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Anesthetic Management for Tracheo-Bronchial Reconstruction

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

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Anesthetic Management for Tracheo-Bronchial Reconstruction

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  1. Anesthetic Management for Tracheo-Bronchial Reconstruction Ayman M. Kamaly

  2. 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.

  3. Why Tracheal Surgery is a Particularly Challenging Situation for Anesthesiologist ?

  4. 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.

  5. Tracheal Anatomy • 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.

  6. Conversely, head extension results in a longer portion of trachea becoming cervical. When the head is flexed, the trachea can become completely mediastinal.

  7. Etiology of Tracheal Pathology • Tracheal stenosis is primarily a result of tracheal tumors (<3:1000,000), penetrating or blunt trauma, and “Post-intubation , &tracheostomystenosis” • Early 1950s (Poliomyelitis epidemic) → tracheostomy became common for treatment of respiratory failure → complications started to appear.

  8. Etiology of Tracheal Pathology • 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.

  9. 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 (prolongedmucosal exposure to FB). • Others: ( Steroid, DM, infection, ↓BP, NGT).

  10. Etiology of Tracheal Pathology Stenosis site varies according to whether trachea is intubated (orally/nasally) or tracheostomized.

  11. Clinical Presentation • 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)

  12. "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. SeminThoracCardiovascSurg1996; 8: 370-80.

  13. Diagnostic Studies • The aim of diagnosis is to assess: • Degree of stenosis, • Length of tracheal damage, • Distance from the vocal cords to the upperend of the lesion & • the distance from the lowerend of the lesion to the carina.

  14. CXR:Not useful. (only retrospective) CT: defining the exact location & gross extension of the obstruction.

  15. 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.

  16. Fluoroscopy: (Dynamic) identifying malacic segments + information on laryngeal & glottic function. • Bronchoscopy: Rigid is the gold standard

  17. PFT (Flow-Volume Loops): • Identify whether the obstruction is: • Fixed or Variable • Intra or Extra thoracic

  18. Surgical Considerations • Surgical techniques include • Insertion of a T-tube, • Resection & 1ry anastomosis, • Resection & reconstruction prosthetic material, • Reconstruction with tissue engineered prosthetic cartilage.

  19. Surgical Approaches • The first 4.5 cm are accessible with cervical approach. • A further 1.5 cm can be added by median sternotomy orantero-lateral thoracotomy. • The lower half of the trachea can be managed through rightpostero-lateral thoracotomy.

  20. Monitoring & Equipment • ETCO2 , SPO2 , • A-line (Lt. arm /compression of innominate A) !! • Anesthesia machine with “High insp P⁰ alarm” + delivering up to 20L/min O2 (preferable), • Assorted sizes of ETTs (4-uncuffed 8-cuffed), • Armoured ETTs, • Long sterile circuit &/or corrugated tubings (forsurgeon) !!.

  21. Premedication ?? • 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).

  22. Induction of Anesthesia • 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

  23. Plan B… Plan C… Unable to advance ETT • Tube exchanger • Retrograde intubation • LMA • Fogerty’s Cath • CPB (femoral line)

  24. Ventilation • Single lumen endo-Tracheal tube, • Single lumen endo-Broncheal tube (one or two), • Low – frequency jet ventilation, • High – frequency jet ventilation, • CPB (heparin,…).

  25. TRACHEAL RECONSTRUCTION Identifying the Stenotic Segment

  26. Resection of High Tracheal Lesion Geffin B, bland J, Grillo HC, et al. Anesthetic management of tracheal resection and reconstruction. AnesthAnalg, 1969; 48:884.

  27. Courtesy of Prof. Ahmed Al-Noory

  28. Courtesy of Prof. Ahmed Al-Noory

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

  30. Courtesy of Prof. Ahmed Al-Noory

  31. Resection of low Tracheal Lesion • One lung ventilation • Ligation of pulm A Geffin B, bland J, Grillo HC, et al. Anesthetic management of tracheal resection and reconstruction. AnesthAnalg, 1969; 48:884.

  32. Resection of Carinal Lesions • We may use 2 bronchial tubes , • + • Y-piece connector Geffin B, bland J, Grillo HC, et al. Anesthetic management of tracheal resection and reconstruction. AnesthAnalg, 1969; 48:884.

  33. Low – frequency jet ventilation/ Low – frequency interrupted High flow Ventilation • Narrow catheter through ETT passed to distal trach., • Attached tohigh p⁰ O2 Source (50 PSI), • Intermittent O2 jets (10-20/m), • Effectiveness: SPO2, ABG, chest expansion !!

  34. 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.

  35. High– frequency ventilation Three Modes: • HFPPV: • Delivers Vt = anatomic dead space • 60-100 b/m • No air entrainment • HFJV: • Delivers pulses of small jets • 100-400 b/m • Air entrainment occurs • HFOV: • Vt = 50-80 ml • 400-2400 b/m

  36. 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. AnesthAnalg 1996; 82: 661-3.

  37. CPB

  38. 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.

  39. Courtesy of Prof. Ahmed Al-Noory

  40. 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.

  41. Anesthesiologists .. You Sleep .. We Care Thank you

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