Rapid Intravenous Induction of Anesthesia for Dilatation of Severe Post-Intubation Tracheal Stenosis with Rigid Bronchoscopy: Report of 100 Cases
DOI:
https://doi.org/10.14205/2310-9394.2013.01.02.1Keywords:
Tracheal stenosis, Anesthesia, Bronchoscopy, Dilatation.Abstract
Background: Rigid bronchoscopic dilatation is the lifesaving method for management of severe tracheal stenosis which is carried out under general anesthesia. However, this procedure is a challenging practice for both anesthesiologist and bronchoscopist because loss of airway control and sever hypoxemia can occur following induction of anesthesia. Inhalational induction with avoiding muscle relaxants and preservation of spontaneous breathing is commonly recommended in these patients. However, this technique needs a long time to reach the appropriate levels of anesthesia and may be associated with the risk of complete airway obstruction during airway manipulation. This paper describes our experience in using rapid intravenous induction of anesthesia for dilation of severe tracheal stenosis with rigid bronchoscopy.
Materials and Methods: We conducted a retrospective chart review of one hundred patients with benign severe post intubation tracheal stenosis who underwent rigid bronchoscopy for dilation of stenosis using intravenous sodium thiopental and succinylcholine for induction of general anesthesia.
Results: In 97 patients adequate airway was established immediately after induction of anesthesia with the first attempt of rigid bronchoscope. In one patient, because of local bleeding and mild hypoxemia the airway was managed by a 4 mm tracheal tube and following improvement of oxygenation, dilatation of stricture was successfully done with rigid bronchoscope. In second patient, after passing the first bronchoscope, due to risk of rupturing the trachea, a small transverse cervical incision was made on the trachea and a tracheal tube was inserted through it for patient's ventilation and dilatation of stricture was managed safely with the rigid bronchoscopes. In the third patient, due to failure of passing the bronchoscope, the trachea was intubated with a 4 mm endotracheal tube and tracheal resection and anastomosis was done successfully.
Conclusion: in patients with severe post intubation tracheal stenosis, rapid intravenous induction of anesthesia is a safe method for passage of rigid bronchoscope for dilatation of stricture. Careful planning and close cooperation of the anesthesia and surgical teams is critical for safe and successful conduction of this procedure.
References
Abbasi Dezfouli A, Shadmehr MB, Javaherzadeh M, Pejhan S, Daneshvar Kakhki A, Saghebi R, et al. Surgical treatment of post-intubation tracheal stenosis. Tanaffos. 2010; 9(4): 9- 21.
Abbasidezfouli A, Shadmehr MB, Arab M, Javaherzadeh M, Pejhan S, Daneshvar A, et al. Postintubation multisegmental tracheal stenosis: treatment and results. Ann Thorac Surg. 2007; 84 (2): 211-14. http://dx.doi.org/10.1016/j.athoracsur.2007.03.050
Pinsonneault C, Fortier J, Donati F. Tracheal resection and reconstruction. Can J Anesth 1999; 46(5): 439-55. http://dx.doi.org/10.1007/BF03012943
Practice guidelines for management of the difficult airway; an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98 (4): 1269-77.
English J, Norris A, Bedforth N. Anaesthesia for airway surgery. Continuing education in anaesthesia, critical care & pain 2006; 6(1): 28-31. http://dx.doi.org/10.1093/bjaceaccp/mki060
Isono S, Kitamura Y, Asai T, Cook TM. Case scenario: perioperative airway management of a patient with tracheal stenosis. Anesthesiology 2010; 112 (4): 970-78. http://dx.doi.org/10.1097/ALN.0b013e3181d4051a
Juvekar NM, Praveen K. Neema PK, Manikandan S, Rathod RC. Anesthetic management for tracheal dilation and stenting. Indian J Anaesth 2003; 47(4): 307-10.
Mentzelopoulos SD, Tzoufi MJ. Anesthesia for tracheal and endobronchial interventions. Curr Opin Anaesthesiol 2002; 15 (1): 85-94. http://dx.doi.org/10.1097/00001503-200202000-00013
Parsa T, Dabir Sh, Jabar Darjani HR, Radpay B. Anesthesia management in a pregnant woman with severe sub-glottic stenosis. Tanaffos 2008; 7(3): 76-80.
Watters MPR, McKenzie JM. Inhalational induction with sevoflurane in an adult with severe complex central airways obstruction. Anaesth Intensive Care 1997; 25(6): 704-06.
Gillbe C, Hillier J. Anaesthesia for bronchoscopy, tracheal and airway surgery. Anaesthesia and intensive care medicine 2005; 6(12): 422-25. http://dx.doi.org/10.1383/anes.2005.6.12.422
Goresky GV, Muir J. Inhalation induction of anaesthesia. Can J Anaesth 1996; 43(11): 1085-89. http://dx.doi.org/10.1007/BF03011832
Doi M, Ikeda K. Airway irritation produced by volatile anaesthetics during brief inhalation: comparison of halothane, enflurane, isoflurane and sevoflurane. Can J Anaesth 1993; 40(2): 122-26. http://dx.doi.org/10.1007/BF03011308
Punj J, Darlong V, Pandey R. Are we responsible for the dizzy operating surgeon? Saudi J Anaesth 2013: 7(3): 357- 58. http://dx.doi.org/10.4103/1658-354X.115345
Macfie A, Hawthorne C. Anaesthesia for surgery of the trachea and main bronchi. Anaesthesia and intensive care medicine 2011; 12(12): 558-62. http://dx.doi.org/10.1016/j.mpaic.2011.09.005
Yang-feng Z, Shao-jun Z, Sheng-mei Z, Xiao-xia A. Anesthetic management of emergent critical tracheal stenosis. J Zhejiang Univ Sci B 2007; 8(7): 522-25. http://dx.doi.org/10.1631/jzus.2007.B0522
Natalini G, Cavaliere S, Seramondi V, Foccoli P, Vitacca M, Ambrosino N, et al. Negative pressure ventilation vs external high-frequency oscillation during rigid bronchoscopy; a controlled randomized trial. Chest 2000; 118 (1): 18-23. http://dx.doi.org/10.1378/chest.118.1.18
Ahmed S, Janjua S. Tracheal stenosis surgery; airway management. Professional Med J 2010; 17(4): 638-42.
Li Y, Khambatta HJ, Stone JG, Met B. Unsuspected concentric tracheal rings in a 14-year- old with scoliosis. Br J Anaesth 2002; 88(1): 732-34. http://dx.doi.org/10.1093/bja/88.5.732
Warren S. Anesthesia and airway management for tracheal resection and reconstruction. Int Anesthesiol Clin 2000; 38(1): 55-75. http://dx.doi.org/10.1097/00004311-200001000-00005
Ellis RH, Hinds CJ, Gadd LT. Management of anaesthesia during tracheal resection. Anaesthesia 1976; 31 (8): 1076- 80. http://dx.doi.org/10.1111/j.1365-2044.1976.tb11947.x
Mentzelopoulos SD, Romana CN, Hatzimichalis AG, Tzoufi MJ, Karamichali EA. Anesthesia for tracheal resection: a new technique of airway management in a patient with severe stenosis of the midtrachea. Anesth Analg 1999; 89 (5): 1156- 60. http://dx.doi.org/10.1213/00000539-199911000-00013
Hakumoto Y, Takasugi Y, Kamamoto H, Shigemori S, Koga Y, Mori K. Tracheal intubation in a patient with undetectable tracheal narrowing on chest radiography. J Anesth 2010; 24 (1): 128-131. http://dx.doi.org/10.1007/s00540-009-0841-5
Conacher ID. Anaesthesia and tracheobronchial stenting for central airway obstruction in adults. Br J Anaesth 2003; 90 (3): 367-74. http://dx.doi.org/10.1093/bja/aeg053
Shetty N, Rao Sh, Vijayakumar V. Questioning succinylcholine usage in grade IV (difficult) mask ventilation. Anesthesiology 2011; 115 (2): 434-49. http://dx.doi.org/10.1097/ALN.0b013e31822552ad
Xue F, Liao X, Yuan Y, Wang Q, Liu J. A modified difficult airway management algorithm incorporating video devices in routine anesthesia practice. Anesthesiology 2011; 115(2): 442-44. http://dx.doi.org/10.1097/ALN.0b013e3182255112
Sugi Y, Kuribara Y, Nagano Y, Ushijima C, Higa K. Anesthetic management of tracheal stent insertion under total intravenous anesthesia--a report of two cases. Masui 2000; 49(11): 1239-41.
Ho AMH, Chung DC, To EWH, Karmakar MK. Total airway obstruction during local anesthesia in a non-sedated patient with a compromised airway. Can J Anesth 2004; 51(8): 838- 41. http://dx.doi.org/10.1007/BF03018461
