CASE REPORT
upper airway bleeding
Massive Upper Airway Bleeding After Thrombolytic Therapy: Successful Airway Management With the Combitube® From the First Department of Medicine, Intensive Care Unit, Wahringer Gurtel, Vienna, Austria.
Renate Klauser, MD Georg R6ggla, MD Johann Pidlich, MD Christian Leithner, MD Michael Frass, MD
Received for publication March 12, 1991. Revision received July 25, 1991. Accepted for publication September 3, 1991.
We present the case of a patient who required immediate intubation because of increasing upper airway bleeding. Endotracheal intubation failed because the glottis could not be visualized. An airway control device designed for cases of difficult emergency intubations was used successfully. This device can be inserted without the use of a laryngoscope. [Klauser R, RSggla G, Pidlich J, Leithner C, Frass M: Massive upper airway bleeding after thrombolytic therapy: Successful airway management with the Combitube.® Ann EmergMedApril 1992;21:431-433.]
INTRODUCTION R a p i d establishment of a patent airway is a p r i m a r y goal in the resuscitation of nonbreathing patients.t E n d o t r a c h e a l intubation may at times, however, be difficult. 2 We present the case of a patient in whom endotracheal intubation using the Combitube ® (Sheridan Catheter Corp, Argyle, New York) 3-6 was successful after other procedures failed.
CASE
REPORT
A 63-year-old man with a history of severe chronic obstructive lung disease was admitted to our ICU with acute dyspnea and chest pain. A diagnosis of acute pulmonary embolus was suspected based on physical examination and chest radiography. A decision to institute emergency thrombolytic t h e r a p y was made. Initial coagulation analysis showed a p r o t h r o m b i n time of 28 seconds; thrombin time, 18 seconds; fibrinogen, 274 mg/dL; antithrombin, 10.5 ~tg/mL; and platelets, 234,000 mm 3. These were within our normal p a r a m e t e r s . Thrombolytic t h e r a p y then was initiated with 230 mg of anisoylated plasminogen streptokinase activator complex (APSAC), which was injected intravenously over a five-minute period. Due to confusion of the therapeutic protocol for APSAC, an additional infusion of 230 mg was administered during the following hour. F o u r hours after the initiation of this therapy, the patient began having massive bleeding from the pharynx. At this time, laboratory analysis showed the following bleeding p a r a m e t e r s : •
APRIL1992
21:4
ANNALS OF EMERGENCY MEDICiNE
431/1
19
UPPER AIRWAY BLEEDING Klau~er et al
prothrombin time, more than 250 seconds; thrombin time, 300 seconds; and fibrinogen, 0 mg/dL. The patient began aspirating large amounts of blood, and required immediate intubation. Attempts to endotracheally intubate the patient were impossible because the glottis could not be seen. Additional attempts at blind intubation and fiberoptic intubation also were unsuccessful. Cricothyroidotomy was not advisable because of the patient's ongoing hemorrhagic diathesis. At this point, the Combitube ®was inserted, and mechanical ventilation was performed successfully. Blood gas analysis showed adequate ventilation (Table). In addition, 37 units/kg of prothrombin complex concentrate and 12.5 units/kg of antithrombin were administered intravenously. Thirty minutes later, the Combitube ®was replaced by conventional endotracheal tube under fiberoptic control. During this procedure, the oropharyngeal balloon was first deflated; then, the distal tube was deflated after successful endotracheal intubation for prevention of aspiration. Blood gas analysis during emergency ventilation is shown (Table). Direct laryngoscopy examination during endotracheal intubation revealed hematomas situated sublingually in the region of the soft palate and right pharyngeal wall. Two days later, the patient was weaned from the respirator and extubated. One week later, he was discharged in good condition without signs of neurologic deficit.
DISCUSSION Intubation of airways, particularly in the presence of massive bleeding and/or emesis, is a problem frequently encountered in the emergency care of patients. Our case was particularly difficult because of the bleeding diathesis secondary to the thrombolysis caused by excess thrombolytic therapy. An airway that can achieve adequate ventilation, be inserted without direct visualization, and at the same
time control bleeding from the pharynx possesses a distinct advantage. The Combitube ~ is a plastic twin-lumen tube in which thc lumens are separated by a partitioned wall (Figure 1). The two lumens are designated tracheal and esophageal, with the tracheal tube being open at the distal end and the esophageal tube being blocked. The device is introduced by grasping the tongue and jaw between the thumb and forefinger and guiding the device gently into the pharynx, where it will be positioned in either the esophagus or the trachea. A pharyngeal balloon blocks the oropharynx, 7 and the distal cuff blocks either the esophagus or the trachea. Test ventilation is done through the longer tube leading to the esophageal lumen. If auscultation demonstrates lung ventilation and no gastric insufflation, it is presumed that the Combitube ®is in the esophagus and that air can continue to be directed into the lungs with gastric fluids aspirated through the other lumen by means of the enclosed suction catheter 6 (Figure 1). If lung ventilation is negative and gastric insufflation is positive, then the tube has been placed endotracheally, in which case one essentially has an endotracheal tube (Figure 2). Previous studies have demonstrated the effectiveness of this device in routine surgery, 5 during CPR, a's and during mechanical ventilation 3 in the ICU. This device offers an advantage over the previously used esophageal obturator airway in that adequate ventilations can be maintained without having to worry about adequate face-mask seal. In addition, it can be inserted quickly and easily by individuals without resorting to direct • Figure 1.
Combitube~ after esophageal placement
/
Table.
Blood gas analysis before intubation, with Combitube®, and with endotracheal tube
Intubation
Before Combitube ®
Endotracheal Tube
Pau2 (mm H20)*
76.3
335.0
537.4
Paco2 (rnm HA0}
58.0
49.0
47.3
pH
7.23
7.24
7.22
FIo2
0.4
1.0
1.O
10
70
Tidal volume [mL/kg) Respirations I:E PEEP (cm H20)
8
15.
15
1:2
1:2
5
5
\ Figure 2.
Combitube® after endotracheal placement
*Pact, arterial oxygen tension; Pac% arterial carbon dioxide tension; Froz, fractional inspired oxygen; I:E, inspiratory/expiratory ratio; PEE~ positive end expiratory pressure. Conversion of SI to conventional units [1 kPa = 7.5 mm Hg).
120/432
\
A N N A L S OF EMERGENCY MEDICINE
21:4
APRIL1992
UPPER AIRWAY BLEEDING K[auser et al
laryngoscopic examination. However, use of this tube still requires the o p e r a t o r to be thoroughly familiar with airway management and able to correctly determine position by auscultation or other methods of assuming p r o p e r airway placement. It should be considered an additional adjunct device that has a useful role in the emergency treatment in patients requiring airway stabilization.
REFERENCES 1. Hammargren Y, Clinton JE, Ruiz E: A standard comparison of esophageal obturator airway and endotracheal tube ventilation in cardiac arrest. Ann Emerg Med 1985;14: 953-958. 2. Tunstall ME, Geddes C: "Failed intubation" in obstetric anesthesia: An indication for use of the "esophageal gastric tube airway." BrJAnaesth 1984;56:659-661. 3. Frass M, Frenzer R, Mayer G, et al: Mechanical ventilation with the esophageal tracheal Combitube (ETC)in the intensive care unit. Arch Emerg Mad 1987;4:219-225. 4~ Frass M, Frenzer R, Rauscha F, et ah Ventilation with the esophageal tracheal Combitube in cardiopulmonary resuscitation: Promptness and effectiveness. Chest 1988;93:781-784.
SUMMARY We r e p o r t the case of a patient with pulmonary embolism who underwent thrombolytic therapy. Rapidly increasing upper airway bleeding r e q u i r e d immediate intubation. Endotracheal intubation failed because the glottis could not be visualized by laryngoscopy. The Combitube ~ was applied, and the patient received adequate ventilation. This device can serve as a noninvasive alternative for emergency intubation. []
5. Frass M, Frenzer R, Zdrahal F, et al: The esophageal tracheal Combitube®: Preliminary results with a new airway for CPR. Ann Emerg Mad 1987;16:768-772. 6. Frass M, R~dler S, Frenzer R, et ah Esophageal tracheal Combitube, endotracheal airway and mask: Comparison of ventilatory pressure curves. J Trauma 1989;29: 1476-1479. 7. Frass M, Johnson JC, Atherton GL, et ah Esophageal tracheal Combitube (ETC) for emergency intubation: Anatomical evaluation of ETC placement by radiography. Resuscitation 1989;18:95-102. 8. Frass M, Freezer R, Rauscha F, et al: Evaluation of esophageal tracheal Combitube in cardiopulmonary resuscitation. Crit Care Mad 1987;15:609-611.
Address for reprints: Michael Frass, MD, First Department of Medicine, Intensive Care Unit, Wahringer GurteJ 18- 20, A-1090, Vienna, Austria.
APRIL1992
21:4
ANNALS OF EMERGENCY MEDICINE
433/121
upper airway bleeding
Massive Upper Airway Bleeding After Thrombolytic Therapy: Successful Airway Management With the Combitube® From the First Department of Medicine, Intensive Care Unit, Wahringer Gurtel, Vienna, Austria.
Renate Klauser, MD Georg R6ggla, MD Johann Pidlich, MD Christian Leithner, MD Michael Frass, MD
Received for publication March 12, 1991. Revision received July 25, 1991. Accepted for publication September 3, 1991.
We present the case of a patient who required immediate intubation because of increasing upper airway bleeding. Endotracheal intubation failed because the glottis could not be visualized. An airway control device designed for cases of difficult emergency intubations was used successfully. This device can be inserted without the use of a laryngoscope. [Klauser R, RSggla G, Pidlich J, Leithner C, Frass M: Massive upper airway bleeding after thrombolytic therapy: Successful airway management with the Combitube.® Ann EmergMedApril 1992;21:431-433.]
INTRODUCTION R a p i d establishment of a patent airway is a p r i m a r y goal in the resuscitation of nonbreathing patients.t E n d o t r a c h e a l intubation may at times, however, be difficult. 2 We present the case of a patient in whom endotracheal intubation using the Combitube ® (Sheridan Catheter Corp, Argyle, New York) 3-6 was successful after other procedures failed.
CASE
REPORT
A 63-year-old man with a history of severe chronic obstructive lung disease was admitted to our ICU with acute dyspnea and chest pain. A diagnosis of acute pulmonary embolus was suspected based on physical examination and chest radiography. A decision to institute emergency thrombolytic t h e r a p y was made. Initial coagulation analysis showed a p r o t h r o m b i n time of 28 seconds; thrombin time, 18 seconds; fibrinogen, 274 mg/dL; antithrombin, 10.5 ~tg/mL; and platelets, 234,000 mm 3. These were within our normal p a r a m e t e r s . Thrombolytic t h e r a p y then was initiated with 230 mg of anisoylated plasminogen streptokinase activator complex (APSAC), which was injected intravenously over a five-minute period. Due to confusion of the therapeutic protocol for APSAC, an additional infusion of 230 mg was administered during the following hour. F o u r hours after the initiation of this therapy, the patient began having massive bleeding from the pharynx. At this time, laboratory analysis showed the following bleeding p a r a m e t e r s : •
APRIL1992
21:4
ANNALS OF EMERGENCY MEDICiNE
431/1
19
UPPER AIRWAY BLEEDING Klau~er et al
prothrombin time, more than 250 seconds; thrombin time, 300 seconds; and fibrinogen, 0 mg/dL. The patient began aspirating large amounts of blood, and required immediate intubation. Attempts to endotracheally intubate the patient were impossible because the glottis could not be seen. Additional attempts at blind intubation and fiberoptic intubation also were unsuccessful. Cricothyroidotomy was not advisable because of the patient's ongoing hemorrhagic diathesis. At this point, the Combitube ®was inserted, and mechanical ventilation was performed successfully. Blood gas analysis showed adequate ventilation (Table). In addition, 37 units/kg of prothrombin complex concentrate and 12.5 units/kg of antithrombin were administered intravenously. Thirty minutes later, the Combitube ®was replaced by conventional endotracheal tube under fiberoptic control. During this procedure, the oropharyngeal balloon was first deflated; then, the distal tube was deflated after successful endotracheal intubation for prevention of aspiration. Blood gas analysis during emergency ventilation is shown (Table). Direct laryngoscopy examination during endotracheal intubation revealed hematomas situated sublingually in the region of the soft palate and right pharyngeal wall. Two days later, the patient was weaned from the respirator and extubated. One week later, he was discharged in good condition without signs of neurologic deficit.
DISCUSSION Intubation of airways, particularly in the presence of massive bleeding and/or emesis, is a problem frequently encountered in the emergency care of patients. Our case was particularly difficult because of the bleeding diathesis secondary to the thrombolysis caused by excess thrombolytic therapy. An airway that can achieve adequate ventilation, be inserted without direct visualization, and at the same
time control bleeding from the pharynx possesses a distinct advantage. The Combitube ~ is a plastic twin-lumen tube in which thc lumens are separated by a partitioned wall (Figure 1). The two lumens are designated tracheal and esophageal, with the tracheal tube being open at the distal end and the esophageal tube being blocked. The device is introduced by grasping the tongue and jaw between the thumb and forefinger and guiding the device gently into the pharynx, where it will be positioned in either the esophagus or the trachea. A pharyngeal balloon blocks the oropharynx, 7 and the distal cuff blocks either the esophagus or the trachea. Test ventilation is done through the longer tube leading to the esophageal lumen. If auscultation demonstrates lung ventilation and no gastric insufflation, it is presumed that the Combitube ®is in the esophagus and that air can continue to be directed into the lungs with gastric fluids aspirated through the other lumen by means of the enclosed suction catheter 6 (Figure 1). If lung ventilation is negative and gastric insufflation is positive, then the tube has been placed endotracheally, in which case one essentially has an endotracheal tube (Figure 2). Previous studies have demonstrated the effectiveness of this device in routine surgery, 5 during CPR, a's and during mechanical ventilation 3 in the ICU. This device offers an advantage over the previously used esophageal obturator airway in that adequate ventilations can be maintained without having to worry about adequate face-mask seal. In addition, it can be inserted quickly and easily by individuals without resorting to direct • Figure 1.
Combitube~ after esophageal placement
/
Table.
Blood gas analysis before intubation, with Combitube®, and with endotracheal tube
Intubation
Before Combitube ®
Endotracheal Tube
Pau2 (mm H20)*
76.3
335.0
537.4
Paco2 (rnm HA0}
58.0
49.0
47.3
pH
7.23
7.24
7.22
FIo2
0.4
1.0
1.O
10
70
Tidal volume [mL/kg) Respirations I:E PEEP (cm H20)
8
15.
15
1:2
1:2
5
5
\ Figure 2.
Combitube® after endotracheal placement
*Pact, arterial oxygen tension; Pac% arterial carbon dioxide tension; Froz, fractional inspired oxygen; I:E, inspiratory/expiratory ratio; PEE~ positive end expiratory pressure. Conversion of SI to conventional units [1 kPa = 7.5 mm Hg).
120/432
\
A N N A L S OF EMERGENCY MEDICINE
21:4
APRIL1992
UPPER AIRWAY BLEEDING K[auser et al
laryngoscopic examination. However, use of this tube still requires the o p e r a t o r to be thoroughly familiar with airway management and able to correctly determine position by auscultation or other methods of assuming p r o p e r airway placement. It should be considered an additional adjunct device that has a useful role in the emergency treatment in patients requiring airway stabilization.
REFERENCES 1. Hammargren Y, Clinton JE, Ruiz E: A standard comparison of esophageal obturator airway and endotracheal tube ventilation in cardiac arrest. Ann Emerg Med 1985;14: 953-958. 2. Tunstall ME, Geddes C: "Failed intubation" in obstetric anesthesia: An indication for use of the "esophageal gastric tube airway." BrJAnaesth 1984;56:659-661. 3. Frass M, Frenzer R, Mayer G, et al: Mechanical ventilation with the esophageal tracheal Combitube (ETC)in the intensive care unit. Arch Emerg Mad 1987;4:219-225. 4~ Frass M, Frenzer R, Rauscha F, et ah Ventilation with the esophageal tracheal Combitube in cardiopulmonary resuscitation: Promptness and effectiveness. Chest 1988;93:781-784.
SUMMARY We r e p o r t the case of a patient with pulmonary embolism who underwent thrombolytic therapy. Rapidly increasing upper airway bleeding r e q u i r e d immediate intubation. Endotracheal intubation failed because the glottis could not be visualized by laryngoscopy. The Combitube ~ was applied, and the patient received adequate ventilation. This device can serve as a noninvasive alternative for emergency intubation. []
5. Frass M, Frenzer R, Zdrahal F, et al: The esophageal tracheal Combitube®: Preliminary results with a new airway for CPR. Ann Emerg Mad 1987;16:768-772. 6. Frass M, R~dler S, Frenzer R, et ah Esophageal tracheal Combitube, endotracheal airway and mask: Comparison of ventilatory pressure curves. J Trauma 1989;29: 1476-1479. 7. Frass M, Johnson JC, Atherton GL, et ah Esophageal tracheal Combitube (ETC) for emergency intubation: Anatomical evaluation of ETC placement by radiography. Resuscitation 1989;18:95-102. 8. Frass M, Freezer R, Rauscha F, et al: Evaluation of esophageal tracheal Combitube in cardiopulmonary resuscitation. Crit Care Mad 1987;15:609-611.
Address for reprints: Michael Frass, MD, First Department of Medicine, Intensive Care Unit, Wahringer GurteJ 18- 20, A-1090, Vienna, Austria.
APRIL1992
21:4
ANNALS OF EMERGENCY MEDICINE
433/121
