Continuous Positive
Airway Pressure
Use in Bilateral Vocal Cord
Paralysis
Robert P. Zitsch III, MD
positive airway pressure has been used in the of management a number of upper airway problems, and has become well established as a treatment option for obstructive sleep apnea. The therapeutic value is achieved by an internal splinting effect on the compromised airway. Airway compromise from bilateral recurrent laryngeal nerve trauma can occur with surgical procedures associated with extensive dissection of these nerves. The use of continuous positive airway pressure for the management of bilateral vocal cord paralysis, although not previously described, to my knowledge, is outlined in this article. (Arch Otolaryngol Head Neck Surg. 1992;118:875-876) \s=b\ Continuous
positive airway pressure (CPAP) has be¬ well established Continuous effective form of for obstructive The col¬ come
treat¬
as an
oropharyngeal
sleep apnea.
ment
lapse characteristic of this disorder can be halted with the use of CPAP, resulting in improved blood oxygénation. The mechanism by which CPAP works in this form of up¬ per airway obstruction is as a pneumatic splinting effect on the upper airway.1 The ability to splint the upper airway in this fashion has led to the application of CPAP to other airway problems such as acute epiglottitis, laryngomalacia, and hyaline membrane disease.2·3 This article demonstrates another clinical situation in which CPAP can be extremely valuable for airway main¬ tenance. Airway obstruction from transient, bilateral vocal cord paralysis following trachéal tumor resection was suc¬ cessfully managed using CPAP. This intervention pro¬ vided airway stability without replacement of an endotra¬ cheal tube across a relatively weak tracheolaryngeal anastomotic line. REPORT OF A CASE with a 40 pack-year smoking history 56-year-old presented with a complaint of hemoptysis of recent onset. She also admitted to a 2-month history of a persistent nonproductive cough and dyspnea. Interestingly, this patient had sudden airway obstruction during a ureteral stent placement for tuberculosis of the bladder 2 months prior to presentation. This was managed by repositioning of the endotracheal tube. A
woman
Accepted
for publication May 6, 1992. From the Division of Otolaryngology,
Columbia School of Medicine. Reprint requests to the Division of
Drive,
Room
University of
Otolaryngology,
Missouri-
One
MA314, Columbia, MO 65212 (Dr Zitsch).
Hospital
Fig 1.—Squamous cell carcinoma of the upper cervical trachea (arrow¬ head).
The
patient had normally mobile true vocal cords on examina¬
tion, and no laryngeal or hypopharyngeal lesions were seen. En¬
doscopie evaluation revealed an exophytic, friable mass originat¬ ing on the right posterolateral trachéal wall, extending from the first trachéal ring a distance of 4.5 cm inferiorly. No other aerodigestive tract lesions were found, and esophageal involvement was absent. A biopsy showed the lesion to be an invasive, mod¬ erately differentiated squamous carcinoma. Computed tomogra¬ phy demonstrated the trachéal lesion (Figs 1 and 2).
It was determined that no distant métastases were present. Therefore, after explanation of the planned procedure and
obtainment of informed consent, the patient underwent trachéal tumor resection. This required a manubriotomy for tumor expo¬ sure inferiorly. Superiorly, the lower portion of the cricoid carti¬ lage was resected with the trachea to obtain an adequate margin, necessitating dissection of both recurrent laryngeal nerves to their point of entry into the larynx. The esophagus was not involved and all surgical margins examined intraoperatively were found to be free of tumor. Primary closure of the larynx to the trachea was facilitated by a suprahyoid laryngeal release and extreme neck flexion. This placed the anastomotic line in a position directly posterior to the innominate artery. The patient was awakened and extubated in the operating room without difficulty. Approximately 30 minutes later however, she developed a progressive, inspiratory stridor. Flexible fiberoptic examination revealed paralyzed true vocal cords bilaterally with paradoxical cord motion during inspiration. The tracheolaryngeal closure was intact and widely open. Complete respiratory failure rapidly ensued and the patient was emergently reintubated to maintain the airway. One week later the patient was extubated and laryngeal exam-
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/19/2015
vocal cord paralysis may be an occasional sequela of op¬ erations that require exposure of considerable portions of the recurrent laryngeal nerves bilaterally. Certain trachéal resections, as in the case presented in this article, as well as in some total thyroidectomies, necessarily involve extended surgical exposure of the recurrent laryngeal nerves and may result in temporary, bilateral vocal cord
paralysis. Airway obstruction from bilateral vocal cord paralysis is in part due to the increased resistance to airflow caused by the paramedian positioning of the cords. According to Poiseuille's law describing laminar flow, such a decrease in the glottic area results in reduced airflow. Active vocal cord motion is not possible and the glottic area cannot in¬ Fig 2.—Marked reduction of cross-sectional trachéal airway by tumor at the thoracic inlet
(arrowhead).
¡nation again demonstrated paralyzed true vocal cords with par¬ adoxical motion. Stridor quickly developed as the true vocal cords prolapsed into the airway on inspiration, and the work of breath¬ ing began to increase. In an attempt to avoid reintubation once again, nasal CPAP was begun using 8-cm water pressure and an oxygen flow of 4 L per minute. This immediately alleviated the airway embarrassment and the patient began breathing comfort¬ ably. No further airway problems developed during the remain¬ der of the hospital stay or after discharge. Seven days after the initiation of the CPAP, slight left true vo¬ cal cord abduction was noted. At this time, the patient was dis¬ charged home on CPAP, where weaning from it was easily accomplished over a period of 2 weeks. Oral feedings had been resumed prior to discharge and the patient was ambulatory. Within the next month, normal true vocal cord motion returned on the left side, and by the end of 3 months the right vocal cord regained motion. The patient received postoperative radiation therapy and was disease free at 1 year.
COMMENT
Squamous cell
carcinoma of the trachea is a relatively can be cured with an aggressive surgical approach.4-5 Extensive surgical resections are nec¬ essary if involvement of the larynx, the membranous tra¬ chea, or the esophagus has occurred. Upper trachéal lesions confined to the cartilaginous wall of the trachea may be treated by trachéal resection without the removal uncommon
tumor that
of the larynx or esophagus. Trachéal resection to the cricoid cartilage, or including the lower portion of the cricoid cartilage, requires bilateral recurrent laryngeal nerve dissection to their points of en¬ try into the larynx. The nerve dissection should be per¬ formed with a delicate technique so as to avoid vocal cord paralysis. However, even careful technique may not be sufficient to prevent traumatic nerve injury.6 Patients having had trachéal resection should be extu¬ bated at the termination of the operation to minimize any tension or mechanical trauma to the trachéal suture line. For the same reason, placement of an endotracheal tube across the trachéal closure is to be avoided if at all possi¬ ble. Airway compromise or obstruction following the pro¬ cedure is best managed by tracheostomy placement such that it does not impinge on the trachéal anastomosis.7 Tra¬ cheostomy, however, may not be performed easily as in this case. Postoperative airway obstruction that is due to bilateral
to facilitate airflow with inspiration. With this rel¬ atively fixed resistance at the glottic level, adequate ven¬ crease
tilation is maintained by increasing inspiratory effort.8 A secondary airway effect of this situation results from the increased inspiratory effort needed to maintain ade¬ quate ventilation. This leads directly to an increased transglottic and transmural pressure gradient, prolapsing the hypotonie true vocal cords into the airway. This, of course, can totally obstruct an already compromised airway. The management options, other than intubation or tra¬ cheotomy for an inadequate airway due to bilateral vocal cord paralysis, are limited. Continuous positive airway pressure is one of these options and, in effect, reduces the magnitude of the transmural and transglottic pressure gradient. This prevents critical airway compromise by the prolapsing vocal cords, facilitating adequate ventilation without extreme effort. Another alternative that has proven effective in this situation is the use of an 80% he¬ lium and 20% oxygen gas mixture.9 Due to its low density compared with air, it can markedly reduce the work of breathing in patients with partial airway obstruction. As this case demonstrates, CPAP may be an effective al¬ ternative for short-term airway management in selected cases of bilateral true vocal cord paralysis. Obviously, pa¬ tients with temporary bilateral vocal cord paralysis man¬ aged in this fashion must be observed closely until it is de¬ termined that the airway is both adequate and stable. Continuous positive airway pressure is not, however, ap¬ propriate for long-term management of this problem and may not be suitable for use outside of an acute care setting. References
Abbey NC, Cooper KR, Kwentus JA. Benefit of nasal CPAP in obstructive sleep apnea is due to positive pharyngeal pressure. Sleep. 1989;12:420\x=req-\ 1.
422. 2. Butt W, Shann
F, Walker C, Williams J, Duncan A, Phelan P. Acute ep-
iglottitis: a different approach to management. Crit Care Med. 1988;16:43-47.
3. Jonson B, Ahlstrom H, Lindroth M, Svenningsen NW. Continuous positive airway pressure: modes of action in relation to clinical applications. Pediatr Clin North Am. 1980;27:687-699. 4. Pearson FG, Todd TRJ, Cooper JD. Experience with primary neoplasms of the trachea and carina. J Thorac Cardiovasc Surg. 1984;88:511-518. 5. Grillo HC. Management of tracheal tumors. Am J Surg. 1982;143:697\x=req-\ 700. 6. Grillo HC. Tracheal tumors: surgical management. Ann Thorac Surg.
1978;26:112-125. 7. Grillo HC, Mathisen DJ. Tumors of the cervical trachea. In: Myers EN, Suen JY, eds. Cancer ofthe Head and Neck. 2nd ed. New York, NY: Churchill Livingstone Inc; 1989:621-643. 8. Templer JW, Von Doersten PG, Quigley PR, Scott GC, Davis WE. Laryngeal airway resistance: the relationships of airflow, pressure and aperture. Arch Otolaryngol Head Neck Surg. 1991;117:867-870. 9. Orr JB. Helium-oxygen gas mixtures in the management of patients with airway obstruction. Ear Nose Throat J. 1988;67:866-869.
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/19/2015
Airway Pressure
Use in Bilateral Vocal Cord
Paralysis
Robert P. Zitsch III, MD
positive airway pressure has been used in the of management a number of upper airway problems, and has become well established as a treatment option for obstructive sleep apnea. The therapeutic value is achieved by an internal splinting effect on the compromised airway. Airway compromise from bilateral recurrent laryngeal nerve trauma can occur with surgical procedures associated with extensive dissection of these nerves. The use of continuous positive airway pressure for the management of bilateral vocal cord paralysis, although not previously described, to my knowledge, is outlined in this article. (Arch Otolaryngol Head Neck Surg. 1992;118:875-876) \s=b\ Continuous
positive airway pressure (CPAP) has be¬ well established Continuous effective form of for obstructive The col¬ come
treat¬
as an
oropharyngeal
sleep apnea.
ment
lapse characteristic of this disorder can be halted with the use of CPAP, resulting in improved blood oxygénation. The mechanism by which CPAP works in this form of up¬ per airway obstruction is as a pneumatic splinting effect on the upper airway.1 The ability to splint the upper airway in this fashion has led to the application of CPAP to other airway problems such as acute epiglottitis, laryngomalacia, and hyaline membrane disease.2·3 This article demonstrates another clinical situation in which CPAP can be extremely valuable for airway main¬ tenance. Airway obstruction from transient, bilateral vocal cord paralysis following trachéal tumor resection was suc¬ cessfully managed using CPAP. This intervention pro¬ vided airway stability without replacement of an endotra¬ cheal tube across a relatively weak tracheolaryngeal anastomotic line. REPORT OF A CASE with a 40 pack-year smoking history 56-year-old presented with a complaint of hemoptysis of recent onset. She also admitted to a 2-month history of a persistent nonproductive cough and dyspnea. Interestingly, this patient had sudden airway obstruction during a ureteral stent placement for tuberculosis of the bladder 2 months prior to presentation. This was managed by repositioning of the endotracheal tube. A
woman
Accepted
for publication May 6, 1992. From the Division of Otolaryngology,
Columbia School of Medicine. Reprint requests to the Division of
Drive,
Room
University of
Otolaryngology,
Missouri-
One
MA314, Columbia, MO 65212 (Dr Zitsch).
Hospital
Fig 1.—Squamous cell carcinoma of the upper cervical trachea (arrow¬ head).
The
patient had normally mobile true vocal cords on examina¬
tion, and no laryngeal or hypopharyngeal lesions were seen. En¬
doscopie evaluation revealed an exophytic, friable mass originat¬ ing on the right posterolateral trachéal wall, extending from the first trachéal ring a distance of 4.5 cm inferiorly. No other aerodigestive tract lesions were found, and esophageal involvement was absent. A biopsy showed the lesion to be an invasive, mod¬ erately differentiated squamous carcinoma. Computed tomogra¬ phy demonstrated the trachéal lesion (Figs 1 and 2).
It was determined that no distant métastases were present. Therefore, after explanation of the planned procedure and
obtainment of informed consent, the patient underwent trachéal tumor resection. This required a manubriotomy for tumor expo¬ sure inferiorly. Superiorly, the lower portion of the cricoid carti¬ lage was resected with the trachea to obtain an adequate margin, necessitating dissection of both recurrent laryngeal nerves to their point of entry into the larynx. The esophagus was not involved and all surgical margins examined intraoperatively were found to be free of tumor. Primary closure of the larynx to the trachea was facilitated by a suprahyoid laryngeal release and extreme neck flexion. This placed the anastomotic line in a position directly posterior to the innominate artery. The patient was awakened and extubated in the operating room without difficulty. Approximately 30 minutes later however, she developed a progressive, inspiratory stridor. Flexible fiberoptic examination revealed paralyzed true vocal cords bilaterally with paradoxical cord motion during inspiration. The tracheolaryngeal closure was intact and widely open. Complete respiratory failure rapidly ensued and the patient was emergently reintubated to maintain the airway. One week later the patient was extubated and laryngeal exam-
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/19/2015
vocal cord paralysis may be an occasional sequela of op¬ erations that require exposure of considerable portions of the recurrent laryngeal nerves bilaterally. Certain trachéal resections, as in the case presented in this article, as well as in some total thyroidectomies, necessarily involve extended surgical exposure of the recurrent laryngeal nerves and may result in temporary, bilateral vocal cord
paralysis. Airway obstruction from bilateral vocal cord paralysis is in part due to the increased resistance to airflow caused by the paramedian positioning of the cords. According to Poiseuille's law describing laminar flow, such a decrease in the glottic area results in reduced airflow. Active vocal cord motion is not possible and the glottic area cannot in¬ Fig 2.—Marked reduction of cross-sectional trachéal airway by tumor at the thoracic inlet
(arrowhead).
¡nation again demonstrated paralyzed true vocal cords with par¬ adoxical motion. Stridor quickly developed as the true vocal cords prolapsed into the airway on inspiration, and the work of breath¬ ing began to increase. In an attempt to avoid reintubation once again, nasal CPAP was begun using 8-cm water pressure and an oxygen flow of 4 L per minute. This immediately alleviated the airway embarrassment and the patient began breathing comfort¬ ably. No further airway problems developed during the remain¬ der of the hospital stay or after discharge. Seven days after the initiation of the CPAP, slight left true vo¬ cal cord abduction was noted. At this time, the patient was dis¬ charged home on CPAP, where weaning from it was easily accomplished over a period of 2 weeks. Oral feedings had been resumed prior to discharge and the patient was ambulatory. Within the next month, normal true vocal cord motion returned on the left side, and by the end of 3 months the right vocal cord regained motion. The patient received postoperative radiation therapy and was disease free at 1 year.
COMMENT
Squamous cell
carcinoma of the trachea is a relatively can be cured with an aggressive surgical approach.4-5 Extensive surgical resections are nec¬ essary if involvement of the larynx, the membranous tra¬ chea, or the esophagus has occurred. Upper trachéal lesions confined to the cartilaginous wall of the trachea may be treated by trachéal resection without the removal uncommon
tumor that
of the larynx or esophagus. Trachéal resection to the cricoid cartilage, or including the lower portion of the cricoid cartilage, requires bilateral recurrent laryngeal nerve dissection to their points of en¬ try into the larynx. The nerve dissection should be per¬ formed with a delicate technique so as to avoid vocal cord paralysis. However, even careful technique may not be sufficient to prevent traumatic nerve injury.6 Patients having had trachéal resection should be extu¬ bated at the termination of the operation to minimize any tension or mechanical trauma to the trachéal suture line. For the same reason, placement of an endotracheal tube across the trachéal closure is to be avoided if at all possi¬ ble. Airway compromise or obstruction following the pro¬ cedure is best managed by tracheostomy placement such that it does not impinge on the trachéal anastomosis.7 Tra¬ cheostomy, however, may not be performed easily as in this case. Postoperative airway obstruction that is due to bilateral
to facilitate airflow with inspiration. With this rel¬ atively fixed resistance at the glottic level, adequate ven¬ crease
tilation is maintained by increasing inspiratory effort.8 A secondary airway effect of this situation results from the increased inspiratory effort needed to maintain ade¬ quate ventilation. This leads directly to an increased transglottic and transmural pressure gradient, prolapsing the hypotonie true vocal cords into the airway. This, of course, can totally obstruct an already compromised airway. The management options, other than intubation or tra¬ cheotomy for an inadequate airway due to bilateral vocal cord paralysis, are limited. Continuous positive airway pressure is one of these options and, in effect, reduces the magnitude of the transmural and transglottic pressure gradient. This prevents critical airway compromise by the prolapsing vocal cords, facilitating adequate ventilation without extreme effort. Another alternative that has proven effective in this situation is the use of an 80% he¬ lium and 20% oxygen gas mixture.9 Due to its low density compared with air, it can markedly reduce the work of breathing in patients with partial airway obstruction. As this case demonstrates, CPAP may be an effective al¬ ternative for short-term airway management in selected cases of bilateral true vocal cord paralysis. Obviously, pa¬ tients with temporary bilateral vocal cord paralysis man¬ aged in this fashion must be observed closely until it is de¬ termined that the airway is both adequate and stable. Continuous positive airway pressure is not, however, ap¬ propriate for long-term management of this problem and may not be suitable for use outside of an acute care setting. References
Abbey NC, Cooper KR, Kwentus JA. Benefit of nasal CPAP in obstructive sleep apnea is due to positive pharyngeal pressure. Sleep. 1989;12:420\x=req-\ 1.
422. 2. Butt W, Shann
F, Walker C, Williams J, Duncan A, Phelan P. Acute ep-
iglottitis: a different approach to management. Crit Care Med. 1988;16:43-47.
3. Jonson B, Ahlstrom H, Lindroth M, Svenningsen NW. Continuous positive airway pressure: modes of action in relation to clinical applications. Pediatr Clin North Am. 1980;27:687-699. 4. Pearson FG, Todd TRJ, Cooper JD. Experience with primary neoplasms of the trachea and carina. J Thorac Cardiovasc Surg. 1984;88:511-518. 5. Grillo HC. Management of tracheal tumors. Am J Surg. 1982;143:697\x=req-\ 700. 6. Grillo HC. Tracheal tumors: surgical management. Ann Thorac Surg.
1978;26:112-125. 7. Grillo HC, Mathisen DJ. Tumors of the cervical trachea. In: Myers EN, Suen JY, eds. Cancer ofthe Head and Neck. 2nd ed. New York, NY: Churchill Livingstone Inc; 1989:621-643. 8. Templer JW, Von Doersten PG, Quigley PR, Scott GC, Davis WE. Laryngeal airway resistance: the relationships of airflow, pressure and aperture. Arch Otolaryngol Head Neck Surg. 1991;117:867-870. 9. Orr JB. Helium-oxygen gas mixtures in the management of patients with airway obstruction. Ear Nose Throat J. 1988;67:866-869.
Downloaded From: http://archotol.jamanetwork.com/ by a New York University User on 06/19/2015
