|LETTER TO EDITOR|
Anaesthesia for tracheal reconstruction – Neither a dilemma nor a catastrophe
Vaijayanti Nitin Gadre, Deoshree Bal Ramteke, Sushila Ramkishan Yadav, Esmat Gulamraza Mundrawala
Department of Anesthesiology, Grant Government Medical College, Mumbai, Maharashtra, India
|Date of Web Publication||11-Feb-2019|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gadre VN, Ramteke DB, Yadav SR, Mundrawala EG. Anaesthesia for tracheal reconstruction – Neither a dilemma nor a catastrophe. Indian J Anaesth 2019;63:152-3
|How to cite this URL:|
Gadre VN, Ramteke DB, Yadav SR, Mundrawala EG. Anaesthesia for tracheal reconstruction – Neither a dilemma nor a catastrophe. Indian J Anaesth [serial online] 2019 [cited 2019 Feb 12];63:152-3. Available from: http://www.ijaweb.org/text.asp?2019/63/2/152/251975
Narrowing of trachea due to prolonged intubation, thyroid mass or cervical malignancies is known. We report a case of tracheal stenosis for proposed tracheal reconstruction.
A 21-year-old 70-kg tracheostomised male had difficulty in breathing through his 4.5-mm tracheostomy tube. He had undergone craniotomy 4 years back, had received mechanical ventilation for 15 days and was discharged after a month with a 7.5 mm tracheostomy tube. Over a period of 4 years, the trachea could not be decannulated even after repeated laser dilatation. Computerised tomography of neck showed 1.4-cm long near-complete (7 mm diameter) obliteration of trachea at C7 to T1 level. The patient was posted for anterior tracheoplasty with tibial periosteal grafting. In the operating room, difficult airway cart including additional small-sized endotracheal tubes was kept ready. The patient was positioned supine, monitors were attached and intravenous access was secured. Nebulisation was done with 2% lignocaine 1 ml for 15 min and for premedication, intravenous ondansetron 4 mg, glycopyrrolate 0.2 mg, midazolam 1 mg, hydrocortisone 100 mg and fentanyl 60 μg were given slowly. Pre-oxygenation was done with closed circuit attached to the tracheostomy tube; anaesthesia was induced with propofol 2 mg/kg and a ratio of O2:N2O was maintained at 50:50 and 2% sevoflurane was given on spontaneous-assisted ventilation. Flexible fibre-optic nasopharyngolaryngoscope was introduced through left nostril by the surgeon to study the vocal cord dynamics and rule out inter-arytenoid and subglottic fibrosis. Overhanging epiglottis was also ruled out before deciding definitive tracheal correction. For examining the sub-glottis up to carina, vecuronium 3 mg IV was given. This step helped surgeons to count total intact tracheal rings above the stoma to plan the extent of tracheal resection or trachaeoplasty with stenting. Only 10 rings were present (normal 16–18); hence, 6-cm long and 1.8-mm internal diameter stent (Montgomery T tube) was inserted to ensure optimal tracheal length. To allow surgery as well as uninterrupted ventilation at this step, laryngeal mask airway (LMA classic size 4) was inserted, cuff was inflated, ventilation was confirmed and continued via the first anaesthesia workstation. The tracheostomy tube was removed [Figure 1] and the open stoma was secured with a sterile cuffed flexo-metallic endotracheal tube (size 5). The machine end of this tube was blocked by anaesthesiologist's gloved finger to prevent leakage of ventilated gases. As and when required, this endotracheal tube was connected to a second anaesthesia workstation. Ventilation continued alternatively through distal endotracheal tube or LMA, in coordination with proximal and distal end suturing, respectively, of the stent inside the trachea.
|Figure 1: Figure showing open stoma and LMA inserted|
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A horizontal incision was taken below the level of stoma, a subplatysmal flap was elevated, the strap muscles were separated and the trachea with stoma was exposed. The perpendicular end of the T-tube was cut and the longitudinal portion inserted from the lower end of the cricoid cartilage superiorly up to the first tracheal ring inferiorly. The anterior wall of the resected trachea was reconstructed with a 5-cm × 2-cm tibial periosteum graft, haemostasis was achieved and wound was closed in layers after confirming no air leak. Ventilation was controlled through the LMA throughout until closure. After return of spontaneous ventilation, reversal was done with neostigmine 0.05 mg/kg and glycopyrrolate 0.008 mg/kg. Patient was extubated and shifted to critical care for monitoring.
Anaesthesia for surgical procedures on the trachea and major airways is essentially perilous because an already compromised airway needs to be shared with the surgeon. The unique challenge is the ability to maintain adequate oxygenation and uninterrupted ventilation. A discrete plan for ventilation at each surgical step is needed. Considering the extent of tracheal pathology, preparations for alternative modes of ventilation are employed in coordination with the surgeon. In the face of an open airway, ventilation can be managed by manual oxygen through a small bore anode tube placed through the upper tracheal lesion combined with a distal endotracheal or bronchial tube inserted distal to the stenosis. Earlier belief was that maximum length of the trachea that can be resected is 2 cm. Lesions requiring resection of more than 6 cm or more than 50% of total length of trachea in adults or more than 30% trachea in children are considered inoperable. Longer segment involvement after previous surgery needs patch augmentation or slide trachaeoplasty. Tissue engineering advances have successfully used cadaveric allografts and autologous tissue.
In the present case, T-tube was appropriate to palliate the obstruction. It allowed respiration through nasopharynx, preserved humidification and speech. It has no tissue irritation and hence proved useful.
Patient was advised postoperatively to retain follow-up until complete reepithelialisation and undergo stent removal.
Meticulous preoperative planning, precise airway control and perfect coordination to oxygenate the patient with each distinct surgical step were the essence of our successful management of anaesthesia during transected airway surgery.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.