anesthesia for tracheal resection

1. D R . D A V I S K U R I A N
TRACHEAL RESECTION

2. TRACHEAL LESIONS - ETIOLOGY
 MC – post intubation injury (traumatic intubation –
cricoid cartilage injury, subglottic injury, TE fistula).
 Risk factors include –
 Prolonged hypotension
 Concurrent infections
 Prolonged intubation
 Persistently elevated cuff pressures

3. TRACHEAL LESIONS - ETIOLOGY
 Second MC cause – tumours – squamous cell and
adenoid cystic carcinomas.
 Sq cell CA – discrete exophytic or ulcerating lesion.
 Adenoid cystic CA – slow growing – spreads either
locally (tracheal submucosa) or directly into the lung
parenchyma or pleura.
 Secondary tumours – thyroid (MC), esophagus, lung,
breast, thymus, head and neck malignancies &
lymphomas.

4. TRACHEAL LESIONS - ETIOLOGY
 Other causes include
 Blunt injury – MC involves laryngotracheal junction
 Congenital causes – tracheal agenesis, congenital stenosis,
congenital chondromalacia.
 Infections – typhoid, diphtheria, syphilis, TB.
 Immunological – SLE, Wegener’s granulomatosis, fibrosing
mediastinitis, amyloidosis.

5. PREOP EVALUATION
 Includes
 Detailed history
 Examination of the patient
 All routine blood investigations
 PFT – flow volume loops
 Radiological evaluation
 Diagnostic bronchoscopy

6. HISTORY AND PHYSICAL EXAMINATION
 History of recent endotracheal intubation or
tracheostomy.
 Presence of coexisiting comorbidities – especially lung,
CVS
 Signs and symptoms of airway obstruction – dyspnea
 Wheeze
 Stridor (4mm or less narrowing)
 Persistent cough
 Hoarseness (involvement of recurrent laryngeal nerve & vocal cords)
 Difficulty in clearing secretions
 Inabilility to tolerate supine position.

7. HISTORY AND PHYSICAL EXAMINATION
 Mandatory to prove adequate laryngeal airway prior to
tracheal resection and reconstruction.
 Tracheal deviation or extra-thoracic compression – by
palpation.
 Stridor at rest/expiratory effort – elicited.
 Auscultation of the upper airway.
 Range of neck movements (should tolerate hyper flexion
and hyperextension comfortably) & C Spine stability.
 Tracheostomy – should be examined for the patency of
the tube and tracheal stoma.

8. PULMONARY FUNCTION TESTING
 Ratio of Peak expiratory flow to FEV1 – index of
airway obstruction.
 Flow volume loops

9. RADIOLOGICAL ASSESSMENT

10. RADIOLOGICAL ASSESSMENT

11. RADIOLOGICAL ASSESSMENT
 Fluoroscopic studies to demonstrate vocal cord
movement, tracheomalacia.
 CT
 MRI
 Other investigations:
 Vocal cord mobility – by Laryngoscopy

12. ANAESTHETIC MANAGEMENT
 Primary goal - to maintain the adequate airway –
maintenance of ventilation and oxygenation and easy
clearance of blood and secretions.
 Intubation is mandatory.
 Airway management – challenging – reasons:
 Distal airways become obstructed with blood or secretions
 Rarely distal trachea may withdraw into the mediastinum.
 Postoperative period – patient’s hyper flexed position or
edema at the anastomotic site.

13. PREMEDICATION
 Patients with significant tracheal narrowing –
shouldn't receive premedication unless they are in
the hands of a person skilled in airway management.
 Over sedation and CNS depression should be
avoided.
 BZD – sedative and anxiolytic properties.
 Antisialagogues – atropine etc. can be disastrous in
patients with tracheal stenosis- tenacious secretions.

14. EQUIPMENT
 Anaesthesia machine with high flow oxygen
 Individualized masks and oral airways
 Mask straps
 Long bronchial sprayer with topical lidocaine
 Endotracheal tubes
 Sterile tubings and connect0rs
 Single leumen endobronchial tubes
 High frequency jet ventilator
 Jet catheters
 Ventilator capable of respiratory rate adjustments,
variable I:E ratio and pressure settings

15. MONITORING
 ECG
 NIBP
 Esophageal stethoscope – breath sounds and heart
sounds.
 Pulse oximetry
 etCO2
 Left radial arterial catheter – for ABG and ABP
 Central venous pressure – depending on the
patient’s cardiac history – best by antecubital
approach or femoral vein.

16. INDUCTION & BRONCHOSCOPIC
EXAMINATION
 Patient with extrinsic compression of trachea or
critical airway lesion – prefer to sit upright.
 If supine – deflated thyroid bag under the shoulder
to gain access.
 All pressure points must be padded.
 Minor degree of airway obstruction – induced with
propofol or thiopentone.
 Significant airway obstruction – volatile agents
preferred for induction.

17. INDUCTION & BRONCHOSCOPIC
EXAMINATION
 Muscle relaxants must be avoided before securing
the airway.
 After adequate anaesthesia – DL scopy – topical
anaesthesia to oropharynx and glottis – face mask
reapplied – volatile agent+O2 continued – deepen
the plane – DL scopy – topical anaesthesia below the
vocal cord – bronchoscopy.

18. INDUCTION & BRONCHOSCOPIC
EXAMINATION
 Rigid bronchoscopy –
 To visualize the nature and extent of lesion
 Potential difficulty in ET tube placement
 Opportunity for tracheal dilation to provide airway of adequate
size – serial dilation with rigid pediatric bronchoscopes.
 Tumor handling and dilation must be done with care
–
 Dislodgement can cause further airway obstruction
 Bleeding can further compromise the airway.

19. INDUCTION & BRONCHOSCOPIC
EXAMINATION
 At the end of bronchoscopy – intubated with
appropriate sized ET tube – generally in a sniffing
position using DL scopy.
 Tube position confirmed by chest movements,
auscultation, etCO2 monitoring, FOB.
 Tube secured, eyes protected, esophageal
stethoscope positioned.
 Orogastric tube – to empty the stomach of gas and
fluid – orogastric tube is removed.

20. POSITIONING
 Extra-thoracic and cervical tracheal lesions –
anterior collar incision.
 Positioned supine with inflated thyroid bag under
the shoulder and head supported with head ring.
 Back of the operating room table elevated to 10-15
degree to position the cervical and sternal areas
parallel to the floor when the head is extended fully.
 Arms tucked/left arm extended on arm board at 45
degree angle to the trunk.

21. POSITIONING
 Lesions of distal trachea – explored through – right
posterolateral thoracotomy in the fourth interspace
or the bed of 4th rib.
 Patient in left lateral decubitus position.
 Right arm – drapped and prepped into the surgical
field – for the surgeon to manipulate the arm to gain
access to the neck.

22. CERVICAL TRACHEAL
RECONSTRUCTION
 Low cervical collar incision.
 Anterior dissection of trachea – careful dissection around
innominate artery and structures around the trachea.
 Anaesthesia maintained by oral ET tube – prior to
tracheal division N2O eliminated from the gas mixture –
maintained by O2+inhalational agent – surgical tape
around the trachea below the lesion – ET tube cuff
deflated prior placement of lateral sutures – trachea
resected – distal part intubated across the field using
flexible, sterile, reinforced tube – connected to circuit.

23. CERVICAL TRACHEAL
RECONSTRUCTION
 After resection – two free ends of trachea are
anastomosed by traction sutures – patient’s neck
flexed from above – once all the sutures have been
put – reinforced tube is removed – the tube in the
proximal trachea is readvanced into the distal
trachea under supervision.
 Prior to the final airway exchange – airway is
suctioned of blood and secretions.
 Anastomotic site is checked for leaks with sustained
positive pressure breath 30 mm Hg.
 Patient’s head is flexed and supported.

24. TRACHEAL RECONSTRUCTION

25. CERVICAL TRACHEAL
RECONSTRUCTION
 At the end – patient must be breathing
spontaneously – awake extubation – head should be
supported in a hyperflexed position to avoid undue
traction at anastomotic site.
 Equipments for re-intubation must be kept ready
including a FOB.
 Upper airway edema – MCC of respiratory distress in
the immediate post operative period.
 Patient must be transported with supplemental
oxygen.

26. DISTAL TRACHEA AND CARINA
RECONSTRUCTION
 Preferred approach is right posterolateral
thoracotomy.
 General principles are the same for cervical tracheal
reconstruction.
 Thoracic epidural before induction of anaesthesia –
then patient in left lateral position.
 Positive pressure ventilation and ms relaxants of
intermediate duration of action – with appropriate
monitoring.
 Ms relaxants must be promptly reversed at the end
of the procedure.

27. DISTAL TRACHEA AND CARINA
RECONSTRUCTION
 Initial resection – performed with the tube proximal
to the airway lesion – once trachea divided – too
short to hold an ET tube – Left mainstem bronchus
intubated from the operative field and one lung
ventilation is employed.
 Second endobronchial tube introduced into right
mainstem bronchus and CPAP or HFPPV via jet
ventilator.
 SPO2 monitored with a pulse oximeter.
 HFPPV may also be used for left lung ventilation.

28. DISTAL TRACHEA AND CARINA
RECONSTRUCTION
 End of procedure – ET tube is withdrawn into
proximal trachea – ventilation proceeds through
area of anastomosis – position of tube confirmed by
FOB.
 Routinely right mainstem bronchus is anastomosed
to distal trachea.
 Left mainstem bronchus is re-implanted in an end to
side anastomosis to the bronchus intermedius or
distal trachea.
 Extubated similar to cervical approach and
transported.

29. DISTAL TRACHEA AND CARINA
RECONSTRUCTION
 Most widely employed method – O2+/-N2O with
volatile anasthetic.
 Inhalational agents – bronchodilators.
 Isoflurane and sevoflurane – pleasant induction, less
arrythmogenic and less hepatotoxicity compared
with halothane (less pungent than both iso and
sevo).

30. POSTOPERATIVE CARE
 ICU admission
 Chest XRay – to r/o pneumothorax
 O2 via high flow, humidified system via face mask –
adequate oxygenation as well as thinning of secretions.
 Head kept in a flexed position.
 Chest physiotherapy.
 Blind nasotracheal suction done with caution in patient
with inadequate cough reflex – take care not to cause
perforation at the anastomotic site, airway edema,
vomiting and aspiration.
 Flexible FOB guided pulmonary toilet to clear off
secretions.

31. POSTOPERATIVE CARE
 Equipments for reintubation must be kept ready.
 Laryngeal edema – another important complication
can present as stridor or hoarseness – management
includes placing the patient in a sitting position to
promote venous drainage, controlled fluid
administration and nebulisation with mixture of
adrenaline and saline, IV steroids.
 Pain contol – IV, epidural, intrapleural analgesia,
intercostal blocks or PCA.