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Continuous Care of a Parturient with Severe Tracheal Stenosis
Abstract Number: SA-64
Abstract Type: Case Report/Case Series
Tracheal stenosis signifies a functional impairment, with a decrease in peak expiratory flow to 30% in a trachea that normally is 2 cm. Tracheal stenosis may be congenital or acquired; the most common cause being trauma from prolonged endotracheal intubation. As related to the pregnant patient, physiologic changes such as increased oxygen consumption, decreased FRC, airway mucosal swelling may exacerbate tracheal stenosis symptoms. Therefore, tracheal stenosis in a pregnant patient presents a significant challenge to safely manage during intrapartum period.
33 yo female at G4P2102 at 21w4d was referred to Pre-Anesthesia clinic for workup with a PMH including history of tracheostomy with subsequent multiple reconstruction surgeries. Two months prior to anticipated due date, the patient underwent fiberoptic laryngoscopy with ENT that showed distorted laryngeal anatomy with bilateral vocal cord fixation and prolapse of R arytenoid tissue with the inability to visualize the vocal cords. Further, ENT stressed that no airway manipulation, including awake fiberoptic, should be attempted without their presence.
An elective tracheostomy was declined by the patient, with the understanding that one would be done should respiratory distress become apparent, more likely becoming a permanent tracheostomy. A multidisciplinary team of MFM, obstetrics, obstetric anesthesia and ENT managed the peripartum patient care. The patient presented to labor and delivery for trial of labor after c-section (TOLAC) at 39w2d. After much convincing of the patient, a labor epidural was placed easily with LOR at 5 cm, secured at 9 cm at the skin. A dedicated tracheostomy was at bedside, along with a difficult airway cart comprised of the standard precautions including adult and pediatric fiberoptic scopes and ETT ranging from 4.0 to 6.0 in size. The patient underwent a successful vaginal delivery, and delivered a healthy neonate.
On postpartum day 6, the patient presented with postpartum hemorrhage. Despite extensive discussions with patient, family, MFM, anesthesia and ENT regarding anticipated surgical and anesthetic plans, she again declined an elective tracheostomy. A Combined Spinal Epidural technique was done, with LOR at 5 cm and again secured at 9cm; spinal 1.4 ml of 0.75% bupivacaine and 10 mcg of fentanyl. The same set up was in the operating room with ENT presence. The patient underwent a Dilation and Curettage without any adverse events, with a blood loss of 1200 cc.
In patients with known subglottic stenosis, coordination between care teams is paramount. One must consider the risks and benefits associated with airway management and neuraxial anesthesia in lieu of potential unanticipated problems that could arise in the obstetric population. Thus, having a secondary and even tertiary plan available is critical for the safe outcome of both mother and baby.
Salama DJ, Body SC. Br J Anapest.1994; 72:354–7