Printer Friendly

Tracheal obstruction caused by fluid extravasation during shoulder arthroscopy.

An endotracheal tube is the most reliable method of securing the airway from airway obstruction during a shoulder arthroscopy procedure (1-4). However, since the airway may become obstructed after extubation, airway patency should be verified before extubation (4). Direct visualisation of the larynx or trachea is difficult due to the presence of the tracheal tube, while a cuff leak around the tracheal tube in a cuff-deflated condition is thought to be a predictor of successful extubation though its reliability has been questioned (5). We present a case of tracheal distortion caused by extravasation of fluid in a 73-year-old male undergoing an arthroscopic shoulder cuff repair, in which a cuff leak was useful in deciding safety of extubation.

Anaesthesia was achieved with thiamylal, fentanyl, sevoflurane and [N.sub.2]O with vecuronium for muscle relaxation. The airway was secured with a reinforced endotracheal tube (internal diameter 8.0, outer diameter 1.1, Phycon, Fuji Systems, Tokyo, Japan). After placing the patient in a right lateral position, a left interscalene brachial plexus block was performed uneventfully with 15 ml of 1.5% mepivacaine. Shoulder arthroscopy was performed with normal saline irrigation using a rotary pump at 60 mmHg. During the operation, blood pressure, heart rate, [SpO.sub.2], [ETCO.sub.2] and lung compliance were stable, but the amount of irrigation fluid was 24 l. The surgery required 2.5 hours and no complications were encountered during the procedure.

At the end of surgery we noticed massive swelling and tension in the left shoulder, chest and lower neck areas, and therefore placed the patient in a headup position. Laryngoscopy showed neither swelling nor haematoma, and conventional chest X-ray demonstrated the trachea remaining in the midline. However, airway pressure to obtain a cuff leak increased from 5 cm of [H.sub.2]O before surgery to greater than 20 cm, even in the head-up position. Lateral cervical X-ray images (Figure 1) showed enlargement of the soft tissue including the retro-tracheal space, which pressed on the membranous side of the trachea (3 to 5, 15 to 18, 15 to 20, and 11 to 22 mm, at C3/4, C4/5, C5/6 and C6/7, respectively). We considered that extravasation of irrigation fluid had spread to compress the trachea in a circumferential manner. To reduce the tracheal compression, the patient was kept in a head-up position and intravenous fluids were restricted. Within 30 minutes, the areas of swelling and tension were reduced and a cuff leak pressure had fallen to below 10 cm [H.sub.2]O. The patient was then extubated after full emergence from anaesthesia. No airway obstruction was seen and swelling disappeared completely within the next 12 hours.

During shoulder arthroscopy procedures, extravasation can occur around the shoulder and is generally reabsorbed asymptomatically within 12 hours (6). Factors that promote extravasation include higher irrigation pressure, longer duration, obesity and arthroscopy within the subacromial space (2,4). In our case, without these factors, loose soft tissue caused by senile changes, gravity or surgical pads placed around the neck might have influenced the large amount of extravasation seen in the neck area (6).

Tracheal compression around a tracheal tube can not be effectively evaluated using laryngoscopy or bronchoscopy, whereas it can be determined indirectly by tracheal tube tightness or air leakage around the tube. Although the efficacy of a cuff leak has been questioned in adult patients, absence of such leakage should be considered a cautionary alert for possible post-extubation airway obstruction (5). A cuff leak is thought to be affected by paratracheal pressure, which is known to be elevated during shoulder arthroscopy. De Vachter et al reported that 5 of 40 patients had a significant elevation of paratracheal pressure during and after the procedure, with an absolute value of 133.4 mmHg in one case (6). A reduction of interstitial pressure around the trachea may also be crucial for safe extubation (3). In our case, cuff leak disappearance and enlargement of the retrotracheal space indicated the risk of airway compression after extubation. Thus, tracheal compression should be considered, even if conventional chest X-ray imaging shows that the trachea remains in a midline position.


Recovery of a safe cuff leak pressure occurred in about 30 minutes, compatible with results reported in a previous study (6). Although we did not directly monitor interstitial pressure, the tracheal tube was safely removed while monitoring the leak, suggesting that a cuff leak may be useful for estimation of paratracheal pressure.



Hiroshima, Japan


(1.) Antonucci S, Orlandi P, Mattei PA, Aamat F. Airway obstruction during arthroscopic surgery: anesthesia for the patient or for the surgeon? Minerva Anesth 2006; 72:995-1000.

(2.) Hynson JM, Tung A, Guevara JE, Katz JA, Glick JM, Shapiro WA. Complete airway obstruction during arthroscopic shoulder surgery. Anesth Analg 1993; 76:875-878.

(3.) Blumenthal S, Nadig M, Gerber C, Borgeat A. Severe airway obstruction during arthroscopic shoulder surgery. Anesthesiology 2003; 99:1455-1456.

(4.) Orebaugh SL. Life-threatening airway edema resulting from prolonged shoulder arthroscopy. Anesthesiology 2003; 99:1456-1458.

(5.) Ochoa ME, Marin Mdel C, Frutos-Vivar F, Gordo F, Latour-Perez J, Calvo E, Esteban A. Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis. Intensive Care Med 2009; 35:1171-1179.

(6.) De Wachter J, Van Glabbeek F, Van Riet R, Van Leemput W, Vermeyen K, Somville J. Surrounding soft tissue pressure during shoulder arthroscopy. Acta Orthop Belg. 2005; 71:521-527.
COPYRIGHT 2011 Australian Society of Anaesthetists
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2011 Gale, Cengage Learning. All rights reserved.

Article Details
Printer friendly Cite/link Email Feedback
Author:Saeki, N.; Kawamoto, M.
Publication:Anaesthesia and Intensive Care
Geographic Code:9JAPA
Date:Mar 1, 2011
Previous Article:Pulmonary interstitial emphysema associated with recruitment manoeuvres on the adult intensive care unit.
Next Article:Morbid Obesity. Second edition.

Terms of use | Privacy policy | Copyright © 2021 Farlex, Inc. | Feedback | For webmasters |