SESSION TITLE: What's New in the ICU
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Tuesday, October 29, 2013 at 07:30 AM - 09:00 AM
INTRODUCTION: Ultrasonography has widespread utility in the diagnosis and treatment of critical illness, and is a valuable and accessible tool for intensivists and pulmonary physician1. We present a case where ultrasonography was utilized to make real time diagnosis of unexplained respiratory failure.
CASE PRESENTATION: A 49 year old female presented with chest pain, found to have small segmental pulmonary emboli. She developed agitation and acute on chronic hypercapnic and hypoxic respiratory failure. Was intubated and transferred to our facility. She never smoked; chest x-ray showed chronic right hemidiaphragm elevation, exam, labs unremarkable. Anticoagulation was continued. Respiratory failure was thought due to the pulmonary embolism and medications received for agitation. The next day she was extubated after successful trial of PSV and good weaning parameters. Immediately after extubation she started to have respiratory distress and hypoxemia requiring reintubation with improvement in her status. There was no difficulty with oxygenation or ventilation, and no change in chest imaging. After another successful extubation, she immediately developed wheezing with worsening hypoxemia and hypercapnia with no response to racemic epinephrine, or nebulized albuterol. Bedside ultrasound of the upper airway showed abnormal vocal cord mobility with opposition of the cords with inspiration. ABG PH 7.22, PCO2 74, PO2 169 on 100% FIO2 on BIPAP. Based on ultrasound finding and worsening respiratory condition she was reintubated. Underwent tracheostomy as we had localized her problem to be in the glottis. Intraoperatively found to have posterior glottic stenosis with large left arytenoid granuloma which has affected vocal cord mobility.
DISCUSSION: Management of critically ill patients is complex. Bedside US can be used as an extension of physical exam2. In our patient, with US we were able to identify vocal cord pathology as the cause of the respiratory failure. We did not find any prior report where US was used to make real time diagnosis of acute respiratory failure due to glottic stenosis. The incidence of laryngeal complications after prolonged intubation is 4-13%, including granuloma formation. Granulomas can prolapse into the glottis at extubation causing upper airway obstruction needing reintubation3
CONCLUSIONS: Ultrasonography is underutilized in evaluation of airway in critical care. Ultrasound can be used to predict difficult airway, confirmation of tracheal intubation, perform percutaneous tracheostomy, cricothyroidotomy, predict post extubation stridor. Competence in airway ultrasound should be emphasized for critical care physicians.
Reference #1: Mayo PH, et al. ACCP statement on competence in critical care ultrasonography, Chest. 2009; 135(4): 1050-1060
Reference #2: Seth J Koenig MD, Ultrasound corner, Chest. 2013; 143(1):4-5
Reference #3: Benjamin B. Prolonged intubation injuries of the larynx: endoscopic diagnosis, classification and treatment. Ann Otol Rhinol Laryngol 1993;102:1-35
DISCLOSURE: The following authors have nothing to disclose: Deepa Kuchelan, Sameh Aziz
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