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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 196-200

Anaesthetic management of acquired tracheal stenosis for tracheal resection and reconstruction


Department of Anaesthesia, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission21-Jun-2021
Date of Acceptance26-Jul-2021
Date of Web Publication26-Aug-2021

Correspondence Address:
Dr. Sunil Rajan
Department of Anaesthesia, Amrita Institute of Medical Sciences, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/arwy.arwy_36_21

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  Abstract 


Tracheal resection is a rare and complex surgery. The critical phases of the surgery are during induction in the presence of a critical airway, intraoperatively during airway transection and postoperatively for the maintenance of the reconstructed airway with planned early extubation to prevent wound dehiscence. An oedematous airway and fixed flexion of the neck are added risks in the postoperative period. We report a case of a 16-year-old boy with tracheal stenosis in the proximal trachea for elective resection and reconstruction. He received intravenous induction with bougie-guided intubation. Intraoperatively, oxygenation was maintained through the transected trachea. As he had an inadequate recovery from anaesthesia at the end of the surgery, he was extubated after few hours of mechanical ventilation and had an unremarkable recovery. A comprehensive planned airway management with anticipation of preoperative airway maintenance and good communication with surgeons are key to the safe management of this complex surgery.

Keywords: Anaesthesia for tracheal resection, tracheal reconstruction, tracheal stenosis


How to cite this article:
Mathew J, Rajan S, Kunjumon BS, Kumar L. Anaesthetic management of acquired tracheal stenosis for tracheal resection and reconstruction. Airway 2021;4:196-200

How to cite this URL:
Mathew J, Rajan S, Kunjumon BS, Kumar L. Anaesthetic management of acquired tracheal stenosis for tracheal resection and reconstruction. Airway [serial online] 2021 [cited 2022 Jan 27];4:196-200. Available from: https://www.arwy.org/text.asp?2021/4/3/196/324658




  Introduction Top


The most common cause of acquired tracheal stenosis is prolonged ventilatory support.[1] Tracheal stenosis is a result of pressure necrosis of tracheal mucosa due to overinflation of the cuff, traction of the endotracheal tube (ETT) during spontaneous or assisted ventilation and excessive drag of the ETT due to the weight of the circuit.[2] Following extubation, these patients usually develop symptoms of dyspnoea on exertion or features of upper airway obstruction such as wheeze or stridor.[3] Airway obstruction results when the tracheal diameter decreases by 5–6 mm or by 30% of the normal diameter. Cyanosis is suggestive of total airway obstruction.[4],[5],[6]

The anaesthetic management of tracheal resection and reconstruction poses unique challenges. Sharing the airway demands that the anaesthesiologist be familiar and prepared with various techniques to ensure adequate ventilation and oxygenation throughout surgery.


  Case Report Top


Our patient was a 16-year-old boy who had sustained a head injury following a road traffic accident that necessitated mechanical ventilation for 2 weeks. He was asymptomatic at discharge but developed exertional dyspnoea with wheeze a month later. He was initially managed with antibiotics, bronchodilators and steroids. Rigid bronchoscopic evaluation revealed a tracheal web that was resected followed by balloon dilatation and mitomycin C application under general anaesthesia (GA). This resulted in the restoration of adequate airway patency.

He was on regular follow-up thereafter and was able to carry out his daily activities without much difficulty for 3 months when his exertional dyspnoea recurred. Surveillance bronchoscopy was done which showed tracheal stenosis 3.5 cm distal to vocal cords with 40% airway occlusion. His symptoms progressed thereafter with exertional dyspnoea and stridor on lying supine.

Rigid bronchoscopy was done which showed significant subglottic stenosis (pin-hole tracheal lumen) causing critical airway compromise 2 cm distal to the vocal cords. The stenotic segment was widened using balloon dilation through a 12-mm rigid scope. Although there was localised tracheomalacia at the site, he could be extubated on table and the postoperative period was uneventful. A follow-up magnetic resonance imaging done 2 weeks later showed a 2-cm long tracheal stenosis in the proximal trachea at the level of the thyroid gland about 1.8 cm below the lower border of cricoid cartilage with the maximally stenotic segment measuring 5 mm in length and 10 mm in width [Figure 1]. The patient was scheduled for elective resection of the stenotic tracheal segment and tracheal reconstruction.
Figure 1: Magnetic resonance image showing stenosis in the proximal trachea measuring 5 mm in length and 10 mm in width in the area of maximal stenosis

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On preoperative assessment, he was found to be asymptomatic with no history of recent upper respiratory tract infection, no difficulty in lying supine and had good effort tolerance. He was 175 cm tall and weighed 50 kg. Airway examination was unremarkable (mouth opening 6 cm, no restriction of neck movements, no stridor on forced inspiration). Room air saturation was 98% and arterial blood gas showed a PaO2 of 84 mm Hg. Vocal cords were normal. The chest was clear with no wheeze. All blood reports, electrocardiography and chest X-ray were normal. He was advised deep breathing exercises, incentive spirometry and nebulisation as a part of preoperative optimisation of lung function.

We planned GA with intravenous (IV) induction, oral intubation and positive pressure ventilation. In the operation theatre, difficult airway equipment including videolaryngoscope, fibreoptic bronchoscope, bougie, stylet and various sizes of ETTs were kept ready. Preinduction monitors included 5-electrode electrocardiogram monitoring Lead II and V5, noninvasive blood pressure and pulse oximetry. Intravenous (IV) access was secured and IV glycopyrrolate 0.01 mg/kg was given. Following preoxygenation for 3 min, the patient was induced with fentanyl 2 μg/kg and propofol 2 mg/kg. After ensuring the ability to mask ventilate, suxamethonium 2 mg/kg was given. Following 1 min of mask ventilation, direct laryngoscopy was performed and intubation attempted with a 7.0 mm ID ETT. As there was some resistance to tube insertion just beyond the vocal cords, a bougie was passed and the same ETT was railroaded over the bougie. The ETT was initially placed endobronchial and gradually withdrawn and fixed at 26 cm after ensuring bilateral air entry to keep the tip of the ETT below the stenosis and above the carina. Anaesthesia was maintained on volume-controlled mode (VT 400 mL, f 14/min, PEEP 5 cm H2O, FIO2 0.5, peak airway pressure 24 cm H2O) with isoflurane 1% in air:oxygen mixture. Intraoperatively, a pharyngeal tube was also placed for easy identification of the oesophagus.

Following the dissection of the distal end of the stenosis, the patient was ventilated with 100% oxygen, ETT was gradually withdrawn till the tip was just above the tracheal opening and retained at that position. The surgeon then introduced a 6.0 mm ID ETT through the distal open end of the trachea and ventilation was resumed through this distal ETT. The trachea was then mobilised and the stenotic segment over 2 tracheal rings was resected. The posterior aspect of the trachea was sutured with the neck in extension and anterior trachea sutured subsequently keeping the head in a flexed position with head up.

The distally placed 6 mm ID ETT was removed and the 7 mm ID proximal ETT was advanced across the anastomotic site. Multiple tension-free sutures were placed to approximate the cut tracheal ends. The tracheal tube was intentionally placed endobronchial and then withdrawn to the point where bilateral air entry was heard ensuring that the tip was just above the carina. The ETT was fixed at 26 cm and cuff inflated. At the end of the surgery, the neck was maintained in a 35° flexed position with a modified Grillo's suture passing from the chin to the sternum [Figure 2] with a pillow under the head to maintain flexion.
Figure 2: Modified Grillo's stitch to maintain the neck in 35° flexed position in postoperative period

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As the patient was sedated and not generating adequate tidal volume, he was shifted to the postoperative intensive care unit (ICU) and ventilated overnight. A postoperative chest X-ray confirmed the tip of the ETT to be above the carina. He received morphine infusion at 1 mg/h and dexmedetomidine 0.5 μg/kg/h overnight for sedation with good tube tolerance. These medications were stopped early next day morning. After the patient became fully awake and established adequate spontaneous breathing, he was placed on pressure support which he tolerated well and was extubated later in the ICU 12 h after surgery. Post-extubation, he was asymptomatic and maintained 98%–100% saturation on room air and was pain-free. Analgesia was provided with paracetamol 1 g 8th hourly. Regular nebulisations were added to avoid the formation of mucous plugs in the tracheobronchial tree and constant reassurance was given regarding the Grillo's stitch which he tolerated well. He was shifted to the ward on postoperative day 2 and discharged on the 7th postoperative day following an unremarkable recovery.


  Discussion Top


Tracheal resection is a rare and complex surgery. A detailed preanaesthetic evaluation with computerised tomography neck and rigid/flexible bronchoscopy provides detailed information of the tracheal stenosis such as grading, length of stenosis, distance from vocal cords, character of stenotic lesion and length of the segment to be resected, all of which are important to plan the surgical and airway management.[7],[8],[9] The major anaesthetic challenges during tracheal resection occur at five phases of surgery-(1) at induction and intubation, (2) during dissection, a period of relative calm during which the lesion is defined, (3) an open airway, a critical period in which anastomosis is being performed and ventilation is across the surgical field, (4) closure and (5) emergence and extubation.[10] Early extubation is recommended to prevent wound dehiscence. An oedematous airway due to intraoperative manipulation and fixed flexion of the neck are added risks in the postoperative period.[4],[11]

Complications to consider following resection can be broadly classified as anastomotic or nonanastomotic. Anastomotic complications include the formation of granulation tissue, restenosis of the trachea, varying degrees of anastomotic dehiscence and fistulae into surrounding structures such as the innominate artery (tracheo-innominate fistula) and oesophagus (tracheo-oesophageal fistula). Nonanastomotic complications specific to upper airway reconstruction include laryngeal oedema, vocal cord palsy and glottic dysfunction. Following surgery, 95% of the patients have a good outcome. Complications occur in 20% of the patients, of which half are anastomotic complications which, if not addressed promptly, have a high risk for mortality.[12]

In patients with decreased effort tolerance, pulmonary function tests can predict the requirement for postoperative ventilation. Flow volume loops can assess and define the obstruction (intrathoracic versus extrathoracic, fixed versus variable). Examination of neck mobility preoperatively is very important as neck extension and flexion facilitate surgical exposure and postoperative healing.[10] Tracheal resection and reconstruction are contraindicated in patients with severe pulmonary dysfunction who would require postoperative ventilatory support because prolonged positive pressure ventilation and an inflated cuff can result in dehiscence of the anastomotic site. Steroid dependence and history of radiation therapy to the neck are relative contraindications to tracheal resection.[10] Preoperative optimisation with antibiotics, steroids, incentive spirometry and deep breathing exercises play a key role in the success of the surgery.

Although it may be ideal to do awake fibreoptic intubation in such cases, we chose IV induction as the patient was status postbronchoscopic dilatation (stenotic segment measuring 5 mm in length and 10 mm in width), asymptomatic, with good effort tolerance and was able to lie supine comfortably. He had an unusually long neck and after intubation, the ETT was fixed at 26 cm at the angle of the mouth. The tube tip was positioned between the stenotic tracheal segment and the carina. With the neck in a flexed position at the end of the surgery, the ETT fixed at 26 cm resulted in bilateral equal air entry and endobronchial position was ruled out by chest X-ray.

A typical Grillo stitch, which passes around the mandible and is deeply anchored over the sternum, is needed when the resected tracheal segment is longer than 4 cm. An orthopaedic brace such as a Shiraz brace is recommended in such situations as it is more comfortable for the patient than the Grillo stitch and maintains the necessary flexion even better. We used a modified Grillo stitch in our patient.

Our patient had an inadequate recovery from anaesthesia at the end of surgery after discontinuing anaesthetic agents. He was sedated and not generating adequate tidal volume. Even though the goal of the surgery is early on-table extubation, we decided to ventilate the patient overnight till he was awake to avoid risks of airway obstruction and respiratory depression if extubated on table. Moreover, reintubation in the immediate postoperative period could have been difficult and dangerous in view of the neck being fixed in a position of flexion. It could have resulted in damage to the freshly reconstructed trachea. Better titration of opioids and other sedative medications intraoperatively might have helped extubation of our patient on table, preferably over a tube exchanger as a precaution. By ensuring that the tip of the ETT was just above the carina, we ensured that the inflated cuff will not be in contact with the reconstructed area of the trachea, thereby reducing the risk of anastomotic dehiscence.

Decision to extubate on table or following a period of postoperative ventilation should be patient-specific, depending on the condition of the patient at the end of surgery. Premature extubation on table could be dangerous with catastrophic results if airway obstruction necessitating reintubation occurs.


  Conclusion Top


A comprehensive plan for airway management with anticipation of preoperative airway maintenance and good communication with surgeons are key to the safe management of this complex surgery. Early extubation after a brief period of neck immobilisation and directed postoperative care contribute to improved outcomes following tracheal reconstructive surgeries.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
D'Andrilli A, Venuta F, Rendina EA. Subglottic tracheal stenosis. J Thorac Dis 2016;8:S140-7.  Back to cited text no. 1
    
2.
Terashima H, Sakurai T, Takahashi S, Saitoh M, Hirayama K. Postintubation tracheal stenosis; problems associated with choice of management. Kyobu Geka 2002;55:837-42.  Back to cited text no. 2
    
3.
Axtell AL, Mathisen DJ. Idiopathic subglottic stenosis: Techniques and results. Ann Cardiothorac Surg 2018;7:299-305.  Back to cited text no. 3
    
4.
Pinsonneault C, Fortier J, Donati F. Tracheal resection and reconstruction. Can J Anaesth 1999;46:439-55.  Back to cited text no. 4
    
5.
Gómez-Caro A, Morcillo A, Wins R, Molins L, Galan G, Tarrazona V. Surgical management of benign tracheal stenosis. Multimed Man Cardiothorac Surg 2011;2011:mmcts. 2010.004945.  Back to cited text no. 5
    
6.
Ramghulam S, Perumal R, Reddy D. The evaluation and surgical management of post-intubation tracheal strictures at a thoracic surgery referral centre in South Africa. Afr J Thorac Crit Care Med 2018;24:82-6.  Back to cited text no. 6
    
7.
Filauro M, Mazzola F, Missale F, Canevari FR, Peretti G. Endoscopic preoperative assessment, classification of stenosis, decision-making. Front Pediatr 2019;7:532.  Back to cited text no. 7
    
8.
Carretta A, Melloni G, Ciriaco P, Libretti L, Casiraghi M, Bandiera A, et al. Preoperative assessment in patients with postintubation tracheal stenosis: Rigid and flexible bronchoscopy versus spiral CT scan with multiplanar reconstructions. Surg Endosc 2006;20:905-8.  Back to cited text no. 8
    
9.
Morshed K, Trojanowska A, Szymański M, Trojanowski P, Szymańska A, Smoleń A, et al. Evaluation of tracheal stenosis: Comparison between computed tomography virtual tracheobronchoscopy with multiplanar reformatting, flexible tracheofiberoscopy and intra-operative findings. Eur Arch Otorhinolaryngol 2011;268:591-7.  Back to cited text no. 9
    
10.
Ranganath N, Arathi B, Ramamani PV, Gowda VB. Anaesthetic considerations for tracheal resection in oncological thyroid surgeries. Indian J Anaesth 2015;59:188-90.  Back to cited text no. 10
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11.
Sandberg W. Anesthesia and airway management for tracheal resection and reconstruction. Int Anesthesiol Clin 2000;38:55-75.  Back to cited text no. 11
    
12.
Auchincloss HG, Wright CD. Complications after tracheal resection and reconstruction: Prevention and treatment. J Thorac Dis 2016;8:S160-7.  Back to cited text no. 12
    


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