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Tracheal resection for critical tracheal occlusion due to intraluminal tumour.

SUMMARY

Anaesthesia for tracheal resection requires careful planning by an experienced team. We report a case of urgent tracheal resection for a vascular tumor in a 41-year-old man who was a heavy smoker. The tumour occupied most of his trachea. A CT reconstruction of the tumor assisted in planning. Perioperative tracheal laser therapy and cardiopulmonary bypass were not used due to concerns about excessive bleeding. Intracperative airway management involved an upper endotracheal tube placed by the anaesthetist and a second, lower, endotracheal tube placed by the surgeon. The existing evidence for anaesthesia management of tracheal resection is currently limited to case reports. This case illustrates how preoperative imaging and careful planning can lead to a successful outcome, despite the potentially life-threatening nature of the pathology and the surgery.

Key Words: tumour, tracheal, surgical resection, anaesthesia

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We present a case of a benign intratracheal tumour treated with tracheal resection, a rare indication for a rare operation (1,2). This case highlights the value of preoperative imaging, including newer reconstructive techniques, for both the surgical and anaesthesia plans. We also discuss alternative approaches to this problem including laser therapy to facilitate or even avoid surgery, and the use of cardiopulmonary bypass to maintain oxygenation. There are many airway management plans for tracheal resection, including the upper and lower endotracheal tube approach used here, however the experience is limited (1). No matter what surgical approach is used, the perioperative care presents many challenges for the anaesthetist (2).

CASE HISTORY

A 41-year-old man with two episodes of haemoptysis was referred to the Respiratory Medicine Unit at Sir Run Run Shaw Hospital, Hangzhou, China. The patient had been a heavy smoker for 20 years but was otherwise in good health. Systematic questioning did not elicit other symptoms. Examination was unremarkable. The patient maintained adequate oxygen saturation on room air. Fibreoptic bronchoscopy showed an intraluminal tracheal mass that was occupying about 80% of the lumen (Figure 1). Because of the highly vascular appearance of the mass the respiratory physicians decided against taking a biopsy and arranged an urgent CT scan and referral to the cardiothoracic surgeons. The CT scan of neck and chest used a volume rendering technique (3) (Figure 2) that demonstrated a homogenous intraluminal mass, about 1.8 cm x 1.3 cm, attached to the left wall of the trachea. The peduncle was situated about six cm above the carina.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

The cardiothoracic surgeons decided to treat the lesion with urgent tracheal resection. They decided against laser therapy, or physical debulking, due to concern about excessive bleeding. Cardiopulmonary bypass was considered but was reserved as an emergency measure. Initial laryngoscopy was performed using propofol 2.5 mg/kg and suxamethonium 2 mg/kg. Mask ventilation was easy, and the larynx was easily visualized. Deeper anaesthesia was induced with isoflurane, rocuronium 0.8 mg/kg, and fentanyl 5 [micro]g/kg. After two minutes of mask ventilation, a 4.1 mm OD fibrescope (Olympus LF-GP; Olympus Optical, Tokyo, Japan) was passed orally to intubate the trachea. The tip of a size eight reinforced endotracheal tube was inserted to about 2 cm above the mass. Anaesthesia was maintained with isoflurane, propofol and rocuronium. Surgical access was by median sternotomy with the trachea exposed down to the carina. There was no extratracheal extension of the mass. The trachea was opened and, as expected, the soft mass had a pedicle to the left lateral wall of the thoracic trachea. The surgeons placed a sterile endotracheal tube below the lesion through their tracheal incision. The lower endotracheal tube was connected under the drapes to the anaesthesia circuit using a sterile connector. The tumour was removed with a ring of trachea. The surgeons subsequently removed the lower endotracheal tube while closing the trachea. Ventilation was continued via the upper, oral endotracheal tube.

At the end of the procedure the patient had a chin-to-chest skin suture placed to reduce the likelihood of the patient extending his neck in the early postoperative period. The patient was ventilated overnight in the Intensive Care Unit, with propofol and midazolam sedation, and was successfully extubated the next day. The patient had an uneventful recovery and was discharged from hospital one week later. The histology of the tumour was schwannoma.

DISCUSSION

Anaesthesia for tracheal resection has several divergent options but with limited evidence for the best approach (1). Further, benign intraluminal tumours, as in this case, are a relatively rare indication for tracheal resection, a rare operation, further limiting the available evidence (1). Because the surgery requires skilled airway management by both anaesthetists and surgeons, careful planning is required. This planning includes assessment of coexisting disease, particularly respiratory disease, appropriate imaging, a clear surgical plan and an agreed airway plan (1,4). Because this is rare and life-threatening surgery (1), only experienced anaesthesia and surgical staff should be involved (5). If necessary, the patient should be transferred to another hospital.

This case demonstrates the value of newer imaging techniques such as volume rendering techniques (VRT) of CT images (Figure 2) (3). Other approaches can give three-dimensional views that may further assist in airway assessment (6). The volume-rendered view from the CT scan gave valuable information about the site, size, shape and attachment of the tumor. The scans helped confirm the airway plan to intubate the trachea, under bronchosocpic view, and for the surgeons to place a second, lower endotracheal tube.

Two preoperative decisions concerned using laser therapy and cardiopulmonary bypass. In some centres, intracheal laser therapy has reduced the number of patients requiring tracheal resection (7,8). If tracheal resection is still planned, laser therapy can reduce tumour bulk which may allow safer resection due to greater airway patency (9). In this case, the vascularity of the tumor and the perceived risk of life-threatening haemorrhage led to a decision to avoid adjuvant laser or curative laser therapy (8). Cardiopulmonary bypass provides oxygen and carbon dioxide exchange via the bypass circuit and allows rapid transfusion, and good temperature control (10). Use of cardiopulmonary bypass may improve patient safety in some cases, by reducing the need for continuous ventilation, and improving surgical access (1,11,12). Further, if the airway were to become obstructed the patient will continue to be oxygenated. Again, in this case, it was decided to have cardiopulmonary bypass on standby rather than to use it as a primary strategy, because of the concern about bleeding associated with heparin anticoagulation (4,11,13).

Many different anaesthetic techniques have been used for tracheal resection ranging from spontaneous ventilation to jet ventilation (1,2,4,14). Awake fibreoptic intubation was considered but was not used due to concerns about bleeding from coughing. Similarly, there were concerns about coughing during a spontaneous ventilation technique. However, a spontaneous ventilation technique was the back-up plan if mask ventilation proved difficult during the initial trial under propofol and suxamethonium. The endotracheal tube management used in this case, with one tube above (placed by the anaesthetist) and one below the area for resection (placed by the surgeon), is one of the more frequently described approaches (1,2,4). Without cardiopulmonary bypass, airway management is more critical. Management of the two endotracheal tubes requires particularly good communication between the anaesthesia and surgical teams. At the end of surgery, some authors suggest that early extubation is preferable (1,4) to minimize stress on the tracheal anastomosis; however both early and later extubation have been used. In this case, it was decided to ventilate the patient in ICU overnight due to concern about bleeding secondary to coughing (in this heavy smoker) or haemodynamic instability.

As with other rare anaesthesia dilemmas, the literature on the management of tracheal resection consists largely of case reports (1). Further, most if not all of the case reports describe approaches that were successful for individuals or small groups of patients. There is very little published information about adverse events and mortality associated with each of the options for tracheal resection. The challenge for the anaesthetist is increased by the knowledge that, as in this report, both the preoperative tracheal pathology and the surgery pose a major risk for the patient.

Accepted for publication on August 7, 2006

REFERENCES

(1.) Sandberg W Anesthesia and airway management for tracheal resection and reconstruction. Int Anesthesiol Clin 2000; 38:55-75.

(2.) Pinsonneault C, Fortier J, Donati E Tracheal resection and reconstruction. Can J Anaesth 1999; 46:439-455.

(3.) Remmy-Jardin M, Remy J, Artaud D, Fribourg M, Duhamel A. Volume rendering of the tracheobronchial tree: clinical evaluation of bronchographic images. Radiology 1998; 208:761-770.

(4.) Wilson WC, Benumof JL. Anesthesia for thoracic surgery. In: Miller RD, ed. Miller's Anesthesia. Philadelphia, Elsevier 2005; 1847-1939.

(5.) Mason RA, Fielder CP. The obstructed airway in head and neck surgery. Anaesthesia 1999; 54:625-628.

(6.) Salvolini L, Bichi Secchi E, Costarelli L, De Nicola M. Clinical applications of 2D and 3D CT imaging of the airways. Eur J Radiol 2000; 34:9-25.

(7.) Prakash U. Bronchoscopic cure of surgically resectable tracheobronchial neoplasms. J Bronchol 2002; 9:85-86.

(8.) Cavaliere S, Foccoli P, Toninelli C. Curative brochoscopic laser therapy for surgically resectable tracheobronchial tumors. Bronchol J 2002; 9:90-95.

(9.) Unger M. Endobronchial therapy of neoplasms. Chest Surg Clin N Am 2003; 13:129-147.

(10.) Nyhan D, Johns RA. Anesthesia for cardiac surgery procedures. In: Miller RD, ed. Miller's Anesthesia. Philadelphia, Elsevier 2005; 1941-2004.

(11.) Chiu CL, Teh BT, Wang CY. Temporary cardiopulmonary bypass and isolated lung ventilation for tracheal stenosis and reconstruction. Br J Anaesth 2003; 91:742-744.

(12.) DeWitt RC, Hallman CH. Use of cardiopulmonary bypass for tracheal resection: a case report. Tex Heart Inst J 2004; 31:188-190.

(13.) Stannard K, Wells J, Cokis C. Tracheal rupture following endotracheal intubation. Anaesth Intensive Care 2003; 31:588-591.

(14.) McRae K. Anesthesia for airway surgery. Anesthesiol Clin North Am 2001; 19:497-541.

T. ZHONG *, Y. WANG ([dagger]), D. A. STORY ([double dagger])

Departments of Anesthesia and Cardiothoracic Surgery, Sir Run Run Shaw Hospital, Hangzhou, China

* M.D., Director, Department of Anaesthesia, Sir Run Run Shaw Hospital, Hangzhou, China.

([dagger]) M.D., Staff Surgeon, Department of Cardiothoracic Surgery, Sir Run Run Shaw Hospital, Hangzhou, China.

([double dagger]) B.Med.Sci., M.B., B.S., M.D., F.A.N.Z.C.A., Joint Director of Research, Department of Anaesthesia, Austin Health and Associate Professor, Department of Surgery, University of Melbourne, Heidelberg, Victoria.

Address for reprints: A/Prof David A. Story, Department of Anaesthesia, Austin Hospital, Studley Rd, Heidelberg, Vic. 3084.
COPYRIGHT 2006 Australian Society of Anaesthetists
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Author:Zhong, T.; Wang, Y.; Story, D.A.
Publication:Anaesthesia and Intensive Care
Date:Dec 1, 2006
Words:1746
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