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Optimal Depth of Tracheal Intubation in Severe ScoliosisTracheal Intubation and Scoliosis FREE TO VIEW

Kadarapura Nanjundaiah Gopalakrishna, DM; Kamath Sriganesh, DM
Author and Funding Information

From the National Institute of Mental Health and Neurosciences (NIMHANS).

Correspondence to: Kamath Sriganesh, DM, Department of Neuroanaesthesia, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India 560029; e-mail: drsri23@rediffmail.com


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2012;142(3):813-814. doi:10.1378/chest.12-0917
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To the Editor:

Severe scoliosis can pose significant problems during airway management. The difficulty in identifying the correctness of the tracheal tube position in patients with severe scoliosis and resultant short stature has been described.

A 35-year-old man was admitted with loss of consciousness following a fall during a seizure episode. His Glasgow Coma Scale score at admission was E3M6V4. Brain CT imaging showed a large extradural hematoma. Clinical examination revealed severe scoliosis of the thoracic spine and short stature (124 cm). For emergent evacuation of hematoma under anesthesia, the tracheal tube was fixed at 22 cm and position was confirmed by visual passage of the tube cuff 2 cm below the glottis, the presence of bilateral lung ventilation on auscultation, normal airway pressure, and oxygen saturation. Chest radiographs showed severe scoliosis with the appearance of a horizontal upper thoracic spine (Fig 1A, vertical white arrows), vertical ribs in the right hemithorax (horizontal white arrows), tube position above the carina (Fig 1A, black arrow), and short stature (Fig 1B).

Figure Jump LinkFigure 1. A, Chest radiograph showing severe scoliosis with appearance of horizontal upper thoracic spine (vertical white arrows), vertical ribs in the right hemithorax (horizontal white arrows), and tube position above the carina (black arrow). B, Chest radiograph showing short stature.Grahic Jump Location

Correct placement of the tracheal tube is vital for safe anesthetic/critical care. The optimal depth of tube placement depends on the distance from the mouth to the glottis and the tracheal length. A patient’s height generally influences the proper depth of intubation.1 In dwarfs, fixation of a tube at standard depth results in endobronchial intubation.2 In patients with short stature, a shorter depth of tracheal intubation is, therefore, expected. However, in patients with severe thoracic scoliosis and resultant short stature, both the tracheal length and oroglottic distance (neck height) are likely to be normal. Therefore, anticipating a shorter orocarinal distance and fixing the tube inappropriately at a lesser depth can lead to accidental extubation. Our experience suggests that short stature due to dwarfism should be differentiated from short stature due to severe scoliosis during tracheal intubation. Fiber-optic or fluoroscopic confirmation of the correct tube position is ideal and should be performed when feasible. However, when such examination is not possible, a meticulous clinical examination and chest radiograph confirmation can overcome the dilemma about the correct placement of tracheal tube.

Cherng CH, Wong CS, Hsu CH, Ho ST. Airway length in adults: estimation of the optimal endotracheal tube length for orotracheal intubation. J Clin Anesth. 2002;14(4):271-274. [PubMed] [CrossRef]
 
Walts LF, Finerman G, Wyatt GM. Anaesthesia for dwarfs and other patients of pathological small stature. Can Anaesth Soc J. 1975;22(6):703-709. [PubMed] [CrossRef]
 

Figures

Figure Jump LinkFigure 1. A, Chest radiograph showing severe scoliosis with appearance of horizontal upper thoracic spine (vertical white arrows), vertical ribs in the right hemithorax (horizontal white arrows), and tube position above the carina (black arrow). B, Chest radiograph showing short stature.Grahic Jump Location

Tables

References

Cherng CH, Wong CS, Hsu CH, Ho ST. Airway length in adults: estimation of the optimal endotracheal tube length for orotracheal intubation. J Clin Anesth. 2002;14(4):271-274. [PubMed] [CrossRef]
 
Walts LF, Finerman G, Wyatt GM. Anaesthesia for dwarfs and other patients of pathological small stature. Can Anaesth Soc J. 1975;22(6):703-709. [PubMed] [CrossRef]
 
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