Faculty Bibliography

Intracranial hypotension (IH) can occur following lumbar drainage for clipping of an intracranial aneurysm. We observed 3 cases of IH, which were all successfully treated by epidural blood patch (EBP). Herein, the authors report our cases.

Introduction: Achalasia is an esophageal dysmotility disorder. Rarely, untreated achalasia can lead to massive dilatation of the esophagus causing tracheal compression and respiratory compromise. We report a case of achalasia causing acute life-threatening ventilatory failure requiring emergent bronchoscopic management. Case report: A forty-seven year old female with presumptive achalasia was admitted to an outside hospital with shortness of breath, six months of weight loss and progressive inability to tolerate oral intake. Chest CT showed a massively dilated esophagus with anterior displacement and compression of the trachea and mainstem bronchi. Two days after admission, she was allowed to eat and developed respiratory distress requiring intubation. Soon after transfer to our institution she was extubated and was without stridor. Esophagogastroduodenoscopy demonstrated an esophagus full of food and inability to pass the endoscope into the stomach. A liquid diet was recommended but the patient continued to eat solids. Several days later the patient vomited, aspirated and developed respiratory distress. She was found to have a pH of 6.86, pCO₂ of 193mmHg and pO₂ of 87mmHg. Airway examination demonstrated diffuse neck enlargement and during direct laryngoscopy only the epiglottis could be visualized. An endotracheal (ET) tube was placed and secured at 20cm at the incisors. However ventilation was nearly impossible with high inspiratory pressures, minimal tidal volume and extremely prolonged exhalation. Bronchoscopy revealed severe extrinsic compression of the trachea and mainstem bronchi (figure 1) causing occlusion of the trachea below the level of the ET tube. The ET tube was advanced to 1cm above the carina with normalization of airway pressures. Several hours later desaturation occurred and clinical exam as well as chest radiograph revealed right mainstem intubation. Bronchoscopy was again performed and the ET tube was placed with the tip immediately above the carina when the neck was in full flexion. Chest CT confirmed previous findings (figure 2). Discussion: There are approximately 30 reported cases of achalasia causing respiratory compromise due to tracheal compression and only a handful of these required intubation for respiratory failure. This case is unique in that the dilated esophagus caused anterior displacement of the larynx, complicating laryngoscopy, and compression of almost the entire trachea, requiring bronchoscopy to precisely place the ET tube to stent open the airway to permit ventilation. This case highlights that achalasia is a possible cause of extrinsic laryngeal, tracheal and bronchial compression whose management may be optimized using fiberoptic bronchoscopy. (Figure Presented)