habit, there is a general tendency to pre-oxygenate via the mouth or nose and very often the absence of this upper airway communication may be initially unrecognised. When the speaking valve is not in place in the TOF, a Foley catheter can be inserted to maintain the patency of the TOF. However, a catheter can affect preoxygenation by interfering with establishment of a good seal. Nevertheless, it is important to leave the catheter in place to prevent closure of the TOF, which can occur in less than 20 minutes following removal of the speaking valve. If closure of the TOF does occur, a surgical procedure is required in due course to re-establish the TOF (13). Importantly, in the immediate situation, the catheter protects the airway from aspiration of gastric contents that might otherwise reflux into the trachea via the TOF. It is also important not to overinflate the Foley catheter balloon in the oesophagus, as this can cause compression of the trachea. Innovative use of devices such as a paediatric Rendell Baker Soucek facemask, an inflated laryngeal mask or a Laerdal mask can be been used to improve the ventilatory seal (14). Alternatively, a laryngectomy tube may be inserted; such tubes were designed to keep the stoma patent immediately following surgery, but may also be useful when desaturation occurs and manual ventilation is needed to manage the crisis.
During the extraction of a foreign body, it is common for the object to get stuck at the narrowest part of the upper airway, which is generally the larynx. However, in patients with a laryngectomy, it is at the orifice of the main bronchi (or in those with a Foley catheter in the TOF, it may be at the site of the inflated balloon of the catheter within the oesophagus bulging into the trachea).
A dislodged foreign body may cause desaturation; not only may it lodge in a main bronchus, typically the right, but its flange may protrude into the other main bronchus further compromising ventilation and oxygenation. Another possible cause of desaturation during bronchoscopy may be a combination of an occluded right main bronchus due to a foreign body, with a non-ventilated left bronchus due to the ventilating tip of the bronchoscope being in the right bronchus. Therefore, preliminary examination by flexible bronchoscopy can be valuable in locating the object.
There are many predisposing factors leading to aspiration of foreign bodies including loss of consciousness from trauma, neurological disorders, the use of sedatives and alcohol intake (12). An aspirated speaking valve may lodge anywhere and a chest X-ray may be of benefit in an incompetent patient who may not be able to recognise and report aspiration.
In most cases forceful coughing should expel the prosthesis, reducing the need for retrieval. In the chronic situation such an event may go unnoticed for days, with the only sign being a missing prosthesis. In this case, the patient may present with a cough and slow onset of signs of breathlessness and pneumonia (15).
The main anaesthetic problems in this report were related to adequate oxygen delivery through an anatomically abnormal, shared airway past an obstruction, while maintaining anaesthesia which must be appropriately deep for such a highly stimulating procedure. This case illustrates that adaptive airway management techniques are needed for the safe management of patients with stomas who present to the emergency department or for incidental surgery.
Accepted for publication on June 27, 2009.
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Address for correspondence: Dr V. Rao Kadam, Department of Anaesthesia, The Queen Elizabeth Hospital, 28 Woodville Rd, Woodville, SA 5011.
V. RAO KADAM *, P. LAMBERT [dagger], H. PANT [double dagger], M. O'REILLY [section]
Department of Anaesthesia, The Queen Elizabeth Hospital, Woodville, South Australia, Australia
* M.D., D.N.B., F.A.N.Z.C.A., Consultant Anaesthetist.
([dagger]) B.M., B.S., Ph.D., Registrar Anaesthesia.
([double dagger]) B.M., B.S., F.R.A.C.S., Ph.D., Clinical Instructor and Fellow, Rhinology and Skull Base Surgery, University of Pittsburgh and Department of Otorhinolaryngology, Head and Neck Surgery, Eye and Ear Institute, Pittsburgh, United States of America.
([section]) M.B., B.S., RMO Anaesthesia.
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|Author:||Kadam, V. Rao; Lambert, P.; Pant, H.; O'Reilly, M.|
|Publication:||Anaesthesia and Intensive Care|
|Date:||Jan 1, 2010|
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