A 22-year-old male patient from rural western Ethiopia arrived to St. Paul's Hospital Millennium Medical College Emergency Center after experiencing progressively worsening shortness of breath. Upon arrival to the ED, the patient was not protecting his airway and had bilateral decreased air entry with diffuse faint wheezes. The patient was in a coma with a GCS of 7/15. His brother gave a pertinent history of cough for 4 months, with snoring during sleep, decreased exercise tolerance, and repeated treatment for pneumonia. Trauma, prior tuberculosis, and allergies were denied. The patient is a high school student that is employed in a job without any chemical exposures. On physical examination his pulse rate was 112 beats per minute sinus rhythm, body temperature of 36.7  C, respiratory rate (RR) of 32 breaths per minutes, blood pressure of 90/ 53 mmHg, and oxygen saturation of 72% on 15 liter per minute face mask oxygen. He had a palpable Crepitus of subcutaneous emphysema involving the neck, chest and upper abdomen. Tympani was heard during percussion in both lungs, but there were no obvious signs of injury.
The patient was taken to a resuscitation area in the ED. Airway management was started with endotracheal intubation and mechanical ventilation. There were no visible masses or anatomical variation in supraglottic area. A bilateral chest tube was immediately inserted, resulting in a gush of air. Adequate fluid was given, and an acute exacerbation of bronchial asthma was treated with 100 mg of hydrocortisone and a standard dose of a salbutamol metered dose inhaler (MDI). The patient was placed on mechanical ventilation with a pressure-regulated volume control (PRVC) mode of 100% oxygen, a positive end-expiratory pressure (PEEP) of 8 mmH2O, a tidal volume of 320 mL, and a respiration rate of 28 breaths per minute.
The patient's blood pressure improved to 100/70 mmHg after the initial resuscitation effort in the ED. Despite receiving mechanical ventilation, his oxygen saturation did not rise above 82%, and the machine could not delivering a tidal volume of more than 120 mL to 150 mL with low minute ventilation and a high peak pressure alarm. The mechanical ventilator's wave form analysis revealed signs of airway obstruction and air leak. The respiratory rate was increased by adjusting the machine. To induce sedation and paralysis, 50 mg/h of ketamine and 3 mg/h of vecuronium were administered. None of these treatments resulted in clinical improvement, and the patient began hypo ventilating, leading to acidosis. A non-contrast computed tomography (CT) scan of the neck and chest revealed a bilateral pneumothorax, as well as a small hydrothorax on the right side and extensive subcutaneous emphysema. A focal tracheal mass was also noticed (Figure 1). A distal tracheal mass with an estimated obstruction of 90% was found during a bedside fiberoptic bronchoscopy, (Figure 2).
The patient was transitioned to an intensive care unit (ICU). Every 8 hours, 4 mg of dexamethasone and a bronchodilator were continued. The antibiotics administered were 1 mg ceftriaxone intravenously and 500 mg azithromycine orally. And mechanical ventilation was maintained. After 12 hours of resuscitation efforts in the ICU, the patient's oxygen saturation was 82%, minute ventilation was less than 3, mental status remained low, GCS was 4, and the endotracheal tube was left in place. Following that, the patient experienced generalized tonic-clonic seizures. After consulting with the cardiothoracic surgery and anesthesia teams, it was decided that the patient would need an emergency sternotomy. The patient was moved to the operating room (OR).
In the OR, noninvasive standard anesthesia monitors were connected to the patient. The patient's vitals showed a pulse rate of 112 beats per minute, an oxygen saturation of 84%, and a blood pressure of 116/53 mmHg. An endotracheal tube was immediately connected to the anesthesia machine, a General Electric 9100c NXT. The ventilator was programmed to operate in the synchronized intermittent mandatory ventilation-pressure control ventilation (SIMV-PCV) mode. The inspiratory pressure was 20 cmH2O, the respiratory rate was 29 breaths per minute, the I:E ratio was 1:3, and the PEEP was 10 cmH2O. The patient had a peak pressure of 27 cmH2O and a maximum tidal volume of 185 ML. The tidal carbon dioxide level was 83 mmHg.
A partial sternotomy to the level of the 3rd rib was performed to access the trachea. A flexible bronchoscopy was used to locate the tumor. After the surgeon incised the trachea, the orotracheal tube was removed and a sterile endotracheal tube was inserted into the distal trachea to facilitate mechanical ventilation. After the diseased trachea was resected and the posterior wall of the trachea was sutured, a laryngoscopy and orotracheal intubation were performed. The tip of the endotracheal tube was inserted beyond the anastomotic site under direct vision. The surgeons then completed suturing the incision and confirmed no air leakage. Extubation was not performed after the operation due to the patient's low mental status and an initial capnometry reading of 83 mmHg, indicating hypercapnia. The hypercapnia most likely induced the seizure episode. A resection of the tumor and four tracheal rings was performed. The tissue was sent for biopsy (Figure 3). The intraoperative course was uneventful and the patient was transferred to the ICU. He was intubated and had stable vital signs during the remainder of his visit.
Post-operatively, the patient's mechanical ventilation parameters and clinical conditions improved. His oxygen saturation improved to 95% on an FiO2 of 50% with a PEEP of 6 cmH2O. The patient's clinical condition significantly improved and his mental status improved to alert. The patient had stable vital signs. He was extubated 48 hours post-operatively and discharged home after a 14-day hospital stay. A histopathologic tissue biopsy showed a malignant synovial cell sarcoma. At the time of publication, the patient is asymptomatic and performing his daily activities without functional impairment.