Presentation on theme: "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."— Presentation transcript:
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 half of the trachea now permits more than half of the trachea to be safely excised.
Why Tracheal Surgery is a Particularly Challenging Situation for Anesthesiologist ?
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.
Adult tracheal length : cm. Approx 2 cartilaginous rings per cm (total of 18-22). Cshaped 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.
Conversely, head extension results in a longer portion of trachea becoming cervical. When the head is flexed, the trachea can become completely mediastinal.
Etiology of Tracheal Pathology tumorstrauma Post-intubation, &tracheostomystenosis Tracheal stenosis is primarily a result of tracheal tumors (<3:1000,000), penetrating or blunt trauma, and Post-intubation, & tracheostomy stenosis 1950s Early 1950s (Poliomyelitis epidemic) tracheostomy became common for treatment of respiratory failure complications started to appear.
cuffed ETT As pts began to survive longer periods, complications related to cuffed ETT starts to evolve Low-volume/High-pressure cuff250 mm Hg 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 High-volume/low-pressure cuffs were introduced in the early 1970s. The incidence of tracheal stricture dramatically reduced. 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 (prolonged mucosal exposure to FB). Others: ( Steroid, DM, infection, BP, NGT). Etiology of Tracheal Pathology
site Stenosis site varies according to whether trachea is intubated (orally/nasally) or tracheostomized. Etiology of Tracheal Pathology
Non specific symptoms – delaying diagnosis for many years. Progressive exercise intolerance (>50%) Hemoptysis, persistent cough, 5 mm Exercise stridor rest (when diameter 5 mm) Recurrent pneumonia Cyanosis: very Late (signaling almost complete occlusion) Clinical Presentation
"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. Post intubation tracheal stenosis 1996 Grillo HC, Donahue DM. Post intubation tracheal stenosis. Semin Thorac Cardiovasc Surg 1996; 8:
The aim of diagnosis is to assess: Degree Degree of stenosis, Length Length of tracheal damage, Distanceupper Distance from the vocal cords to the upper end of the lesion & lower the distance from the lower end of the lesion to the carina. Diagnostic Studies
I. CXR: I. CXR: Not useful. (only retrospective) II.CT: II.CT: defining the exact location & gross extension of the obstruction.
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:
IV.Fluoroscopy: + (Dynamic) identifying malacic segments + information on laryngeal & glottic function. V.Bronchoscopy: Rigid Rigid is the gold standard
VI.PFT (Flow-Volume Loops): Identify whether the obstruction is: Fixed or Variable Intra or Extra thoracic
Surgical Considerations Surgical techniques include T-tube Insertion of a T-tube, Resection & 1ry anastomosis, Resection & reconstruction prosthetic material, tissue engineered prosthetic cartilage Reconstruction with tissue engineered prosthetic cartilage.
first 4.5 cm cervical The first 4.5 cm are accessible with cervical approach. 1.5 cm median sternotomy or antero-lateral thoracotomy A further 1.5 cm can be added by median sternotomy or antero-lateral thoracotomy. lower half right postero-lateral thoracotomy. The lower half of the trachea can be managed through right postero-lateral thoracotomy. Surgical Approaches
ETCO 2, SPO 2, Lt A-line (Lt. arm /compression of innominate A) !! High insp P alarm + 20L/min O 2 Anesthesia machine with High insp P alarm + delivering up to 20 L/min O 2 (preferable), Assorted sizes of ETTs (4-uncuffed 8-cuffed), Armoured ETTs, sterilefor surgeon Long sterile circuit &/or corrugated tubings (for surgeon) !!. Monitoring & Equipment
Sedation ? Sedation ?: requires good judgment ( degree of obstruction ), Moderate Obst: anxiety quieter breathing airway resistance. (Х Х) Severely Obst: Resp dep should be avoided (Х Х) Antisialogues ?: Antisialogues ?: use with caution (drying secretion mucus plug). Premedication ??
Surgeon+Rigid bronchoscopes Readily available in O.R.: Surgeon + Rigid bronchoscopes (in case of obst) Inhalationalsafest Inhalational: is the safest IVBUT IV: may be used (airway judgment) BUT Spont breathing: maintained Spont breathing: should be maintained MR:better avoided MR: better avoided Awake intubation:option Awake intubation: is an option Induction of Anesthesia
Unable to advance ETT Tube exchanger Retrograde intubation LMA Fogertys Cath CPB (femoral line) Plan B… Plan C…
1. Tracheal 1. Single lumen endo-Tracheal tube, 2. Broncheal 2. Single lumen endo-Broncheal tube (one or two), Low – frequency jet ventilation, High – frequency jet ventilation, CPB (heparin,…). Ventilation
Identifying the Stenotic Segment TRACHEAL RECONSTRUCTION
Resection of High Tracheal Lesion Anesthetic management of tracheal resection and reconstruction Geffin B, bland J, Grillo HC, et al. Anesthetic management of tracheal resection and reconstruction. Anesth Analg, 1969; 48:884.
Courtesy of Prof. Ahmed Al-Noory
After placement of post suture line, the distal tube is removed from the trachea
Courtesy of Prof. Ahmed Al-Noory
One lung ventilation One lung ventilation Ligation of pulm A Ligation of pulm A Resection of low Tracheal Lesion Anesthetic management of tracheal resection and reconstruction Geffin B, bland J, Grillo HC, et al. Anesthetic management of tracheal resection and reconstruction. Anesth Analg, 1969; 48:884.
Resection of Carinal Lesions Anesthetic management of tracheal resection and reconstruction Geffin B, bland J, Grillo HC, et al. Anesthetic management of tracheal resection and reconstruction. Anesth Analg, 1969; 48:884. We may use 2 bronchial tubes, We may use 2 bronchial tubes, + + Y-piece connector Y-piece connector
Narrow catheter through ETT passed to distal trach., 50 PSI Attached to high p O 2 Source (50 PSI), 10-20/m Intermittent O 2 jets (10-20/m), Effectiveness: SPO 2, ABG, chest expansion !! Low – frequency jet ventilation/ Low – frequency interrupted High flow Ventilation
Disadvantages Disadvantages: » » Hypercarbia, » » Blood & debris entrained into distal trach. (venturi principle), » » Spraying of blood in the field, » » Movement of lungs & mediastinum.
Three Modes: I. HFPPV: » » Delivers V t = anatomic dead space » » b/m » » No air entrainment II. HFJV: » » Delivers pulses of small jets » » b/m » » Air entrainment occurs III. HFOV: » » V t = ml » » b/m High– frequency ventilation
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: * * Joynt GM, Chui PT, Mainland P, Abdullah V. Total intravenous anesthesia and endotracheal oxygen insufflations for repair of tracheoesophageal fistula in an adult. Anesth Analg 1996; 82:
Special Considerations chinant chest A guardian stitch is placed bet the chin and ant chest to achieve head flexion (35°). not to extend 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.
Courtesy of Prof. Ahmed Al-Noory
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 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.
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