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Table of Contents
Year : 2021  |  Volume : 24  |  Issue : 1  |  Page : 121-123
Bronchoscopy examination of a patient with tracheobronchial injury having intractable cough: Role of sevoflurane sedation and paraoxygenation

Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India

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Date of Submission26-Nov-2019
Date of Decision14-Jan-2020
Date of Acceptance27-Jan-2020
Date of Web Publication22-Jan-2021

How to cite this article:
Panda CK, R Karim HM, Neema PK. Bronchoscopy examination of a patient with tracheobronchial injury having intractable cough: Role of sevoflurane sedation and paraoxygenation. Ann Card Anaesth 2021;24:121-3

How to cite this URL:
Panda CK, R Karim HM, Neema PK. Bronchoscopy examination of a patient with tracheobronchial injury having intractable cough: Role of sevoflurane sedation and paraoxygenation. Ann Card Anaesth [serial online] 2021 [cited 2022 Jan 28];24:121-3. Available from:

To the Editor,

Anesthesia or sedation for intervention or examination of the tracheobronchial tree is a challenging task. Presence of an intractable cough during the procedure is distressing for the patient as well as the examiner. To achieve an adequate level of conscious sedation without obtunding the airway reflexes is the key to success in procedures where positive pressure ventilation may be hazardous.[1],[2] Obtaining sedation in such patients is challenging as the options are limited.[2],[3]

A 22-year-old, well-built, non-smoker, without any known comorbidity, presented to emergency with increasing breathing difficulty and interactable coughs for 2 days following a road traffic accident. He was asymptomatic on the day of the accident except for a small abrasion over the right scapular region; he did not attend any trauma or medical centre. Examination revealed pulse-rate 110 per min, blood pressure 110/76 mmHg, respiratory rate 24 per min, and room air saturation 96'. Emphysema over the anterior part of the neck and chest up to the nipple line, including the axillary area on both side (more on the right) was noted. These features suggested a possible mild pneumothorax, but, emergency X-ray and point of care ultrasound could not rule out pneumothorax due to subcutaneous air. The patient underwent an emergency tracheobronchial examination under anesthesia/sedation; emergency trac?heostomy was planned in case of airway compromise.

Intravenous Glycopyrrolate 0.2 mg, 3 ml of 2' xylocaine nebulization, and intravenous paracetamol 1 gm were administered. With standard American Society of Anesthesiologists' monitoring, a 7.5 mm ID nasopharyngeal airway inserted and connected to the closed-circuit system of Mindray A7 workstation through endotracheal tube adapter, and 100' O2 was delivered. The patient was asked to breathe with the mouth closed, and the anesthesiologist manually closed the other nostril to prevent leak. Sevoflurane concentration increased from 1 to 5' over 2 min, and MAC-age 0.6–0.8 maintained. The fibreoptic bronchoscope was inserted through the other nostril and revealed injury at the junction of the trachea and primary bronchus on the right side [Figure 1].
Figure 1: Fibreoptic bronchoscopic view of right tracheobronchial junction injury

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Tracheobronchial tree injury in blunt trauma can be caused by multiple mechanisms and the injury noted near the carina is explained by the shearing force theory.[4] It is associated with inflamed airway, vigorous coughing, and air leak in surrounding tissue, which may cause pneumothorax and subcutaneous emphysema, and breathing difficulty.[5] Bronchoscopy in this situation is often difficult due to the need for a calm and cooperative patient with obtunded cough and still keeping airway reflexes intact. Moreover, positive pressure ventilation in this situation, if required, may further aggravate the air-leak increasing breathing difficulty. The sedation should be aimed at maintaining spontaneous breath and obtundation of coughing. Controlled sevoflurane administration at a MACage 0.6–0.8 suppressed cough, ensured control over the airway and kept airway reflexes intact while maintaining sedation and amnesia. Additionally, sevoflurane is a bronchodilator, non-irritant, and does not cause apnoea when used in an escalating dose.[6] Furthermore, it helps to avoid the untoward effect of opioids and benzodiazepine. Miakami et al. studied dexmedetomidine in Guinea pig for awake sedation and reported that it has a favourable effect on airway smooth muscle and cough suppression,[7] but human data is not available. Dexmedetomidine-based conscious sedation can also be used in such patients, but, sevoflurane offers easy manoeuvrability of depth of sedation with intact airway reflexes.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Sengupta S, Saikia A, Ramasubban S, Gupta S, Maitra S, Rudra A, et al. Anaesthetic management of a patient with complete tracheal rupture following blunt chest trauma. Ann Card Anaesth 2008;11:123-6.  Back to cited text no. 1
[PUBMED]  [Full text]  
Zhao Z, Zhang T, Yin X, Zhao J, Li X, Zhou Y. Update on the diagnosis and treatment of tracheal and bronchial injury. J Thorac Dis 2017;9:E50-6.  Back to cited text no. 2
Mohammed S, Biyani G, Bhatia PK, Chauhan DS. Airway management in a patient with blunt trauma neck: A concern for anesthesiologist. Egyptian J Anaesth 2014;30:431-3.  Back to cited text no. 3
Altinok T, Can A. Management of tracheobronchial injuries. Eurasian J Med 2014;46:209-15.  Back to cited text no. 4
Hyeon Oh J, Jun Hong S, Soo Kang S, Mi Hwang S. Successful conservative management of tracheal injury after forceful coughing during extubation: A case report. Anesth Pain Med 2016;6:e39262.  Back to cited text no. 5
Hays SR. Inhalation anesthetic agents: Clinical effects and uses. In: Nussmeier NA, editor. UpToDate. Waltham, MA: UpToDate Inc; 2019. Available from: [Last accessed on 2019 Aug 23].  Back to cited text no. 6
Mikami M, Zhang Y, Kim B, Worgall TS, Groeben H, Emala CW. Dexmedetomidine's inhibitory effects on acetylcholine release from cholinergic nerves in guinea pig trachea: A mechanism that accounts for its clinical benefit during airway irritation. BMC Anesthesiology 2017;17:52.  Back to cited text no. 7

Correspondence Address:
Habib M R Karim
Faculty Room A001, Block A, All India Institute of Medical Sciences, Raipur - 492 099, Chhattisgarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aca.ACA_182_19

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