Airway management and anesthesia for intrathoracic tracheal stenosis resection and reconstruction with midline sternotomy (2024)

Dear editor,

A 33-year-old male patient had severe COVID-19 pneumonia and had prolonged mechanical ventilation, discharged 21 days ago. Patient presented with breathing difficulty and stridor. Computed tomography (CT) neck was performed showed focal narrowing of the trachea at the T2-T3 level; stenotic segment 20 millimeters (mm) in length and lumen 6 × 6 mm at the narrowest part. Patient underwent tracheal resection and reconstruction (TRR). We report airway and anesthetic management of the case.

Patient is thin built, poorly nourished (cachexia), 54 kilograms, alert, Heart Rate (HR) -82/min, blood pressure (BP) 110/55 mmHg, saturation (SpO₂) 88% room air, 97% with 5 liters/min oxygen (O₂), respiratory rate (RR) 28/min with biphasic stridor. Bilateral crepitations are present on auscultation of chest. CT chest showed ground glass opacities in bilateral lower zone. Other blood investigations were normal.

High-risk consent was obtained. Kept nil oral for 8 hours; pantoprazole (40 mg) and ondansetron (4 mg) intravenously (IV) were given. Patient premeditated with glycopyrrolate (0.2 mg), midazolam (1 mg), analgesia with fentanyl (100 mcg) IV. Patient was induced with propofol (70 mg) IV, confirmed the possibility of manual ventilation, and atracurium (30 mg) was given. Patient was intubated with an endotracheal tube (ETT-7.5 mm), able to push the tube to 18 cm (resistance encountered beyond), and bilateral air entry was equal with adequate ventilation. Patient was maintained with oxygen (O₂) 50%, nitrous oxide (N₂O) 50%, isoflurane (ISO) 1%(O₂:N₂O: ISO), and with atracurium 5 mg and fentanyl 50 mcg IV boluses. Neck exploration was performed, but could not reach stenosis via neck approach, so sternotomy was performed. Patient was ventilated at 100%O₂ for 5 minutes, and then the trachea was opened just below the stenosis. Sterile flex metallic ETT-7 mm was inserted (distal tracheal intubation), and adequate ventilation was achieved as the tip of the ETT was seated just above Carena and switched to O₂:N₂O: ISO. Stenotic part resection was performed, and end-to-end anastomosis was performed except ETT holding the anterior part. Patient was ventilated with 100%O₂ for 5 minutes, and then tracheal ETT removed and patient was reintubated orally with 6.5 mm flex metallic ETT, was able to push beyond the resection part without any resistance, and switched to O₂:N₂O:ISO. Anterior part anastomosis was completed over ETT. Sternotomy and neck closed. Patient had uneventful extubation on the table. Patient was hemodynamically stable throughout. The total duration was 4 hours, total intravenous fluids were 3000 ml, urine output was 1200 ml, and blood loss was 800 ml. Patient was shifted to the intensive care unit for monitoring and analgesia. Patient was conscious, HR 92/min, BP-136/64 mmHg, SpO₂ 97% with oxygen, RR 30/min. Analgesia was continued with fentanyl infusion.

The complex nature of airway management in tracheal resection depends on the site of the tracheal pathology. The complexity increases when the stenosis is lower.[1] Our case tracheal stenosis was in middle of the trachea; the oral inserted ETT tip was sitting just above the stenosis and able to achieve good ventilation. Distal tracheal intubation provides good control of the airway and clear surgical and adequate oxygenation.[2] In our case, we had enough tracheal length below stenosis for distal tracheal ETT and achieved good ventilation without becoming endobronchial. Spontaneous ventilation is key during the open-airway phase of reconstruction.[1] Contrary to this, we had controlled ventilation while doing the open-airway phase before exchanging the tube oral to distal tracheal and vice versa, ventilated with 100% O₂ for 5 mins; exchanging was quick, and the patient was never desaturated.

Successful ventilation and patient management depend on (1) Tracheal diameter at the site of stenosis; if sufficient enough for smaller size ETT, which can ventilate the patient adequately, can do reconstruction with oral ETT. (2) Site of stenosis: With sufficient tracheal length above and below stenosis can be managed with oral intubation and distal tracheal intubation like in our case. Narrow and upper tracheal, where stenosis cannot safely be intubated via conventional technique, i-gel^® was used.[3] 3) Extent of tracheal stenosis: Earlier belief was that the maximum length of the trachea that can be resected is 2 cm.[4] Lesions requiring resection of more than 6 cm or more than 50% of a total length of trachea in adults or more than 30% of the trachea in children are considered inoperable.[5] When the patient cannot be ventilated adequately due to the complexity of stenosis, they may need cardiopulmonary bypass[6] or extracorporeal oxygenation[7] for TRR.

Declaration of patient consent

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

Conflicts of interest

There are no conflicts of interest.

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