Laryngeal mask versus endotracheal tube for airway management in tracheal surgery: a case-control matching analysis and review of the current literature

[Anesthesia and Surgery of the Trachea]

This article aims to review the current anaesthetic management of tracheal resections.Apart from the "traditional" approach of induction of general anaesthesia with conventional tracheal intubation and cross-field intubation or jet ventilation during the resection phase, there has lately been a trend towards less invasive techniques.Regional anaesthesia, laryngeal mask airways and preservation of spontaneous ventilation are among the new anaesthetic approaches. Current data suggest potential advantages compared with conventional tracheal intubation.Extracorporeal membrane oxygenation may provide adequate gas exchange and/or cardiovascular support for complex resections and reconstructions. In addition, it may serve as a reliable "backup" technique, in case of oxygenation difficulties with the use of other devices.Given the vast spectrum of different anaesthetic approaches to tracheal surgery, interdisciplinary planning is essential to identify the optimal technique on a case-by-case basis. During that process, the localisation and consistency of the airway lesion, comorbidities and the functional status of the respiratory system and specific surgical approach need to be taken into account.As there is a lack of high-quality data, evidence-based comparisons of different anaesthetic techniques are not possible.

New Insight into Laryngo-Tracheal Surgery: High-Flow Oxygen Therapy to Prevent Early Complications after Surgery

BACKGROUND

Early post-operative airway management after laryngo-tracheal surgery is crucial. Acute respiratory failure due to glottis' edema may occur, requiring reintubation. This can prolong ventilatory assistance, jeopardizing anastomosis. To date, only judicious steroid administration and fluid management are available to avoid more invasive procedures. High-flow oxygen therapy (HFOT) is a noninvasive O2 support method providing humidification, warmed air, and Positive End-Expiratory Pressure (AIRVO2). No data about HFOT use to prevent early complications after laryngo-tracheal surgery are reported in the literature.

METHODS

Between September 2020 and September 2022, 107 consecutive patients who underwent laryngo-tracheal surgery received HFOT (Group A). Data and long-term results were compared with those of 80 patients operated between September 2018 and August 2020 (Group B), when HFOT was not available. All patients were operated in a single center. No pre- or post-operative settings changed, except for HFOT introduction. We analyzed and compared the risk for "delayed" reintubation (unexpected reintubation within the first 24-48 h after extubating/laryngeal mask removal) in the two groups.

RESULTS

No patients reported HFOT-related adverse events. The control group (B) presented "delayed" reintubation in 37% (p = 0.027), intensive care unit admission in 67% (p = 0.005) and longer hospital stay (p = 0.001) compared to the HFOT group (A). The minor complications' rate was 3% in both group and overall mortality was 0%. Re-stenosis was described in 4.6% of the HFOT group, without a statistically significant difference (p = 0.7006).

CONCLUSIONS

Our study is the first to investigate HFOT use in patients undergoing laryngo-tracheal surgery, potentially representing a consistent innovation in the peri-operative management of these patients. With the limitation of a retrospective series, we would suggest HFOT use for preventing post-operative reintubation rate, possibly reducing ICU admissions and hospital stays.

Anesthetic management of thyroid carcinoma invading the upper tracheal segment: A case report

INTRODUCTION AND IMPORTANCE

Intratracheal tumors account for approximately 0.2 % of respiratory tumors, including primary and secondary tumors. Secondary tumors of the upper trachea are most commonly derived from advanced thyroid cancer. Surgical resection is currently the general curative modality for thyroid cancer with tracheal invasion. Patients with tracheal tumors invading and protruding into the lumen may have reduced oxygen reserve capacity, leading to a shorter safe window for general anesthesia induction. Establishing an appropriate artificial airway is essential to ensure intraoperative safety for these patients. Here, we report a case of tracheal tumor caused by differentiated papillary thyroid carcinoma invading the upper segment of the trachea and the non-conventional approach used for intraoperative airway management without traditional endotracheal intubation.

PRESENTATION OF CASE

A 59-year-old female presented with bilateral neck masses and hemoptysis. The CT scan revealed suspicious malignant thyroid nodules, and tracheoscopy showed an approximately 50 % obstruction of the tracheal lumen. The patient's physical examination and biochemical examination showed no significant abnormalities. Based on imaging studies and pre-anesthetic assessment, a multidisciplinary team decided against performing endotracheal intubation in the patient due to the risk of tumor bleeding during the procedure. Instead, they opted for a modified endotracheal tube and the insertion of a laryngeal mask airway (LMA). The anesthesia induction and maintenance proceeded smoothly, with stable intraoperative hemodynamics. The tumor was successfully resected and tracheal anastomosis was performed without any complications.

CLINICAL DISCUSSION

The strategy adroitly evades the risk of bleeding and dislodgement due to tumor contact during the intubation process. In this case report, the anesthetic highlight is the employment of a reverse insertion technique for endotracheal intubation, facilitated by a sterile suction catheter and complemented by an innovative modification to the tracheal tube.

CONCLUSION

For patients with thyroid cancer invading the upper segment of the trachea, and in whom rapid induction anesthesia is anticipated not to cause tumor collapse, the use of laryngeal mask airway combined with modified tracheal tube mechanical ventilation is both safe and feasible.

New perspectives on tracheal resection for COVID-19-related stenosis: A propensity score matching analysis

OBJECTIVE

The large number of patients with COVID-19 subjected to prolonged invasive mechanical ventilation has been expected to result in a significant increase in tracheal stenosis in the next years. The aim of this study was to evaluate and compare postoperative outcomes of patients who survived COVID-19 critical illness and underwent tracheal resection for postintubation/posttracheostomy tracheal stenosis with those of non-COVID-19 patients.

METHODS

It was single-center, retrospective study. All consecutive patients with post-intubation/posttracheostomy tracheal stenosis who underwent tracheal resection from February 2020 to March 2022 were enrolled. A total of 147 tracheal resections were performed: 24 were in post-COVID-19 patients and 123 were in non-COVID-19 patients. A 1:1 propensity score matching analysis was performed, considering age, gender, body mass index, and length of stenosis. After matching, 2 groups of 24 patients each were identified: a post-COVID-19 group and a non-COVID group.

RESULTS

No mortality after surgery was registered. Posttracheostomy etiology of stenosis resulted more frequently in post-COVID-19 patients (n = 20 in the post-COVID-19 group vs n = 11 in the non-COVID-19 group; P = .03), as well as intensive care unit admissions during the postoperative period (16 vs 9 patients; P = .04). Need for postoperative reintubation for glottic edema and respiratory failure was higher in the post-COVID-19 group (7 vs 2 postoperative reintubation procedures; P = .04). Postoperative dysphonia was observed in 11 (46%) patients in the post-COVID-19 group versus 4 (16%) patients in the non-COVID-19 group (P = .03).

CONCLUSIONS

Tracheal resection continues to be safe and effective in COVID-19-related tracheal stenosis scenarios. Intensive care unit admission rates and postoperative complications seem to be higher in post-COVID-19 patients who underwent tracheal resection compared with non-COVID-19 patients.

The effect of intraoperative transnasal humidified rapid-insufflation ventilatory exchange on emergence from general anesthesia in patients undergoing microlaryngeal surgery: a randomized controlled trial

BACKGROUND

Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) has received extensive attention for its utility in tubeless anesthesia. Still, the effects of its carbon dioxide accumulation on emergence from anesthesia have not been reported. This randomized controlled trial aimed at exploring the impact of THRIVE combined with laryngeal mask (LM) on the quality of emergence in patients undergoing microlaryngeal surgery.

METHODS

After research ethics board approval, 40 eligible patients receiving elective microlaryngeal vocal cord polypectomy were randomly allocated 1:1 to two groups, THRIVE + LM group: intraoperative apneic oxygenation using THRIVE followed by mechanical ventilation through a laryngeal mask in the post-anesthesia care unit (PACU), or MV + ETT group: mechanically ventilated through an endotracheal tube for both intraoperative and post-anesthesia periods. The primary outcome was duration of PACU stay. Other parameters reflecting quality of emergence and carbon dioxide accumulation were also recorded.

RESULTS

Duration of PACU stay (22.4 ± 6.4 vs. 28.9 ± 8.8 min, p = 0.011) was shorter in the THRIVE + LM group. The incidence of cough (2/20, 10% vs. 19/20, 95%, P < 0.001) was significantly lower in the THRIVE + LM group. Peripheral arterial oxygen saturation and mean arterial pressure during intraoperative and PACU stay, Quality of Recovery Item 40 total score at one day after surgery and Voice Handicap Index-10 score at seven days after surgery were of no difference between two groups.

CONCLUSIONS

The THRIVE + LM strategy could accelerate emergence from anesthesia and reduce the incidence of cough without compromising oxygenation. However, these benefits did not convert to the QoR-40 and VHI-10 scores improvement.

TRIAL REGISTRATION

ChiCTR2000038652.

Tracheal injury from dog bite in a child

BACKGROUND

Dog bites associated with the head and neck area in children are a common problem. Most of the lacerations are found in the upper lip and the nose region, and tracheal injury is rare [1]. Tracheal injury requires prompt and accurate diagnosis and treatment to rescue the patient. Especially in children, securing the airway is often more difficult than in adults because of their short neck and narrow trachea. In this report, we experienced a pediatric case of multiple dog bites with tracheal injuries in the neck.

CASE PRESENTATION

We report the case of a 3-year-old girl who presented with multiple dog bites. There were multiple wounds on the head, face, neck, and anterior chest, and air leakage was observed from the cervical wound at the time of transfer. It was difficult to perform oral endotracheal intubation, therefore, we extended the neck wound, probed the trachea with finger, and inserted a tracheal tube directly from the cervical wound in the emergency room. Tracheoplasty and another wound cleansing were performed in the operating room. The patient was discharged on the 18th day after surgery, without further complications.

CONCLUSION

Tracheal injury from a dog bite is rare. It is important to prompt and accurate diagnosis and treatment. Children should be especially careful because of their short necks and narrow tracheas.

Anesthetic Management of Upper Tracheal Cancer Resection and Reconstruction: A Case Report

Tracheal tumor resection and reconstruction is the primary treatment for tracheal tumors. The trachea is the surgical site as well as an important channel to ensure ventilation and maintain oxygenation during surgery. In this report, we describe the successful management of an upper tracheal tumor in a 50-year-old patient. The tumor was situated approximately 2–3 cm below the vocal cords, occluding the tracheal lumen by 80%. Conventional orotracheal intubation was expected to be impossible, and the patient was managed with an I-Gel supraglottic airway for mechanical ventilation with the assistance of venovenous extracorporeal membrane oxygenation (VV ECMO). After securing tracheal intubation via the tracheostomy site, VV ECMO was weaned off, and mechanical ventilation was changed to tracheal intubation. Eventually, tracheal tumor resection and reconstruction were successfully performed under general anesthesia. No specific events occurred during anesthetic management. Careful preoperative planning and good teamwork made the procedure possible without complications.

Successful Total Tracheal Replacement by Cryopreserved Aortic Allograft in a Patient Post-COVID-19 Infection

This is the first report to our knowledge of a successful total tracheal replacement in a post-COVID-19 patient by cryopreserved aortic allograft. The graft was anastomosed to the cricoid and carina; a silicon stent was inserted to ensure patency. The patient was extubated on the operative table and was immediately able to breathe, speak, and swallow. No immunosuppression was administered. Three weeks after surgery, the patient was discharged from hospital in excellent health, and was able to resume his normal lifestyle, work, and activity as an amateur cyclist. Two months after surgery, the patient assumes aerosol with saline solution three times per day and no other therapy; routine bronchoscopy to clear secretions is no longer needed.