Management of anaesthesia during tracheal resection

Anaesthesia for tracheal resection and anastomosis

Tracheal resection anastomosis is one of the most challenging surgeries. Notable advances in this field have made possible a variety of surgical, anesthetic, and airway management options. There are reports of newer approaches ranging from use of supraglottic airway devices, regional anesthesia, and extracorporeal support. Endotracheal intubation with cross-field ventilation and jet ventilation are the standard techniques for airway management followed. These call for multidisciplinary preoperative planning and close communication during surgery and recovery. This review highlights the anesthetic challenges faced during tracheal resection and anastomosis with specific considerations to preoperative workup, classification of tracheal stenosis, airway management, ventilation strategies, and extubation. The newer advances proposed have been reviewed.

Non-cardiac surgery applications of extracorporeal circulation

Although the efficacy of extracorporeal circulation (ECC) is well established for open-heart surgery, application of ECC in other surgical areas has not been given much attention. Advances in the related surgical technique and anesthetic management combined with refinements in the ECC procedure itself have encouraged several institutions to use ECC for complex non-cardiac surgeries. ECC is beginning to be used for circulatory support or tissue oxygenation during surgery on the lung, brain, liver, and kidney as well as in emergency situations. With ECC, difficult and complex surgeries can be performed more safely, and the success rate of certain surgeries has been positively affected. It is important that the surgeon, anesthesiologist, and perfusionist are trained in non-cardiac surgery applications of ECC. Thus, we review here non-cardiac uses that have emerged and summarize the related procedures.

Anesthesia for patients with a mediastinal mass

Anesthesia for patients with mediastinal masses carries a significant risk for fatal or near-fatal cardiorespiratory events. Careful history taking and thorough preoperative investigation, including CT, identify most susceptible patients. Preoperative fiberoptic bronchoscopy performed by or involving the anesthesiologist is invaluable for determining the plan for intubation and ventilation. A coordinated approach involving anesthesiologists and surgeons is essential.

Anesthesia for airway surgery

Surgery of the upper airway requires diagnostic or therapeutic manipulation of the respiratory tree despite ongoing ventilation. Whether internal or external access to the conducting airway is required, anesthesiologist and surgeon, who must work together closely, share the airway. The anesthetic technique is influenced by the chosen mode of ventilation.

An unusual cause of tracheal stenosis

PURPOSE

To report a large chronic tracheal foreign body, causing tracheal stenosis in an 11-yr-old girl.

CLINICAL FEATURES

The history was suggestive of obstructive airways disease with secondary bronchiectasis. Physical findings were crepitations and rhonchi all over the chest. Blood gases were normal. Chest X-ray showed bronchiectasis and a ventilation perfusion scan identified a tracheo-esophageal fistula. During anesthesia to confirm this, intubation and ventilation were difficult because of tracheal stenosis. The hypoventilation resulted in severe hypercarbia and acidosis. A subsequent CT scan showed a stenosis of 2 mm diameter and 1 cm length in the middle third of trachea, bronchiectasis, and an air filled pocket between the trachea and esophagus. PFT showed a severe obstruction. Antitubercular treatment which was started on the presumptive diagnosis of tuberculous stenosis and tracheoesophageal fistula caused a delay with deterioration of patient from intermittent dyspnea to orthopnea with severe hypecarbia and acidosis. The anesthetic management of the tracheal reconstruction was difficult due to her moribund condition even after medical treatment, the short length of the trachea above the obstruction, its severity and lack of resources for alternative techniques. A large foreign body was found lying obliquely in the trachea dividing it into an anterior narrow airway mimicking a stenosed trachea, and a wider posterior blind passage.

CONCLUSION

The anesthetic consequences were peculiar to the unexpected etiology of the stenosis and poor general condition of the patient. Minor details like the tracheal tube bevel and ventilatory pattern became vitally important.

Airway management of a child after tracheal resection

PURPOSE

To report a strategy for minimizing airway risks and optimizing airway management in the post-reanastomosis phase of the anesthetic management of a patient undergoing tracheal reconstruction.

CLINICAL FEATURES

A 14-yr-old boy with squamous cell carcinoma of his trachea underwent a tracheal resection and end-to-end reanastomosis for removal of tumour. This procedure was accomplished through a right thoracotomy. A thoracic epidural had been placed before induction of anesthesia through which 3 mg morphine and 10 ml bupivacaine 0.25% with epinephrine were administered during surgery. After chest wall closure the patient was allowed to recover spontaneous respiration and the trachea was extubated during deep anesthesia to eliminate airway response with coughing which might have stressed the anastomosis. An infusion of bupivacaine 0.0625% and morphine (100 microg x ml(-1)) was maintained until the third postoperative day. The patient had an unremarkable postoperative course and was discharged on the eighth postoperative day.

CONCLUSION

In this case thoracic epidural analgesia and tracheal extubation during deep anesthesia was a safe and effective strategy for minimizing airway risks and optimizing airway management in after the reanastomosis phase of tracheal resection.

Tracheal resection and reconstruction

PURPOSE

To review the literature on tracheal and carinal resection and reconstruction, and to report the general approach to these patients, as well as the general guidelines for the safe administration of anesthesia. The airway management is extensively reviewed.

SOURCE

Articles obtained from a Medline search (1960 to October 1997; keywords: tracheal surgery, carinal surgery, airway management). Textbook literature including the bibliographies were also consulted.

PRINCIPAL FINDINGS

Benign or malignant tracheal and carinal pathology causing obstruction can be managed in several ways but resection and reconstruction are the treatment of choice for most patients with tracheal stenosis or tumour. Surgery of the trachea is a special endeavour where the airway is shared by the surgeon and the anesthesiologist. The principal anesthetic consideration is ventilation and oxygenation in the face of an open airway. Ventilation can be managed in different ways, including manual oxygen jet ventilation, high frequency jet ventilation, distal tracheal intubation, spontaneous ventilation, and cardiopulmonary bypass.

CONCLUSION

The management of anesthesia for tracheal surgery presents many challenges to the anesthesiologist. Knowledge of the various techniques for airway management is crucial. Meticulous planning and communication between the anesthesia and surgical teams are mandatory for the safe and successful outcome of surgery for patients undergoing this procedure.

Resection of distal tracheal and carinal tumours with the aid of cardiopulmonary bypass

Two cases of carinal and tracheal reconstruction with the aid of cardiopulmonary bypass (CPB) are presented. The technical problems of surgery and anaesthesia which necessitated CPB in these two patients are discussed. CPB provides both adequate oxygenation and an unobstructed surgical field with optimal access to the trachea and carina. It permits atraumatic handling of the airways and reduction of anastomotic tension during the repair.

Anaesthesia for tracheal resection: report of 17 cases

PURPOSE

Laryngo-tracheal stenosis remains a major complication after prolonged intubation or tracheostomy. Surgical resection with end-to-end anastomosis carries the best long term prognosis. For the anaesthetist, however, this procedure represents a most challenging situation.

METHODS

Since 1993, we have used high frequency jet ventilation (HFJV) for tracheal resection. This paper describes the technique and the results of our series including 7 adults and 10 children.

RESULTS

There were no adverse haemodynamic or ventilatory consequences due to HFJV. Oxygenation was well maintained during the HFJV period. Sixteen of the 17 patients had a good outcome. Despite the good result of the resection-anastomosis, one child still suffers from an associated posterior glottic stenosis.

CONCLUSION

Since the introduction of HFJV for surgery of tracheal stenosis in our institution no complication of this ventilatory technique has occurred. It reduces the manipulation of the ventilation system and the period of apnea, thus decreasing the risk of hypoxaemia. The good access to the surgical field contributes to the success of resection-anastomoses in laryngo-tracheal stenosis.

Carinal resection with two high-frequency jet ventilation delivery systems

A 76-yr-old man underwent carinal resection for squamous cell carcinoma through the right posterolateral thoracotomy approach. Ventilation was maintained by the use of two high-frequency jet ventilators, each attached to a separate catheter during the time of resection and reconstruction of the tracheal carina. These catheters were introduced through the endotracheal tube and positioned into the left and right main bronchi at the beginning of the tracheal resection. Then, conventional ventilation was replaced by high-frequency jet ventilation (HFJV) with different ventilatory variables for each lung. During two-lung jet ventilation there was good oxygenation, normocapnia and no cardiovascular complications. The principle advantage of using two separate high-frequency ventilators is that it allows for maximum ventilatory efficiency with lungs of different compliance.

Modified jet ventilation during total laryngectomy: a prospective study using pulse oximetry and a pressure regulator

A method of jet ventilation during total laryngectomy is described. During the construction of the terminal tracheostomy, a small metal tube is used, instead of the traditional tracheostomy tube, to provide intermittent jet ventilation down the distal trachea. A pressure regulator is also employed to choose a driving pressure best suited to the chest and lung compliance of each patient. Excellent surgical access for tracheo-cutaneous anastomosis is achieved. Satisfactory ventilation during the jet period is also confirmed by unaltered PaCO2 and increased PaO2 levels. The use of pulse oximetry as a non-invasive and continuous monitor of arterial oxygenation is a simple alternative to arterial blood sampling.

[Development of anesthetic technics for resection-anastomosis of the trachea]

A series is reported of 109 patients, 45 +/- 18 yr old, undergoing tracheal sleeve resection. 101 patients had iatrogenic tracheal stenosis, 5 tracheal cylindroma, 2 tracheal cancer and 1 tracheal trauma. 84 patients underwent preoperative laser coagulation to increase the airway internal diameter. Anaesthesia for the sleeve resection was induced by thiopentone, and maintained by an opiate, nitrous oxide and, if necessary, a volatile anesthetic. Patients were intubated, after having been given a muscle relaxant, with either a normal length and diameter tube with a low pressure cuff, or a narrow (internal diameter less than 6 mm) 50 cm long tube with or without a low pressure cuff. Patients with long tubes were ventilated with intermittent positive pressure, and the others with high frequency jet ventilation (HFJV) via a urethral catheter within the endotracheal tube. 20% of the long tubes had to be replaced during surgery because of perforation of the cuff by a tracheal stitch. In all, six patients died, one as a result of a pneumothorax and air embolus due to HFJV. Preoperative photocoagulation reduced the risk of induction and intubation; the choice of endotracheal tube no longer depended on the tracheal diameter, but on the method of ventilation chosen. However, HFJV has tended to be phased out, except for the surgery of lesions close to the carena; it has been replaced by intermittent positive pressure ventilation via long tubes. Because laser photocoagulation can completely cure small stenoses, these patients requiring surgery were those with long stenoses which were difficult to treat.(ABSTRACT TRUNCATED AT 250 WORDS)

One lung anaesthesia. Cardiovascular and respiratory function compared during conventional ventilation and high frequency jet ventilation

Ten patients about to undergo left-sided thoracotomy for carcinoma of the lung were entered into a crossover trial to compare cardiovascular and respiratory function during high frequency jet ventilation and conventional mechanical ventilation for one lung anaesthesia. All patients were anaesthetised with a standard technique using double lumen tubes and placed in the lateral position with the left chest open. The results showed no significant differences with regard to ventilation sequence but one lung high frequency jet ventilation gave higher values than one lung conventional ventilation for shunt (p less than 0.01) and positive end expiratory pressure (p less than 0.05) and lower peak inflation pressure values (p less than 0.01). There were no significant differences in cardiac output, pulmonary capillary wedge pressure, arterial carbon dioxide or available oxygen. Surgical conditions were satisfactory during both methods of ventilation and satisfactory gas exchange occurred. It was, however, more difficult to assess adequacy of ventilation during high frequency jet ventilation and the routine use of this method of ventilation is not recommended during one lung anaesthesia.

High-frequency jet ventilation for tracheal surgery

The anaesthetic requirements for tracheal resection include a clear airway, adequate ventilation and good surgical access. Many techniques have been described, none of which is entirely satisfactory. This case reports on the use of high-frequency jet ventilation with 10Fg catheter combined with muscle relaxants and intravenous anaesthesia in a patient with tracheal stenosis.

Anaesthetic management during repair of tracheo-oesophageal fistula

A flexible fibreoptic laryngoscope was used to facilitate the passage of a long polyvinyl chloride tracheal tube into the left main bronchus during repair of a tracheo-oesophageal fistula situated near the carina in a patient in whom intubation with a double-lumen endobronchial tube was difficult. Close monitoring of neuromuscular transmission using a peripheral nerve stimulator also contributed to the successful anaesthetic management of this patient.

Continuous intravenous anaesthesia with Althesin for resection of tracheal stenosis

The anaesthetic management of patients undergoing tracheal resection for tracheal stenosis and the advantage of the maintenance of spontaneous respiration without intubation of the distal tracheal segment is discussed. The case reports of two such patients using a continuous intravenous infusion of Althesin with maintenance of spontaneous respiration are presented. The technique expedited the surgical reanastomosis due to lack of instrumentation in the surgical field. While some mild respiratory depression as evidenced by carbon dioxide retention did occur, the technique is worthy of consideration for the procedure.

One-lung high-frequency ventilation for tracheoplasty and bronchoplasty: a new technique

Major airway surgery requires the maintenance of adequate ventilation and oxygenation during the period of resection and reconstruction, as well as an unobstructed surgical field and optimal access to the airway's circumference. High-frequency positive-pressure ventilation (HFPPV) at a frequency of 1 Hz (60 breaths/min) or more, along with a small tidal volume (50 to 250 cc), provides adequate ventilation and oxygenation with minimal impairment of pulmonic and systemic circulatory functions. We have used HFPPV of one lung through a 2 mm internal diameter catheter in six patients (three undergoing right sleeve pneumonectomies, two having carinal tumor resections, and one having tracheal resection). High-frequency positive-pressure ventilation of the left lung provided continuous and adequate ventilation and oxygenation during the period of resection and reconstruction of the airways, while the small catheter permitted unimpaired visualization and adequate access to the operative site.

Sleeve pneumonectomy for bronchogenic carcinoma

Carcinomas of the right upper lobe that locally infiltrate the trachea represent a major challenge with regard to removal and reconstruction. Sixteen patients who had right pneumonectomy with carina resection between 1969 and 1977 were reviewed, and some implications of the surgical and anesthetic techniques were analyzed. The short-term results give merit to this extended procedure, and the fact that there is one long-term survivor suggests that some patients can be cured of their disease.

Anaesthesia for tracheal resection. Modified use of the Carden Tube

Surgical procedures involving sharing of the airway between the anaesthetist and surgeon, such as bronchoscopy, microlaryngeal surgery and tracheal resection impose special problems on the anaesthetist. The surgeon requires unrestricted surgical access, whereas the anaesthetist must ensure adequate and safe pulmonary ventilation and anaesthesia. This case report describes a two stage technique for management of the airway and ventilation during tracheal resection for stenosis. Initially a modified Carden tube with a ventilating injector was used through a tracheostomy stoma and subsequently an orotracheal tube was substituted. Anaesthesia was maintained entirely by the inravenous route. The surgical access was unrestricted and there was no pulmonary contamination.

Anaesthesia for tracheal resection: a new way to manage the airway

A case of lower tracheal resection is reported. A number 28 Foley catheter was modified and successfully used to ventilate the lungs through the short distal tracheal stump.

Anaesthesia for carinal resection

A case of adenocystic carcinoma (cylindroma) of the trachea is reported. Ventilation was successfully maintained for long periods by use of the venturi technique during resection of the carina, and during a later operation for relief of tracheal stenosis.

Suspension laryngoscopy under general anaesthesia. A technique using an injector

A technique is described of laryngoscopy under general anaesthesia and curarisation using a modification of the Sanders oxygen injection. A plastic catheter is introduced into the trachea through a brass tube fitted on to the laryngoscope blade and oxygen is injected intermittently through the catheter to provide ventilation. Operating conditions are excellent and serial blood-gas measurements on six patients showed that a safe level of Pao2, Paco2 and pH can be maintained.

Clinical evaluation of high-frequency positive-pressure ventilation (HFPPV) in laryngoscoy under general anaesthesia

A technique for automatic ventilation during laryngoscopy under general anaesthesia was evaluated in a lung model and in 5 patients (3--57 y) submitted for routine laryngoscopy. this technique has been given the name laryngoscopic HFPPV and utilizes an insufflation frequency (f) of 60 per min and a relative insufflation time (t%) of 22%. Ventilation is given via a nasotracheal insufflation catheter. Laryngoscopic HFPPV permits laryngeal surgery with a virtually unobstructed surgical field under complete muscular relaxation. The alveolar ventilation of the patient may be controlled by adjustment of the pressure of the anaesthetic gas mixture and there is no air entrainment through the larynx during insufflation. This makes possible use of O2/N2O mixtures and the oxygenation of the patient may be controlled by adjustment of the oxygen concentration of the anaesthetic gas mixture. As there is a continuous upward has flow through the larynx, blood or pieces of loose tissue are not sucked down into the trachea. A simple ventilation nomogram for clinical use is proposed. Adequately used, this nomogram guarantees safe ventilation during laryngoscopic HFPPV. An Fio2 of 0.3--0.4 gives adequate arterial oxygenation.