Presentation on theme: "Anesthetic Management for Tracheo-Bronchial Reconstruction"— Presentation transcript:
1Anesthetic Management for Tracheo-Bronchial Reconstruction Ayman M. Kamaly
2Tracheal surgery was first performed in the 1950s. The maximum length to be resected was believed to be 2 cm.Progress in surgical and anesthesia techniquesnow permits more than half of the trachea to be safely excised.
3Tracheal Surgery is a Particularly Challenging Situation WhyTracheal Surgery is a ParticularlyChallenging Situationfor Anesthesiologist ?
4Prolonged 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.
5Tracheal 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.
6When the head is flexed, the trachea can become completely Conversely, head extension results in a longer portion of trachea becoming cervical.When the head is flexed, the trachea can become completelymediastinal.
7Etiology of Tracheal Pathology Tracheal stenosis is primarily a result of tracheal tumors (<3:1000,000), penetrating or blunt trauma, and “Post-intubation , & tracheostomy stenosis”Early 1950s (Poliomyelitis epidemic) → tracheostomy became common for treatment of respiratory failure → complications started to appear.
8Etiology 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.
9Etiology 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 ventilationHeavy circuitPt. survival (prolonged mucosal exposure to FB).Others: ( Steroid, DM, infection, ↓BP, NGT).
10Etiology of Tracheal Pathology Stenosis site varies according to whether trachea is intubated (orally/nasally) or tracheostomized.
11Clinical Presentation Non specific symptoms – delaying diagnosis for many years.Progressive exercise intolerance (>50%) √√√Hemoptysis, persistent cough,Exercise stridor rest (when diameter ≤ 5 mm)Recurrent pneumoniaCyanosis: 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. Semin Thorac Cardiovasc Surg 1996; 8:
13Diagnostic Studies The aim of diagnosis is to assess: Degree of stenosis,Length of tracheal damage,Distance from the vocal cords to the upper end of the lesion &the distance from the lower end of the lesion to the carina.
14CXR: Not useful. (only retrospective) CT: defining the exact location & gross extension of the obstruction.BronchoscopyRequired for all pt.sProvides a ventilation pathwaySuctioning is more efficientIn case of bleeding, tamponade is easy.Spont. breathing pt. identify malacic segment.
15III. 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:
16Fluoroscopy:(Dynamic) identifying malacic segments + information on laryngeal & glottic function.Bronchoscopy:Rigid is the gold standard
17PFT (Flow-Volume Loops): Identify whether the obstruction is: Fixed or VariableIntra or Extra thoracic
18Surgical Considerations Surgical techniques includeInsertion of a T-tube,Resection & 1ry anastomosis,Resection & reconstruction prosthetic material,Reconstruction with tissue engineered prosthetic cartilage.
19utilizing the patient’s own stem cells, has been successfully transplanted into a young woman with a failing airway. The procedure was performed in June 2008 at the Hospital Clinic, BarcelonaBy using an autologous vascularized matrix in form of a small intestinal segment harvested from the patient, reinforced with cryopreserved tracheal cartilage rings and reseeded with the patients own epithelial cells,
20Surgical ApproachesThe first 4.5 cm are accessible with cervical approach.A further 1.5 cm can be added by median sternotomy or antero-lateral thoracotomy.The lower half of the trachea can be managed through right postero-lateral thoracotomy.
21Monitoring & Equipment ETCO2 , SPO2 ,A-line (Lt. arm /compression of innominate A) !!Anesthesia machine with “High insp P⁰ alarm” + delivering up to 20 L/min O2 (preferable),Assorted sizes of ETTs (4-uncuffed 8-cuffed),Armoured ETTs,Long sterile circuit &/or corrugated tubings (for surgeon) !!.
22Premedication ??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).
23Induction of Anesthesia Readily available in O.R.: Surgeon + Rigid bronchoscopes (in case of obst)Inhalational: is the safestIV: may be used (airway judgment) BUTSpont breathing: should be maintainedMR: better avoidedAwake intubation: is an option
24Plan B… Plan C… Unable to advance ETT Tube exchanger Retrograde intubationLMAFogerty’s CathCPB (femoral line)
25Ventilation Single lumen endo-Tracheal tube, Single lumen endo-Broncheal tube (one or two),Low – frequency jet ventilation,High – frequency jet ventilation,CPB (heparin,…).
26TRACHEAL RECONSTRUCTION Identifying the Stenotic Segment
27Resection of High Tracheal Lesion Geffin B, bland J, Grillo HC, et al. Anesthetic management of tracheal resection and reconstruction. Anesth Analg, 1969; 48:884.
32Resection of low Tracheal Lesion One lung ventilationLigation of pulm AGeffin B, bland J, Grillo HC, et al. Anesthetic management of tracheal resection and reconstruction. Anesth Analg, 1969; 48:884.
33Resection of Carinal Lesions We may use 2 bronchial tubes ,+Y-piece connectorGeffin B, bland J, Grillo HC, et al. Anesthetic management of tracheal resection and reconstruction. Anesth Analg, 1969; 48:884.
34Low – frequency jet ventilation/ Low – frequency interrupted High flow Ventilation Narrow catheter through ETT passed to distal trach.,Attached to high p⁰ O2 Source (50 PSI),Intermittent O2 jets (10-20/m),Effectiveness: SPO2, ABG, chest expansion !!
35Low – 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.
36High– frequency ventilation Three Modes:HFPPV:Delivers Vt = anatomic dead spaceb/mNo air entrainmentHFJV:Delivers pulses of small jetsb/mAir entrainment occursHFOV:Vt = mlb/m
37Spontaneous 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:
39Special 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.
41Early 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.