The Real-World Boards: Question #25
A post-laryngectomy intubation turns extra-difficult
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A 75-year-old woman is being admitted for an acute exacerbation of COPD with acute hypoxemic respiratory failure. She underwent total laryngectomy for advanced laryngeal cancer two months ago.
She was hypoxemic on presentation, and the respiratory therapist advanced a 6.0 mm tracheostomy tube through her stoma in the ED. She initially had an SpO2 of 95% on FiO2 40% being delivered by trach collar oxygen, with other vital signs stable.
Ten minutes later, her SpO2 fell to 85% on FiO2 100% with a pulse of 130/min. A suction catheter could not be passed through the tracheostomy tube. It was removed but could not be easily reinserted. She became unconscious and was emergently reintubated in the ED by another clinician. The intubation was described as very difficult.
SpO2 is 65%. Her pulse falls to 30, and she experiences a PEA cardiac arrest. CPR is begun.
