Tracheal Oedema Treated by Instillation of Adrenaline

Examination Pale, anxious. Pulse 136, temperature 99, respiratory rate 28, and gross bronchospasm. Erythema nodosum legs and arms and herpes labialis present. Diarrhcea with blood and mucus noted. Haemoglobin, 3%; white blood count, 19,000 (85 per cent, neutrophils); E.S.R. 112. X-ray chest: no evidence of hilar adenopathy or active pulmonary disease. Sputum culture was subsequently found to be sterile and negative for T.B. She was given penicillin intramuscularly. The following day there was obvious increased stridor. Indirect laryngoscopy revealed swelling and three superficial ulcers of the right ventricular band with surrounding erythema and three similar ulcers were seen close to the left arytenoid in the inter-arytenoid area, but there was an adequate airway and the cords moved normally. In the next few hours her condition became worse and tracheotomy was performed under local anaesthetic with marked deterioration during the procedure, when the patient became grossly dyspnceic, comatose and even cyanosed in spite of the low haemoglobin, being very close to death. On opening the trachea the mucosal lining was noted to be markedly thickened and swollen and a metal tracheotomy tube was inserted. After operation her condition improved with frequent tracheal suction and blood transfusion was commenced. Six hours later marked difficulty was noted in passing a No. 9 E.G. Jacques catheter down the trachea and only a fine No. 5 E.G. catheter could be introduced, and this caused great respiratory distress. Four hours after this there was gross indrawing of intercostal and supra-clavicular areas with tremendous respiratory effort and very inadequate tidal volume. X-ray of the chest revealed slight surgical emphysema in the neck and axillae with a small right pneumothorax, which was aspirated without improvement in the general condition. Only the finest catheter available (No. 3 E.G.) could be passed, with difficulty, down the trachea through the tracheotomy tube and it appeared that the patient was about to die at any minute. She was taken to theatre (11.30 p.m.) in order to perform bronchoscopy to ensure that the tracheotomy