tracheal surgery was first performed in the 1950s. the maximum length to be resected was believed to...

Anesthetic

Management

for Tracheo-Bronchial

Reconstruction

Ayman M. Kamaly

• Tracheal surgery was first performed in the 1950s.

• The maximum length to be resected was believed to be 2 cm.

• Progress in surgical and anesthesia techniques now permits more than half of the trachea to

be safely excised.

Why

Tracheal Surgery is a Particularly Challenging Situation for Anesthesiologist ?

Prolonged procedures,

Unavoidable episodes of ventilatory insufficiency,

Adequate gas exchange must be guaranteed,

Adequate visualization of an immobile endotracheal lumen is essential for the surgeon,

Require utmost communication bet. anesthesia & surgical teams,

Anesthetic plane should be fashioned for extubation at OR.

• Adult tracheal length : 10-13 cm.

• Approx 2 cartilaginous rings per cm (total of 18-22).

• These C-shaped rings form the Ant. & Lat. tracheal walls. The post. wall is membranous.

• The tracheal ID: – about 2.3 cm lat. – about 1.8 cm anteropost.

Tracheal Anatomy

Conversely, head extension results in a longer portion of trachea

becoming cervical.

When the head is flexed, the trachea can become

completely mediastinal.

Etiology of Tracheal Pathology

• Tracheal stenosis is primarily a result of tracheal tumors (<3:1000,000), penetrating or blunt trauma, and “Post-intubation , & tracheostomy stenosis”

• Early 1950s (Poliomyelitis epidemic) → tracheostomy became common for treatment of respiratory failure → complications started to appear.

• As pts began to survive longer periods, complications related to “cuffed ETT” starts to evolve

• “Low-volume/High-pressure cuff”: up to 250 mm Hg before ETT sealed to the tracheal wall.

With the recognition of the problem;

• “High-volume/low-pressure cuffs” were introduced in the early 1970s. The incidence of tracheal stricture dramatically reduced.

Etiology of Tracheal Pathology

• Post-intubation stricture continued to occur, but at a much lower rate due to: Damage at the stomal site (tracheostomy), Cuffs (over-inflation), ETT size (Large-bore), ETT movement;

Spont/Assist ventilation Heavy circuit

Pt. survival (prolonged mucosal exposure to FB). Others: ( Steroid, DM, infection, ↓BP, NGT).

Etiology of Tracheal Pathology

Stenosis site varies

according to whether

trachea is intubated

(orally/nasally) or

tracheostomized.

Etiology of Tracheal Pathology

• Non specific symptoms – delaying diagnosis for many years.

• Progressive exercise intolerance (>50%) √√√• Hemoptysis, persistent cough, • Exercise stridor stridor @ rest (when

diameter ≤ 5 mm)• Recurrent pneumonia• Cyanosis: very Late (signaling almost complete

occlusion)

Clinical Presentation

"Any patient who has received ventilatory support in the recent past or even not so recent past, who develops signs

and symptoms of upper airway obstruction, has an organic lesion until proved otherwise.“

Grillo HC, Donahue DM. Post intubation tracheal stenosis. Semin Thorac Cardiovasc Surg 1996; 8: 370-80.

• The aim of diagnosis is to assess: Degree of stenosis, Length of tracheal damage, Distance from the vocal cords to the upper end of

the lesion & the distance from the lower end of the lesion to

the carina.

Diagnostic Studies

I. CXR: Not useful. (only retrospective)

II. CT: defining the exact location & gross extension of the obstruction.

III. Three-Dimensional CT

Toyota K, Uchida H, Ozasa H, Motooka A, Sakura S, Saito Y. Preoperative airway evaluation using multi-slice three-dimensional computed tomography for a patient with severe tracheal stenosis. Br J Anaesth. 2004;93:865-867.

IV. Fluoroscopy: (Dynamic) identifying malacic segments +

information on laryngeal & glottic function.

V. Bronchoscopy: Rigid is the gold standard

VI. PFT (Flow-Volume Loops): Identify whether the obstruction is:

Fixed or Variable Intra or Extra thoracic

Surgical Considerations

• Surgical techniques include Insertion of a T-tube, Resection & 1ry anastomosis, Resection & reconstruction prosthetic

material, Reconstruction with tissue engineered

prosthetic cartilage.

• The first 4.5 cm are accessible with cervical approach.

• A further 1.5 cm can be added by median sternotomy or antero-lateral thoracotomy.

• The lower half of the trachea can be managed through right postero-lateral thoracotomy.

Surgical Approaches

• ETCO2 , SPO2 ,

• A-line (Lt. arm /compression of innominate A) !!

• Anesthesia machine with “High insp P⁰ alarm” + delivering up to 20 L/min O2 (preferable),

• Assorted sizes of ETTs (4-uncuffed 8-cuffed),

• Armoured ETTs,

• Long sterile circuit &/or corrugated tubings (for surgeon) !!.

Monitoring & Equipment

• Sedation ?: requires good judgment (degree of obstruction),

Moderate Obst: ↓anxiety → quieter breathing → ↓ airway resistance.

Severely Obst: Resp dep should be avoided (Х Х)

• Antisialogues ?: use with caution (drying secretion mucus plug).

Premedication ??

• Readily available in O.R.: Surgeon + Rigid bronchoscopes (in case of obst)

• Inhalational: is the safest

• IV: may be used (airway judgment) BUT

• Spont breathing: should be maintained

• MR: better avoided

• Awake intubation: is an option

Induction of Anesthesia

Unable to advance ETT Tube exchanger

Retrograde intubation

LMA

Fogerty’s Cath

CPB (femoral line)

Plan B… Plan C …

1. Single lumen endo-Tracheal tube,

2. Single lumen endo-Broncheal tube (one or two),

3. Low – frequency jet ventilation,

4. High – frequency jet ventilation,

5. CPB (heparin,…).

Ventilation

Identifying the Stenotic Segment

TRACHEAL RECONSTRUCTION

Resection of High Tracheal Lesion

Geffin B, bland J, Grillo HC, et al. Anesthetic management of tracheal resection and reconstruction. Anesth Analg, 1969; 48:884.

Courtesy of Prof. Ahmed Al-Noory

Courtesy of Prof. Ahmed Al-Noory

After placement of post suture line, the distal tube is removed from the trachea

Courtesy of Prof. Ahmed Al-Noory

• One lung ventilation

• Ligation of pulm A

Resection of low Tracheal Lesion

Geffin B, bland J, Grillo HC, et al. Anesthetic management of tracheal resection and reconstruction. Anesth Analg, 1969; 48:884.

Resection of Carinal Lesions

Geffin B, bland J, Grillo HC, et al. Anesthetic management of tracheal resection and reconstruction. Anesth Analg, 1969; 48:884.

• We may use 2 bronchial tubes ,

+

• Y-piece connector

• Narrow catheter through ETT passed to distal trach.,

• Attached to high p⁰ O2 Source (50 PSI),

• Intermittent O2 jets (10-20/m),

• Effectiveness: SPO2, ABG, chest expansion !!

Low – frequency jet ventilation/ Low – frequency interrupted High flow Ventilation

Low – frequency jet ventilation/ Low – frequency interrupted High flow Ventilation

• Disadvantages: » Hypercarbia,» Blood & debris entrained into

distal trach. (venturi principle),» Spraying of blood in the field,» Movement of lungs &

mediastinum.

Three Modes:I. HFPPV: » Delivers Vt = anatomic dead space

» 60-100 b/m» No air entrainment

II. HFJV:» Delivers pulses of small jets » 100-400 b/m» Air entrainment occurs

III. HFOV:» Vt = 50-80 ml

» 400-2400 b/m

High– frequency ventilation

Spontaneous Ventilation

• Only 2 case reports,• Inhalational induction,• Trachea opened pt breath in his own + TIVA

* VyasAB, Lyons SM, Dundee JW. Continuous intravenous anaesthesia with Althesin for resection of tracheal stenosis .Anaesthesia 1983; 38: 132-5.

* Joynt GM, Chui PT, Mainland P, Abdullah V. Total intravenous anesthesia and endotracheal oxygen insufflations for repair of tracheoesophageal fistula in an adult. Anesth Analg 1996; 82: 661-3.

CPB

Special Considerations

• A guardian stitch is placed bet the chin and ant chest to achieve head flexion (35°).

• left for 7-10 days, serves as a reminder to the pt not to extend the neck to avoid traction on the anastomosis.

• It is surprisingly well tolerated by patients.

Courtesy of Prof. Ahmed Al-Noory

Early extubation is highly desirable as post operative ventilation carries the risk of an endotracheal tube cuff lying on a fresh anastomosis and positive airway pressure that can lead to wound necrosis or dehiscence.

Anesthesiologists ..

Thank you

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