Intraoperative airway obstruction in a Duchenne muscular dystrophy patient

Abstract

Purpose To report a complication of airway obstruction during spinal deformity correction surgery in Duchenne muscular dystrophy (DMD) patient, due to lordoscoliosis, airway malacia, and prone surgical positioning, which was rectified by changing the position of the patient and surgery was successfully completed. Case description A 15-year-old boy was diagnosed with DMD and admitted for surgical treatment of thoracolumbar scoliosis. The patient's preoperative Cobb's angle was 79 degrees and the kyphotic angle was -19 degrees. During the initial period of surgery, while in the prone position, peak inspiratory pressure (PIP) suddenly increased from 20-21 to 38-41 cmH(2)O, wheezing sounds were heard on auscultation of both lungs, and his blood pressure began to fall. Under suspicion of airway problem, intraoperative fiber-optic bronchoscopy was performed which confirmed airway obstruction. Attributing patient's prone position as the cause of airway obstruction, the surgical position of the patient was changed from prone to semi-lateral. After this change, the PIP stabilized to within normal limits (20-23 cmH(2)O). The surgical correction was successfully completed with a posterior-only pedicle screw by the free-hand technique, with the patient in the semi-lateral position for the rest of surgery. Conclusions Lordoscoliosis and airway malacia in a patient with DMD can lead to occlusion of the tracheo-bronchial lumen when the patient is in the prone position. Changing the patient's position from prone to semi-lateral can be of help to reverse this airway obstruction and complete the surgery. Pedicular screw insertion can be safely and effectively carried out in this position using free-hand technique.