Of Rings, Slings and
many other things
Diego Gonzalez M.D.
Gregory Gordon M.D.
Metrohealth Medical Center
November 26, 2002
Pre Op
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7 month old
8kg
PMHx & PSHx:
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Former Premie intubated x 6 weeks in CCF NICU
History of previous “asthma episode” admitted to
hospital 2-3 weeks prior
Double aortic arch repair
Presenting for evaluation of stridor
Procedure
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Mask induction
Start IV and Change to TIVA
Confirm Satisfactory bag/mask control
Short acting muscle relaxant
Reconfirm good bag mask ventilatory control
Ventilation via bronchoscope inserted by
surgery
Physical Exam
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Airway unable to assess
Pt was noticed to have biphasic stridor
Lungs with adventitious breath sounds
Regular rate and rhythm
Neurologically was awake and alert, acting
like a 7 month old.
Infant Airway
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Differences from adult
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Larger tongue
Larynx is higher in the
neck
Epiglottis is short and
stubby and angled over
the laryngeal inlet
Vocal cords are angled
Infant airway is funnel
shaped narrowest portion
Causes of Stridor
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Expiratory stridor: (also prolonged expiration)
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Bronchiolitis
Asthma
Intrathoracic foreign body
Inspiratory stridor:
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Epiglotitis
LTB
Laryngeal foreign body
Vascular rings
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Definition: when any
anomalous
configuration or vessel
surrounds trachea or
esophagus forming a
ring around them, they
can be complete or
incomplete
Vascular rings
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Frequency:
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2 most common are (85-90% of cases)
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< 1% of congenital heart defects
Equal in both sexes
Double aortic arch
Right aortic arch with left ligamentum aretriosum
Other anomalies make like left pulmonary
artery sling make 10%, incomplete ie sling
Etiology of rings and slings
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Non-regression or incomplete regression of any of the
6 embryonic branchial arches
Normally what happens:
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1 and 2 arches irrigate the face
3 arch forms carotids
Dorsal aorta in 3 and 4 involutes
4 form aortic arch
5 arch involutes
6 becomes the proximal right pulmonary artery
7 distal right subclavian and left subclavian
Intra Operative Course
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Easy mask induction
Easy to ventilate
Difficult time getting IV in (probably from
previous surgeries)
Once IV started changed to TIVA pt paralyzed
with Mivacron
Bag mask ventilatory control confirmed
Surgeon unable to introduce bronchoscope
Intra Op 2
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Pt desaturated into low 90’s
Try to reventilate by mask.
Unable to mask
Sats dropping
Repositioned and remasked
Sats dropping
Some air entry to stomach and lungs
Sats dropping, cyanosis markedly increased
DL glottis visualized unable to inserted styletted #3 OETT
Unable to intubate, sats in the low 40s
Slash trach performed by surgeon
Intra op 3
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Unable to pass Shiley, Number 3ETT tube
passed and could not ventilate adequately.
PALS started Atropine and Epi given for
bradycardia.
Now WHAT????
Intra OP 4
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Shiley replaced with Shiley 3# cuffed
Ventilation possible via right lung
Tube pulled back able to ventilate both lungs
Shiley # 3 replaced with Shiley #4 adequate
ventilation of both lungs
Follow Up
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Followed up pt that same day.
H/D stable purposeful neurologically.
Pt consequently followed days 2,3,4,5 and 7
Round 2
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7 days later pt taken for rigid bronchoscope,
tracheoscopy possible flex bronchoscopy
Able to pass small rigid suction tube
Pt noticed to have severe sub-glottic stenosis.
Able to pass OETT 2.5 styleted with snug fit.
Flex scope through trachea which showed
severe stenosis at the carina level.
Pt transferred to CCF for further evaluation
possible surgery.
Round 3?
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Pt transferred back to Metro
Plan?
Stent?
Outgrow stenosis?
Surgical repair?
Sub Glottic Stenosis
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Congenital malformation of the cricoid
cartilage
Acquired- Pathophysiology
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Mucosal edema
Hyperemia
Pressure necrosis of mucosa
Fibrosis
Risk factors for SGS
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ETT
Duration of intubation
Repeated intubation
GERD
Factors that affect healing
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Systemic illness
Malnutrion
Anemia
Hypoxia
SGS
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Incidence 1-2% of graduated NICU patients
Morbi-mortality
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Difficulty breathing
Exercise intolerance
Death
Clinically
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Inspiratory stridor
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Expiratory stridor
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Supraglottic lesion
Tracheal, bronchial, pulmonary lesion
In SGS that is moderate to severe they may
have biphasic stridor
Staging
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Percentage is evaluated
by using ETT of
different sizes the
largest ETT that can be
place with 20cm
pressure is evaluated
against a scale
developed by Myers and
Cotton
Staging
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Grade 1- Obstruction of
0-50 % of the lumen
Grade 2- Obstruction of
51-70% of the lumen
Grade 3- Obstruction of
71-99% of the lumen
Grade 4- Obstruction of
100% (no visible
lumen)
Treatment
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No medical treatment
Surgery indicated with SGS + symptoms
present
Residents hard at work!!