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Extubation in the Third Trimester: Airway Edema, Leak Tests, and Tube Size Dilemmas
Abstract Number: T-29
Abstract Type: Case Report/Case Series
A 22 y/o G3P0 at 33 weeks was admitted in transfer from an outside hospital where she had presented with a rapid onset of obtundation requiring tracheal intubation for airway protection. The intubation was described as easy and atraumatic via direct laryngoscopy (DL) and a 7.5 mm ID endotracheal tube (ETT). MRI revealed bilateral thalamic infarcts due to emboli from sterile vegetations on the mitral valve in the setting of Antiphospholipid Syndrome (APS).
At 48 hours, extubation was considered but the cuff leak test (CLT) was negative. After IV methylpredisolone 20mg q4h x 4 doses and diuresis CLT remained negative. Following a further 48 hours of dexamethasone IV and more diuresis, the ICU, anesthesia, and ENT teams felt that the 7.5 ETT was the source of the negative CLT rather than airway edema due to pregnancy or any other laryngo-tracheal pathology. Extubation in the OR with ENT standby was planned. Prior to extubation, the onset of recurrent variable fetal heart rate decelerations prompted a semi-emergent cesarean delivery. After delivery of a premature neonate under GA, micro DL revealed the injuries outlined in the Figure. In light of the airway injuries and the high probability of developing sub-glottic stenosis during healing, the trachea was then reintubated without difficulty and a tracheostomy was performed with a 4.0 cuffed Shiley tube.
APS presents many challenges in the care of parturients, including a higher risk for pre-eclampsia and other causes of CNS dysfunction. The coordination of antithrombotic therapy and anesthesia care is a common concern, while maternal thrombosis and stroke during anticoagulation as occurred in this case is rare.
Obstetric anesthesiologists are very aware of the need for small ETTs in pregnancy, but in this case the large ETT used was chosen outside the obstetric anesthesia setting. The cautious approach toward extubation was based on the recurrently negative CLT and the effect that a difficult reintubation might have on maternal/fetal wellbeing. The CLT has been shown to have poor predictive value for decision making for reintubation. This report illustrates the injuries that can be caused by too large an ETT and suggests that a negative CLT with a large ETT in pregnancy may be an impetus, not a contraindication to extubation or ETT exchange.
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2. Respir Care. 2012;57:2026-31
3. Am Surg. 2008;74:1182-5