brace cases of difficult ventilation are at handed the first caused by endotracheal tube obstruction with nasal turbinate.

brace cases of difficult ventilation are at handed the first caused by endotracheal tube obstruction with nasal turbinate, and the inferior caused by tracheobronchial obstruction with progeny clots. The clinical presentation in each case was characterized at extreme difficulty in ventilating and unadorned hypercapnia despite vigorous ventilatory efforts with either a mechanical ventilator or resuscitator bag. A simple manipulation of the endotracheal tube beat helped to differentiate between increased impedance caused by the agency of endotracheal tube obstruction as oppos to increased respiratory rule impedance beyond the tip of tube. In the next to the first patient, in whom even a short interruption of ventilation was poorly tolerated, simultaneous rigid bronchoscopy (for removal of intratracheal masses) and ventilation via endotracheal tube were prosperously performed.

Acute difficulty ventilating the lung after traumatic nasoendotracheal intubation has been described. In these cases, the endotracheal tube (ETT) because occlud with pharyngeal tissue, teeth or nasal turbinates.[1-3] In contrast, difficulty ventilating a patient because of tracheobronchial obstruction may happen more gradually, especially in the mechanically ventilated[4] or tracheostomized[5] patient, or when using transtracheal oxygen catheters.[6,7]

We describe couple patients in whom mechanical ventilation was rigorously impaired: the first because of ETT obstruction with a nasal turbinate, and the next to the first because of tracheobronchial occlusion by way of blood clots. Both adumbrations of airway obstruction may be life threatening, and rapid recognition is essential. We discuss the simple degrees performed in evaluating our patients as well as a novel way to perform rigid bronchoscopy in patients in whom ventilating [i]or[/i] part of to the other the bronchoscope would otherwise impose a significant threat to alveolar gas exchange.

CASE REPORTS

CASE 1

A 38-year-old man with a history of epilepsy was set up unconscious and was intubated at the spectacle At the time of admission to the hospital, he was agitated and combative and required restraint. Difficulty ventilating the patient's lung using a resuscitator bag and 75-mm internal diameter (ID) nasoendotracheal tube was attributed to the patient's agitation. He was given medication for sedation (midazolam) and muscle relaxation (vecuronium). Continuing difficulty in ventilating the lung was associated with the following arterial progeny gas values: [PaO.sub.2], 460 mm Hg ([SaO.sub.2], 100 percent); [PaCO.sub.2], 117 mm Hg; and pH 70 ([FIO.sub.2], 10) Auscultation of the lung revealed bilaterally diminished breath heartys faint inspiratory wheezing, and limited expansion of the chest wall despite high inflation influences During laryngoscopy, a substantial amount of progeny which appeared to be becoming to epistaxis originating from the side with the nasoendotracheal tube, was suctioned from the patient's oropharynx. The ETT blow was then deflated, resulting in neither improved ventilation nor a significant leak around the tube. These findings moveed that the ETT was stoped An attempt to pass a suction catheter between the sides of the ETT into the trachea was unlucky A suction catheter marked to the duration of the ETT disclosed that the resistance to advancing the catheter was approximately at the flat of the ETT tip. subject to direct visualization of the vocal cords, the nasoendotracheal tube was replaced with an oroendotracheal tube. Ventilation with the resuscitator bag outcomeed in normal respiratory system impedance and expansion of the chest wall. Inspection of the ETT revealed that a nasal turbinate was firmly impacted into the tip of the ETT and partially occlud the Murphy eye

CASE 2

A 52-year-old man was admitted to the hospital for exploratory laparotomy and biopsy of an abdominal mass that was subsequently diagnosed as an unresectable retroperitoneal malignant lymphoma. The anesthetic course and surgical proceeding were uneventful. On postoperative day 5 thrombosis of the inferior vena cava accrueed in pulmonary embolism, which required endotracheal intubation and resuscitation. The postresuscitation clinical findings and chest radiography were consistent with pulmonary aspiration, thus necessitating mechanical ventilation. Fiberoptic bronchoscopy revealed that the walls of the trachea and the pair main-stem bronchi were covered with flaps of necrotic tissue. through the whole extent of the next several days, the patient's clinical status gradually revealed symptoms consistent with adult respiratory distress syndrome (ARDS). onward postoperative day 10, the peak inspiratory constraining force (PIP) required to ventilate the patient's lung increased across 2 h from 61 to 96 cm [Hsub2]O upon unchanged ventilator settings and during ended paralysis (vecuronium). To deliver adequate minute ventilation, ventilatory settings were changed, resulting in PIP of 113 cm [Hsub2]O Hemodynamic parameters were minimally affected with the acute increase in peak ventilatory urgency A central venous influence (CVP) tracing did not manifest any respiratory fluctuations. An increase in the gas leak around the ETT was associated with diminished breath hardys and faint inspiratory wheezing. The chest wall mov minimally with forceful inflation attempts and, concerning deflation of the cuff, the gas leak dramatically increased. These findings hinted obstruction distal to the ETT Fiberoptic bronchoscopy revealed that the tracheal lumen was impacted with material that appeared to be clott line The mucosa of the trachea, carina, and bronchi could not be visualized.

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