# Anaesthetic Management of Critical Tracheal Obstruction Secondary to Granulation Tissue in a Patient With an In Situ Tracheal Stent: A Case Report

## TL;DR

This case report describes the challenges of managing a patient's airway when a tracheal stent and tissue growth caused severe breathing difficulties.

## Contribution

The paper presents a novel case highlighting the difficulties of intubation in patients with tracheal stenosis and granulation tissue.

## Key findings

- Awake fiberoptic intubation failed due to resistance from granulation tissue and a tracheal stent.
- A Shiley™ cuffless tube was successfully used after an emergent tracheostomy failed.
- Granulation tissue was found to nearly block a bronchus, causing intubation resistance and breathing issues.

## Abstract

Tracheal stenosis is a rare condition that poses significant challenges in airway management. We report a case of failed emergency awake fiberoptic intubation necessitating difficult front-of-neck access in a patient with respiratory failure, tracheal stenosis, and an in situ tracheal stent. The patient presented to the emergency department with acute respiratory distress and was urgently transferred to the operating theatre for emergent intubation. An awake intubation technique was attempted; however, the patient deteriorated during airway topicalization, necessitating rescue airway maneuvers. Bag-valve-mask ventilation proved difficult, and an attempt to insert a Portex™ size 6 endotracheal tube (Smiths Medical, Minneapolis, MN, USA) was unsuccessful due to resistance encountered after passing the vocal cords. An emergent tracheostomy was performed, but was complicated by the presence of the tracheal stent. Ultimately, a Shiley™ cuffless size 4 tube (Medtronic, Mansfield, MA, USA) was successfully inserted. Bronchoscopic assessment revealed granulation tissue both proximal and distal to the tracheal stent, with near-complete obstruction of the left main bronchus, accounting for the intubation resistance and ventilatory difficulties. The silicone tracheal stent remained in place with no signs of migration post-intubation. This case underscores the complexities of airway management in critical tracheal stenosis secondary to granulation tissue with an in situ tracheal stent.