Interventional bronchoscopy for tracheal tumours: An anaesthetic challenge

Jyoti Sharma; Prashant Kumar; Shweta Bhardwaj; Sumit Das

doi:10.4103/ARWY.ARWY_30_19

CASE REPORT

Year : 2019 | Volume : 2 | Issue : 3 | Page : 157-160

Interventional bronchoscopy for tracheal tumours: An anaesthetic challenge

Jyoti Sharma, Prashant Kumar, Shweta Bhardwaj, Sumit Das
Department of Anaesthesiology and Critical Care, Pt. BD Sharma PGIMS, Rohtak, Haryana, India

Date of Submission	25-Sep-2019
Date of Acceptance	30-Nov-2019
Date of Web Publication	30-Jan-2020

Correspondence Address:
Dr. Jyoti Sharma
H. No. 305, Sector 14, Rohtak - 124 001, Haryana
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ARWY.ARWY_30_19

Abstract

Tracheal tumours may present with potentially catastrophic airway obstruction. There are many challenges in the management of anaesthesia for obstructing intratracheal tumours by rigid bronchoscopy, such as difficulty in ventilation, securing airway, sharing of airway with the surgeon and control of seepage of blood and tumour tissues distally into the tracheobronchial tree during resection. We report a 58-year-old woman, known case of renal cell carcinoma for whom right nephrectomy was done, who presented with sudden respiratory distress. Computed tomography showed a polypoidal lesion measuring 8 mm anteroposteriorly and 9 mm transversely in the trachea with attachment at the 6 o'clock position just before the tracheal bifurcation obstructing 70%–80% of the lumen. The tumour was resected through a rigid bronchoscope using electrocautery and a polypectomy snare. Careful preoperative evaluation of the site and degree of obstruction, on-going communication between surgeon and anaesthesiologist, tailored anaesthetic management techniques and meticulous postoperative care can help to deal with the difficulties and complications associated with the management of these cases.

Keywords: Resection of tracheal tumour, rigid bronchoscopy, secondary tracheal tumours

How to cite this article:
Sharma J, Kumar P, Bhardwaj S, Das S. Interventional bronchoscopy for tracheal tumours: An anaesthetic challenge. Airway 2019;2:157-60

How to cite this URL:
Sharma J, Kumar P, Bhardwaj S, Das S. Interventional bronchoscopy for tracheal tumours: An anaesthetic challenge. Airway [serial online] 2019 [cited 2023 Mar 30];2:157-60. Available from: https://www.arwy.org/text.asp?2019/2/3/157/277327

Introduction

Secondary tracheal tumours are defined as tumours located in the trachea but not directly originating from it. They may arise from haematogenous or lymphatic sites of metastasis or by direct extension from adjacent structures, including the thyroid or oesophagus.^[1] Patients with tracheal tumours may present with catastrophic airway obstruction. The majority of tumours located in the trachea can be removed by interventional bronchoscopy. There are many challenges in the management of anaesthesia for obstructing intratracheal tumours by rigid bronchoscopy, such as difficulty in ventilation, securing airway, sharing of airway with the surgeon and control of seepage of blood and tumour tissues distally into the tracheobronchial tree during resection.^[2],[3] The principle anaesthetic consideration during bronchoscopic removal is ventilation and oxygenation in the presence of an open airway.

Case Report

A 58-year-old woman, a known case of renal cell carcinoma for 3 years for which right nephrectomy was done, presented with the complaints of progressive breathlessness for the past 9 months which recently worsened to the point of dyspnoea on moderate exertion and feeling of something obstructing the airway. There were no other complaints. There was no history of chemotherapy or radiotherapy. She was initially treated with bronchodilators and steroids. She gave a history of hypertension for the past 10–12 years for which she was on treatment with tablet amlodipine 5 mg once daily and tablet telmisartan 40 mg once daily for 7 years. She had undergone bronchoscopy-guided biopsy 7 months prior. She had presented a week earlier to the emergency room with severe respiratory distress and was put on noninvasive ventilation (NIV) with pressure support of 10 cm H₂O and positive end-expiratory pressure of 8 cm H₂O. She had sudden respiratory distress 3 days later and was not able to maintain saturation on NIV when she was sedated, intubated and put on mechanical ventilation.

Computed tomography (CT) showed a polypoid lesion measuring 8 mm anteroposteriorly and 9 mm transversely in the trachea with attachment at the 6 o'clock position just before the tracheal bifurcation obstructing 70%–80% of the lumen. Left-sided pleural effusion with basal atelectasis was noted. Mediastinal lymph nodes were also noted with the largest lymph node in the paratracheal region measuring 1.3 cm. A chest radiograph revealed blunting of left costophrenic angle. Blood investigations were within normal limits except haemoglobin which was 8.1 g%. The patient was on spontaneous mode of ventilation and receiving an infusion of aminophylline at 62.5 mg/h, midazolam at 1 mg/h and fentanyl at 20 μg/h. Heart rate was 130/min and blood pressure (BP) was 160/80 mm Hg. Auscultation of the chest revealed bilateral conducted sounds with decreased air entry in bilateral lung bases. It was decided to excise the intratracheal growth using rigid bronchoscopy in view of the vascular nature of the growth and episode of bleeding and haemorrhage in the growth as evidenced by blood-stained secretions on suctioning of the endotracheal tube (ETT).

After obtaining informed high-risk consent, the patient was taken up for surgery. Adequate blood and blood products were arranged. In the operating room, monitors were attached. A 16 SWG peripheral intravenous line as well as subclavian central venous line was already in situ. Pulse rate was 138/min, oxygen saturation was 92% and BP was 156/90 mm Hg. The patient was preoxygenated with 100% oxygen through the ETT. Anaesthesia was induced with incremental concentrations of sevoflurane in 100% oxygen. Intravenous fentanyl 100 μg and injection propofol 100 mg were given. The ETT was removed and a rigid bronchoscope was introduced. Ventilation was continued via the side port of the bronchoscope by connecting the anaesthesia breathing circuit to it and providing manual ventilation. Three intratracheal growths obstructing the lumen were visualised [Figure 1]. Muscle relaxation was achieved with intravenous atracurium 25 mg. Boluses of injection propofol 20 mg were given intraoperatively, and anaesthesia was maintained with sevoflurane in oxygen and positive pressure ventilation. The tumour was resected through the rigid bronchoscope using electrocautery and polypectomy snare. The tumour was encircled with a loop and electrosurgical excision was done. Once the tumour got separated at its base, it was removed with forceps. Several attempts were made to excise the growths. During these attempts, saturation started falling and dropped to 50%. Multiple attempts to remove the tumours had to be made despite rapid desaturation. Desaturation was allowed to a point of 50%, and the ventilation was resumed immediately at that point with 100% oxygen via the ventilating port. After completion of the procedure, trachea was reintubated successfully with a 7.0 mm ID ETT and the patient was shifted to the intensive care unit.

Figure 1: Tumour arising from lateral wall of trachea

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Discussion

Tracheal or bronchial neoplasms can lead to airway compromise and obstruction secondary to either intraluminal or extraluminal growth. Patients may present with nonspecific and common symptoms such as cough, dyspnoea and wheezing, which may lead to delayed diagnosis and treatment. There can also be signs of upper airway obstruction.^[4] Before dyspnoea is experienced, the tumour must generally advance to a size that obstructs about 75% of the tracheal lumen.^[5] Perioperative risk is increased when dyspnoea (orthopnoea) or cough in supine position is present.^[6] In 30%–75% of patients, the chest X-ray is normal and pulmonary function tests may suggest the presence of upper airway obstruction. An obstructive flow pattern not responding to bronchodilator therapy should raise the possibility of fixed airway obstruction. A CT scan may show the intraluminal and extraluminal extent of tumour as well as the relationship with adjacent structures.^[7]

The mainstay for diagnosis of tracheal tumours is bronchoscopy.^[8] Rigid bronchoscopy is preferred due to more accurate evaluation of the extent of tumour, more secure control of the obstructed airway and better control of bleeding following biopsy. Tumour excision can be done through biopsy forceps, laser therapy with neodymium-doped yttrium-aluminium-garnet laser or potassium-titanyl-phosphate laser, cryotherapy or electrocoagulation.^{[9],[10],[11],[12]} Local anaesthesia or general anaesthesia with spontaneous ventilation, manual or mechanically controlled ventilation or high-frequency jet ventilation (HFJV) can be considered as the methods for adequate oxygenation during bronchoscopic ablation. Each approach carries certain advantages as well as complications and limitations. The final technique chosen depends not only on the site and extent of lesion but also the choice of the surgeon and anaesthesiologist.

Stepwise gradual induction of general anaesthesia should be carried with continuous monitoring of haemodynamics and gas exchange. Assisted ventilation should be assessed first before giving muscle relaxants to ensure possibility of positive pressure ventilation. Spontaneous breathing has the disadvantage of ineffective ventilation and hindrance to surgery. HFJV should be available in case the tumour is completely obstructing the airway.^[13] However, during HFJV, there can be risk of barotrauma from build-up of pressure due to impaired escape of expired gases. The broken tumour fragments or tumour mass can be dislodged distally, further worsening airway obstruction. Oxygenation can be compromised due to collapse of tracheal lumen distal to the mass during expiration.

In our patient, a stepwise approach for general anaesthesia was followed. As the trachea was already intubated, the ETT was removed after administering opioids and intravenous anaesthetics. Adequacy of face mask ventilation was assessed, and muscle relaxant was given to facilitate the introduction of the rigid bronchoscope. Anaesthesia was maintained with inhalation agents along with boluses of propofol and fentanyl. However, inhalational agents were stopped after the tumour was localised due to interruptions in ventilation several times during the procedure and also because of periods of desaturation which were managed with administration of 100% oxygen. Previous reports on anaesthetic management of intratracheal masses describe passage of the rigid bronchoscope beyond the growth and initiation of manual ventilation.^[14],[15]

Conclusion

The successful management of this case demonstrates the use of rigid bronchoscopy for biopsy and debulking of obstructing tumours. Hence, careful preoperative evaluation of the site and degree of obstruction, on-going communication between surgeon and anaesthesiologist, tailored anaesthetic management techniques and meticulous postoperative care can help to deal with the difficulties and complications associated with management of these cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her image and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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