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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 88-90

Anaesthetic management following tracheal reconstruction: Two heads are better than one as we navigate the airway challenge!


Department of Anesthesiology, PD Hinduja Hospital and Medical Research Centre, Mumbai, India

Date of Submission05-Jul-2020
Date of Acceptance26-Jul-2020
Date of Web Publication30-Aug-2020

Correspondence Address:
Dr. Joseph Nascimento Monteiro
D 61 Nirvana, Bhagoji Keer Marg, Mahim, Mumbai - 400 016, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ARWY.ARWY_24_20

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  Abstract 


Being prepared for airway management is of paramount importance in any anaesthetic. This involves knowledge, skill, comprehensive assessment and strategic planning. We present the case of a 17-year-old boy who developed tracheal stenosis following a low-level tracheostomy for prolonged ventilation after polytrauma 2 years prior. The stenosed trachea had been resected and anastomosed 9 months earlier. The patient now presented for brachial plexus repair for a flail dominant right hand. Comprehensive assessment with special focus on the airway, anticipation, interdisciplinary communication with the neurosurgeon and otorhinolaryngological surgeon and consensus planning help in an uneventful and successful surgery.

Keywords: Anticipated airway difficulty, consensus planning, interdisciplinary communication, tracheal anastomosis


How to cite this article:
Monteiro JN, Aishwarya AA. Anaesthetic management following tracheal reconstruction: Two heads are better than one as we navigate the airway challenge!. Airway 2020;3:88-90

How to cite this URL:
Monteiro JN, Aishwarya AA. Anaesthetic management following tracheal reconstruction: Two heads are better than one as we navigate the airway challenge!. Airway [serial online] 2020 [cited 2020 Sep 18];3:88-90. Available from: http://www.arwy.org/text.asp?2020/3/2/88/293963




  Introduction Top


Tracheal stenosis following prolonged ventilation in the intensive care unit requiring resection and reconstruction with anastomosis is a relatively rare procedure with an incidence of 2%–3%. Administration of general anaesthesia and airway management in such patients is a unique challenge due to the possibility of scarring and further compromise of a previously compromised airway.


  Case Report Top


We present the case of a 17-year-old boy with a history of road traffic accident 2 years prior, who underwent a craniotomy, right subclavian artery repair and an elective tracheostomy for prolonged ventilation in the perioperative period. He developed tracheal stenosis following tracheostomy for which he underwent tracheal resection and anastomosis. He presented to our hospital for right intercostal to musculocutaneous nerve repair. Preoperatively, the patient's laryngeal function and patency was jointly assessed by the anaesthesiologist as well as the otorhinolaryngological (ENT) surgeon. History revealed that the patient had a normal speech and no stridor or shortness of breath.

Preoperative awake flexible laryngoscopy performed by the ENT surgeon with a 2.9 mm fibreoptic scope introduced through the nares revealed sluggish movement of the right vocal cord with normal mobility of the left vocal cord. Glottic closure was good, and the subglottic area showed Grade 1 stenosis with almost 20% occlusion of the lumen (Cotton–Myer classification of subglottic stenosis). A small bulge anteriorly at the level of the cricoid was seen but not within the lumen. The tracheal anastomosis appeared good with a patent albeit narrow distal lumen up to the carina. The area beyond the subglottic area could not be assessed. It was decided to do a more thorough airway assessment following anaesthetic induction with a rigid endoscope. The risk of a potentially difficult airway, damage to the relatively recently repaired trachea and the need for postoperative ventilation versus benefit of surgery were explained to the parents. A plan to perform rigid bronchoscope-guided intubation with a smaller-sized endotracheal tube after assessing the size of the tracheal lumen was made. The ENT surgeon was available prior to anaesthetic induction and a consensus was arrived at regarding the airway management strategy.

Baseline electrocardiogram (lead II), noninvasive blood pressure and pulse oximetry were recorded, and an intravenous access was secured. The patient was adequately preoxygenated with 100% oxygen using a well-fitting face mask. The patient was induced with intravenous fentanyl 1.5 μg/kg and carefully titrated intravenous propofol following which C-MAC videolaryngoscopy was performed to orient to the anatomy and visualise the vocal cords. The C-MAC-guided rigid bronchoscopy was preferred to permit all the other assisting team members to visualise the larynx and orient them to the anatomy prior to insertion of the rigid endoscope and thus obtain both views while the procedure was performed on two separate screens. Soon after the visualisation of the glottic opening, 100 mg of intravenous succinylcholine was administered. The ENT surgeon introduced a 4 mm high-definition endoscope mounted on a camera for visualisation of the vocal cords, subglottic area, the anastomotic site and the tracheal lumen distal to the anastomosis [Figure 1]. On confirming the finding of Grade 1 subglottic stenosis (Cotton–Myer classification) with lumen blockage of almost 20%, it was decided to use a slightly smaller (5.5 mm ID) cuffed endotracheal tube [Figure 2]. This was done in order to avoid injury to the subglottic stenotic scar tissue and avoid airway oedema in the postoperative period. Anaesthesia was maintained on an air: oxygen mixture (FIO20.5), sevoflurane and a propofol infusion. Further neuromuscular blockade was avoided, and real-time neuromuscular monitoring was performed.
Figure 1: High-definition rigid endoscopic view of tracheal anastomosis

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Figure 2: High-definition endoscopic view of guided endotracheal tube beyond tracheal anastomosis

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At the end of surgery, careful extubation was performed, with the entire team standing by in case of airway compromise and obstruction. The patient was shifted to the high-dependency unit for overnight observation and discharged from the hospital following an uneventful recovery.


  Discussion Top


Tracheal resection and anastomosis can compromise the size of the tracheal lumen by scarring at the time of healing. Dyspnoea on exertion and inspiratory stridor, which are signs of severe reduction in tracheal lumen, were absent in our patient. Elective preoperative awake fibreoptic laryngoscopy by the ENT surgeon helped to assess the anatomy and function of the vocal cords. As the area beyond the subglottic region could not be assessed, the decision to perform a rigid bronchoscopic assessment intraoperatively and perform a bronchoscopic-guided intubation was taken. As tracheal injury and oedema at the time of intubation could lead to further narrowing of the airway, elective intubation was performed with a smaller-sized endotracheal tube. Though a supraglottic airway device (SAD) could have been used, it was not preferred in this potentially difficult airway scenario as the surgery was at the head end (with the risk of dislodgement of SAD and possibility of laryngospasm as neuromuscular blockade was avoided).

Advances and improvements in the treatment of critical illness have resulted in more patients requiring prolonged airway and ventilatory support.[1] Prolonged duration of intubation predisposes to tracheomalacia and stenosis, which can be managed by elective tracheostomy, as done in our patient. Post-tracheostomy stenosis is a rare but serious complication. Although the degree of tracheal stenosis may vary, it most commonly results from abnormal wound healing with excess granulation tissue formation around the tracheal stomal site. Excess granulation tissue can also develop over a fractured cartilage which can occur during tracheostomy.[2] In the past, tracheal stenosis was managed with dilatation alone and success was measured by the ability to wean patients from their tracheostomy tubes.[3] Until recently, surgical resection and end-to-end anastomosis was considered the only definitive treatment for tracheal stenosis.[4] Airway management in a patient following tracheal reanastomosis surgery in the past is a challenge to the anaesthesiologist because the preoperative assessment of the airway does not always correlate with the ease of ventilation.[5] Airway management strategies may vary even amongst experts.


  Conclusion Top


We conclude that a comprehensive preoperative evaluation including a focused airway assessment, meticulous planning and communication between the anaesthesia and surgical teams are the key to success. A multidisciplinary approach involving the ENT surgeon perioperatively leads to a successful surgical outcome.

Declaration of patient consent

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 his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chang E, Wu L, Masters J, Lu J, Zhou S, Zhao W, et al. Iatrogenic subglottic tracheal stenosis after tracheostomy and endotracheal intubation: A cohort observational study of more severity in keloid phenotype. Acta Anaesthesiol Scand 2019;63:905-12.  Back to cited text no. 1
    
2.
Nikolovski N, Kopacheva-Barsova G, Pejkovska A. Laryngotracheal stenosis: A retrospective analysis of their aetiology, diagnose and treatment. Open Access Maced J Med Sci 2019;7:1649-56.  Back to cited text no. 2
    
3.
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. 3
    
4.
Ansari A, Thomas A. Multimodality surgical approach in management of laryngotracheal stenosis. Case Rep Otolaryngol 2018;2018:1-3.  Back to cited text no. 4
    
5.
Yadav N, Ahmad SR, Kumar N, Mishra B. Airway management of a post tracheostomy stenosis patient with respiratory difficulty: Make sure you have fibre optic guidance before administering a muscle relaxant! Trauma Mon 2016;21:e20927.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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