|Year : 2021 | Volume
| Issue : 2 | Page : 135-138
Anaesthetic management for removal of intratracheal precarinal tumour: A unique challenge
Naresh R Kabra, Harshal D Wagh
Department of Anaesthesia, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, Maharashtra, India
|Date of Submission||26-May-2021|
|Date of Acceptance||07-Jul-2021|
|Date of Web Publication||10-Aug-2021|
Dr. Naresh R Kabra
S/O Ramlal N. Kabra, “Ramkunj”, Near Police Station, Gandhinagar, Ambad - 431 204, Jalna, Maharashtra
Source of Support: None, Conflict of Interest: None
We present successful management of a case of intratracheal tumour situated just above the carina in a 46-year-old male without any adverse outcome or the need for cardiopulmonary bypass. The tumour was originating from the right lateral wall of trachea just proximal to the carina and partially obstructing the right main bronchus. A reinforced endotracheal tube was guided over a fibreoptic bronchoscope into the left main bronchus and the patient provided one-lung ventilation till the trachea was opened. During tracheal resection and closure, the first reinforced tube was withdrawn till mid-trachea and a second reinforced tube was placed in the left main bronchus under direct vision by the surgeon and used for ventilation. Towards the end of procedure, the first reinforced tube (which had been withdrawn till mid-trachea before the surgeon passed the second tube) was advanced beyond the tracheal opening and used for ventilation. At the end of the procedure, the patient was extubated on table and was subsequently discharged without any complication. Our case illustrates the paramount importance of extensive planning, preparation of the operation theatre, good communication and coordination between all team members while dealing with these difficult cases.
Keywords: Airway surgery, bronchial intubation, fibreoptic intubation, intratracheal tumour, precarinal tumour
|How to cite this article:|
Kabra NR, Wagh HD. Anaesthetic management for removal of intratracheal precarinal tumour: A unique challenge. Airway 2021;4:135-8
|How to cite this URL:|
Kabra NR, Wagh HD. Anaesthetic management for removal of intratracheal precarinal tumour: A unique challenge. Airway [serial online] 2021 [cited 2021 Dec 2];4:135-8. Available from: https://www.arwy.org/text.asp?2021/4/2/135/323575
| Introduction|| |
Primary tracheal tumours are very rare (0.2 in 100,000 persons per year), and their surgical removal makes it one of the rare anaesthetic experiences. Surgeries where the airway is shared between surgeons and anaesthesiologists are always challenging. Apart from the surgical difficulties faced by surgeons, anaesthesiologists have to face different challenges including maintaining a patent airway and ensuring adequate ventilation, especially during tracheal resection and closure.
We report one such unique experience wherein tumour was located just above the carina causing partial obstruction of the right main bronchus. We provided one-lung ventilation with bronchial intubation into the left main bronchus and change of tube twice during the procedure.
| Case Report|| |
A 46-year-old male with a history of diabetes for 10 years, on regular oral medications with no previous surgical history, was posted for resection of a tracheal tumour. He had a history of multiple admissions for breathlessness in the recent past. He was initially given bronchodilators and steroids with a diagnosis of recent-onset chronic obstructive pulmonary disease. However, upon further evaluation, he was diagnosed to have an intratracheal tumour originating from the right lateral wall of trachea and the line of management was changed.
Apart from the routine preoperative laboratory investigations, chest X-ray and computed tomography scan of chest in various planes along with reconstruction of three-dimensional images were done [Figure 1]a and [Figure 1]b. It showed a mass in the lower third of the trachea, just proximal to the tracheal bifurcation, originating from the right lateral wall of the trachea. While the lower lobe of the right lung was collapsed, air shadows in the right upper lobe suggested either preserved ventilation to the right upper lobe or trapped air within it. Pulmonary function tests revealed a normal forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio excluding any significant obstructive defect. However, forced expiratory flow 25%–75% was reduced (32%) suggestive of diminished flow in small airways. FVC was reduced (46%) suggestive of severe restrictive defect. No reversibility was seen after administration of a bronchodilator. Diffusion capacity (DLCO) was reduced (45%). Bronchoscopy had revealed a broad-based mass, smooth and glistening with increased vascularity, arising from the anterolateral wall of the trachea just before its bifurcation causing 70% luminal obstruction.
|Figure 1: (a) Computerised tomographic image of the mass in the lower third of the trachea just proximal to the tracheal bifurcation (b) Three-dimensional reconstructed images showing the right lower lobe is collapsed whereas right upper lobe is aerated suggesting preserved ventilation or trapped air|
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It was decided to do an awake fibreoptic bronchoscopy to visualise the tumour and assess the situation followed by rigid bronchoscopy for debulking of the tumour so as to facilitate passage of a double-lumen tube and subsequent surgical resection of the tumour with one-lung ventilation. An adult fibreoptic bronchoscope (Ambu® aScope™ 4 Broncho Large 5.8/2.8), a paediatric fibreoptic bronchoscope (Ambu® aScope™ 4 Broncho Slim 3.8/1.2), a rigid bronchoscope, double-lumen tubes (sizes ranging from 35F to 41F), reinforced tubes (sizes 6.0–8.5 mm ID), bronchial blockers and a jet ventilator set were kept ready in the operation theatre. One extra anaesthesia machine was kept as a standby in the operation theatre to provide dual-lung ventilation if the need arose. The cardiopulmonary team was informed about the case.
After counselling and informing the procedure to the patient, airway preparation was done with 4% lignocaine nebulisation and intratracheal injection of lignocaine 2%. Preinduction monitors included a 5-electrode electrocardiogram, noninvasive blood pressure and pulse oximetry. The patient was preoxygenated with 100% oxygen administered using a nonrebreathing mask (SpO2 100%). After giving 50 μg fentanyl, an awake nasal fibreoptic bronchoscopy was done by the surgeon and the tumour location and size were assessed. The tumour was located in the distal trachea, just proximal to the carina. Originating from the right lower quadrant of trachea and occupying around 70% of tracheal lumen, it appeared vascular [Figure 2]. Some space was available in the left upper quadrant of the tracheal lumen between 8 o'clock and 10 o'clock positions through which the bronchoscope could be negotiated to visualise the carina and tracheal bifurcation beyond. As sufficient space was available for a fibreoptic scope to pass beyond the tumour and locate the left main bronchus, the possibility of a fibreoptic-guided endobronchial intubation was discussed with the surgical team and the plan was changed. It was decided to perform an awake fibreoptic intubation and guide the tracheal tube into the left main bronchus and ventilate the patient.
|Figure 2: Tumour located in the distal trachea just proximal to carina occupying around 70% of tracheal lumen with a crescentic tracheal lumen visible between 8 o'clock and 10 o'clock positions|
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A 7.0 mm ID reinforced endotracheal tube (Rüsch® cuffed reinforced endotracheal tube) was preloaded over a paediatric fibreoptic scope (Ambu® aScope™ 4 Broncho Slim 3.8/1.2). Following bronchoscopy through the oral route, the tumour was negotiated and the left main bronchus was visualised. The scope was manoeuvred into the bronchus, and the tube was guided over it into the left main bronchus. Injection propofol 100 mg and atracurium 40 mg were given. The position of the tube was confirmed with fluoroscopy [Figure 3]. One-lung ventilation was initiated with a tidal volume of 300–350 mL and a respiratory rate of 15–20/min. Following induction of anaesthesia, a triple-lumen central venous catheter and a right radial arterial line were secured. Anaesthesia was maintained with sevoflurane in air:oxygen mixture and infusions of atracurium and fentanyl. The patient was positioned in the left lateral position for surgery and air entry was reconfirmed. Paravertebral block was given under ultrasound guidance at T4 to T6 spaces using an 18 SWG Tuohy epidural needle with 30 mL of 0.1% ropivacaine.
|Figure 3: Correct position of tracheal tube in left main bronchus confirmed by fluoroscopy|
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One-lung ventilation was performed through the reinforced tube placed in the left main bronchus in the left lateral position till the dissection of the trachea. At this point, the patient was ventilated with 100% oxygen and sevoflurane, and the reinforced tube was withdrawn till the mid-tracheal level. A vertical incision was placed over the lower trachea, and a second reinforced tube (size 7.0 mm ID) was inserted into the left main bronchus by the surgeon under direct vision and the left lung was ventilated through it. During dissection of distal part of tumour, the tube was intermittently withdrawn and the bronchial lumen covered with gauze to avoid aspiration of blood and leak of gases. The patient was ventilated with 100% oxygen between periods of dissection. The patient maintained saturation throughout this phase. After resection of the tumour and achieving haemostasis, the second tube was removed and the first tube (which was withdrawn till mid-trachea) was once again directed into the left main bronchus by the surgeon to facilitate tracheal closure. Gauze packing was used to reduce leak around the tube during tracheal closure. Primary closure was achieved without any significant tissue loss. After finishing the tracheal closure, the tube was withdrawn till the mid-tracheal level and the integrity of the suture line checked by flooding the surgical field with saline. Once an air-tight closure was confirmed, the patient was ventilated with the endotracheal tube at mid-tracheal level and the tracheal closure was completed. After the incision was closed, a paravertebral catheter was placed under ultrasound guidance for postoperative pain relief. An elastomeric pump (Baxter) loaded with 300 mL of 0.1% ropivacaine was started at 5 mL/h and increased to 7 mL/h if needed. The paravertebral catheter was removed on the 3rd postoperative day. Arterial blood gases were analysed which were normal. After the patient achieved full consciousness and started showing signs of returning muscle power, residual neuromuscular blockade was antagonised, and the patient was extubated and shifted to ICU where he was observed for 24 h. A check bronchoscopy was performed before discharge from the ICU on the 1st postoperative day which revealed a healthy surgical site. The patient was discharged from hospital on the 6th postoperative day and is on regular follow-up at present.
| Discussion|| |
Primary tracheal tumours are very rare (0.2 in 100,000 persons per year), and their surgical removal makes it one of the rare anaesthetic experiences. Although the clinical situation seems unsurmountable, various anaesthetic methods have been applied for resection and anastomosis of the trachea which include but are not restricted to the use of jet ventilation, one-lung ventilation, distal tracheal ventilation, ventilating both lungs separately and cardiopulmonary bypass with femoral vascular access.,,, Each of these options poses new challenges so there cannot be a one-protocol-to-suit-all to manage them. Anaesthetic management of a patient with a tracheal tumour is challenging as the airway is always shared with the surgeon, and patency must be maintained despite airway manipulation., Intratracheal masses usually start getting symptomatic when 75% or more of the tracheal lumen is obstructed. Tracheal lesions present at lower level can make airway management, anaesthesia and surgery for successful and safe removal of the mass more complex.
In recent years, new methods have been used to manage cases of tracheal tumours in which authors have used techniques such as high-flow nasal oxygenation during biopsy and surgical resection of tumour, cardiopulmonary bypass secured under spinal anaesthesia followed by general anaesthesia and sternotomy and partial tumour resection through a low tracheostomy.
There is a possibility of total airway obstruction during ventilation attempts using positive pressure because the airway obstruction has a fixed and a dynamic component. Dislodgement of the tumour, possibly from trauma following intubation causing total obstruction, should also be kept in mind. For cases where the lesion is situated in the upper trachea, fibreoptic-guided intubation with the cuff placed distal to the lesion and double-lung ventilation is a workable strategy. However, for lesions located in mid-trachea or distal trachea, it is better to consider one-lung ventilation. Tumour debulking before securing the airway is an option depending on availability of resources, location and dimensions of lesion and skills of the surgical team.
We acknowledge the help of Dr Rajesh Mistry (Consultant and Head of the Department of Oncosurgery, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India), and the help of his department in the compilation of this case report.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]