return to: Tracheotomy - Tracheostomy or Resources for Laryngology Update - Innovative Approaches to Common Problems

BMI > 70 with h/o sleep apnea and acute respiratory failure warranting intubation and mechanical ventilation

Modified Operative Note #1 (August 2013):

Initial failed attempt to perform targeted 4-flap tracheostomy:

The patient was transported to the main operating room. A bariatric bed was prepared in advance and patient was transferred to the operating room bed. It was difficult to maintain the patient in a back-up position (despite use of footboard) and with positioning him supine (lowering the back of the bed) he began desaturating. Multiple attempts were made at repositioning but it was determined that we were unable to obtain an appropriate position where tracheostomy could be performed with maintenance of adequate oxygenation. Support from anesthesia and nursing with 1 1/2 hours spend adjusting table/patient in the unsuccessful efforts to obtain positioning to permit positioning to do tracheotomy without rapid desaturations requiring re-adjucting of position. He was returned to the MICU without a tracheotomy.

Modified Operative Note #2 (one week later August 2013):

Successful four flap tracheostomy with thyroid isthmusectomy and anterior cervical lipectomy:

Patient was transported to the operating room table which had been prepared ahead of time given the patient's previous positioning issues. Considerable time was spent positioning the patient on the bed and securing him with straps to ensure that he was safe to proceed with surgery. Once the patient was safely positioned on the table and the decision was made to proceed with surgery, general anesthesia was induced. Once the patient was asleep, two towel clamps were secured to the chest to decrease the weight on his chest in order to help with lung expansion in the course of retracts soft tissue with suspension of the clamps from an overhead beam. This maneuver permitted the back to be lowered to a position to permit performance of the tracheotomy. A 4 flap epithelial lined trach incision was designed over the anterior neck, centered over the cricoid cartilage and extending superior to the hyoid and inferiorly toward the sternum. The planned incision was injected with 1% lidocaine with 1:100,000 epinephrine. The patient was then prepped and draped in sterile fashion. The epithelial lined tracheostomy was accomplished without incident. See: Four-flap Epithelial Lined Tracheotomy (includes step-by-step operative procedure). Additional example: Four flap epithelial lined tracheotomy - Clinical case example.

Modified Clinic Follow-up Note (May 2014):

The patient returns appearing upbeat, having lost 200 pounds. He had been outfitted with a #6XLT plastic tracheotomy with the safety of his tracheotomy care improved by placement of a #7 metal Jackson with a larger inner cannula - with his affirmation he was able to breath through it better and also able to cork it during the day.

References

Abrons RO. Novel positioning solution for difficult tracheostomy. Saudi J Anaesth. 2016 Apr-Jun;10(2):240-1. doi: 10.4103/1658-354X.168836. PMID: 27051382; PMCID: PMC4799623.