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. Tracheal Surgery is a Particularly Challenging Situation
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. When 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 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 , & tracheostomy stenosis”
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 (prolonged mucosal 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  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. Semin Thorac Cardiovasc Surg 1996; 8:

13. Diagnostic 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.

14. CXR: Not useful. (only retrospective)
CT: defining the exact location & gross extension of the obstruction.
Bronchoscopy
Required for all pt.s
Provides a ventilation pathway
Suctioning is more efficient
In case of bleeding,  tamponade is easy.
Spont. breathing pt.  identify malacic segment.

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:

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. utilizing 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, Barcelona
By 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,

20. Surgical Approaches
The 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.

21. Monitoring & 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) !!.

22. 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).

23. 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

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

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

26. TRACHEAL RECONSTRUCTION
Identifying the Stenotic Segment

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

28. Courtesy of Prof. Ahmed Al-Noory

29. Courtesy of Prof. Ahmed Al-Noory

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

31. Courtesy of Prof. Ahmed Al-Noory

32. 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. Anesth Analg, 1969; 48:884.

33. 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. Anesth Analg, 1969; 48:884.

34. Low – 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 !!

35. 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.

36. High– frequency ventilation
Three Modes:
HFPPV:
Delivers Vt = anatomic dead space
b/m
No air entrainment
HFJV:
Delivers pulses of small jets
b/m
Air entrainment occurs
HFOV:
Vt = ml
b/m

37. 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:

38. CPB

39. 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.

40. Courtesy of Prof. Ahmed Al-Noory

41. 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.

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