Journal of Clinical Anesthesia (2014) 26, 697–698

Case Report

Tracheal resection with regional anesthesia Shital Vachhani MD ⁎, January Y. Tsai MD, Teresa Moon MD Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA Received 1 April 2013; revised 29 September 2014; accepted 2 October 2014

Abstract A 52-year-old man underwent tracheal resection during regional anesthesia with sedation. The patient had a prior history of tracheostomy resulting in tracheal stenosis and expiratory wheezing. Awake tracheal resection with spontaneous ventilation was performed. Patient cooperation was essential to identify the lesion and perform the resection safely. Published by Elsevier Inc.

1. Introduction Tracheal resections are a type of airway surgery requiring extensive intraoperative communication between the surgeon and the anesthesiologist. With recent surgical and anesthetic advances, more than half the trachea may be safely excised in selected cases [1]. The type of anesthesia selected is mainly dependent on the skill and comfort of the anesthesiologist and surgeon. In critical tracheal stenosis, there are reports of femoral-to-femoral cardiopulmonary bypass [2]. In this nonemergent operation, however, the decision was made to manage the patient using regional anesthesia with sedation. This type of anesthesia allowed easy identification of the lesion with spontaneous ventilation and the ability to test for nerve injury during the dissection and resection. A 52-year-old man had a previous history of acute respiratory distress syndrome requiring prolonged ventilator support with tracheostomy in 2009. Three years later, the patient presented with expiratory wheezing due to tracheomalacia at the previous tracheostomy site. Resection of the ⁎ Correspondence: Shital Vachhani, MD, Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe, Unit 409, Houston, TX 77030, USA. E-mail address: [email protected] (S. Vachhani). http://dx.doi.org/10.1016/j.jclinane.2014.10.001 0952-8180/Published by Elsevier Inc.

affected trachea segments was indicated for symptom reduction and ease of work of breathing.

2. Case report A 52-year-old man presented with expiratory wheezing and no other signs or symptoms. The patient's workup included bronchoscopy, revealing tracheomalacia at the site of a previous tracheostomy. There was a patent trachea with the lesion location correlating with the tracheal cuff and measuring 1 cm in length. The patient recovered from his original pulmonary insult with minimal respiratory repercussions until the onset of expiratory wheezing. Radiologic images including chest x-ray and computed tomography were obtained and reviewed yet did not reveal the stenosis. Pulmonary function tests were performed and reviewed. The findings were consistent with minimal airflow obstruction with no response to bronchodilator therapy. The FVC was 87% predicted; FEV1, 79%; and FEV1/FVC, 92% predicted. A decision was made to resect this lesion as a combined procedure with thoracic and otolaryngology (ENT) surgical teams. Because of the dynamic nature of the lesion (unable to easily visualize and pinpoint the exact location with static imaging), spontaneous ventilation was deemed necessary for the surgery.

698 After entering the operating room, standard monitors were placed. Oxygen was administered via nasal cannula. Midazolam 2 mg was administered for sedation. As there were no contraindications, an epidural was placed in the C7-T1 interspace with loss of resistance at 3 cm at midline. The epidural catheter was left at 5.5 cm. After negative aspiration, a test dose of 3 mL of lidocaine 2% with epinephrine 1:1,000,000 was administered with no evidence of intravascular or intrathecal injection. The patient was then prepped and draped in a sterile manner with a shoulder roll in place. Sedation was started with infusions of dexmedetomidine 0.7 mg/kg/min and remifentanil 0.5 mg/kg/h. The patient maintained verbal communication throughout most of the operation. Ropivacaine 0.5% 2 mL was titrated into the epidural catheter. Local anesthesia with ropivacaine 0.5% was supplemented into the surgical site. The patient remained comfortable throughout the procedure with the combination of the local anesthetics and intravenous sedation, with constant communication with the patient. The ENT surgeon then began his dissection starting with mobilization of the nerves away from the side of the trachea. The patient denied any pain. When the airway was reached, the patient verbalized his understanding that he would be unable to communicate for a brief period. The 1-cm lesion was easily identified with spontaneous ventilation via nasal fiberoptic bronchoscopy just distal to the cricoid cartilage, and a tracheotomy was performed. An additional 2-mL ropivacaine 0.5% was injected via the epidural catheter, and midazolam 2 mg intravenous was titrated for the end-to-end anastomosis, which required flexion of the patient's neck. Once the tracheal wound was closed, the patient was again able to phonate and demonstrate cranial nerve functionality. The patient remained comfortable with oxygen saturations N 94% throughout the procedure. The patient was transferred to the intensive care unit for close postoperative monitoring with no complications. Although blood aspiration remains a real risk with this procedure just as with an awake tracheostomy, the surgeons were careful in dissection to decrease this risk. The cough reflex was also intact, although decreased due to the sedation and local anesthetic infiltration.

S. Vachhani et al. The type of anesthesia selected is mainly dependent on the skill and comfort of the anesthesiologist and surgeon. There are case reports that describe different methods of oxygenation and ventilation during tracheal resections. At our institution, this was the first case of such a resection performed with an awake and spontaneously ventilating patient without necessitating cross-field oxygenation. Spontaneous ventilation was critical in our patient for precise identification of the tracheal lesion and to decrease the risk of injury to the recurrent laryngeal nerve. The lesion is considered dynamic due to changes in the stenosis during inspiration and expiration, similar to a patient with chronic obstructive pulmonary disease or morbid obesity. More routinely, alternative anesthetic techniques are used. In 1 scenario, an endotracheal tube is placed above the area of the tracheal lesion. After surgical exposure, a second tube is then placed distal to the stricture, and mechanical positivepressure ventilation is initiated with sterility across the field. Once the trachea is resected, the primary endotracheal tube can again be passed distal to the lesion and the anastomosis completed. A similar technique involves induction of anesthesia with a supraglottic airway, followed by surgical dissection with a distal endotracheal tube for mechanical ventilation, and then ultimately jet ventilation for the tracheal anastomosis [3]. Another case report describes critical tracheal stenosis in a patient who is placed on femoral extracorporeal bypass before induction. An endotracheal tube was placed after induction, and the patient was kept intubated with positive pressure ventilation while weaning from cardiopulmonary bypass at the conclusion of surgery [2]. Macchiarini et al [4] in Europe has done a case series on resections for tracheal stenosis. Our anesthetic technique was very similar to that outlined in his article, “Awake upper airway surgery” [4]. He reported 20 consecutive patients with tracheal stenosis. He concluded that awake tracheal resections are feasible and may be performed. It is important to maintain the integrity of the anastomosis of the trachea and protect the airway postoperatively. Our technique allows continuous communication with the patient, enabling assessment of cranial nerve integrity, respiratory function, and the specific lesion location.

3. Discussion Tracheal resections are a type of airway surgery. The surgeon and anesthesiologist must share the airway, and it is important to keep a patient comfortable while maintaining adequate oxygenation and ventilation during surgical dissection. Hence, extensive intraoperative communication between the surgeon and the anesthesiologist is required. In our example, extensive communication regarding a back-up plan was initiated at the beginning in case the patient did not tolerate an awake anesthetic, and the conclusion was a supraglottic device with spontaneous ventilation would be the best alternative.

References [1] Pinsonneault C, Fortier J, Donati F. Tracheal resection and reconstruction. Can J Anesth 1999;46(5):439-55. [2] Zhou Y, Zhu S, et al. Anesthetic management of emergent critical tracheal stenosis. J Zhejiang Univ Sci B 2007;8(7):522-5. [3] Adelsmayr E, Keller C, et al. The laryngeal mask and high-frequency jet ventilation for resection of high tracheal stenosis. Anesth Analg 1998; 86:907-8. [4] Macchiarini P, Rovira I, Ferrarello S. Awake upper airway surgery. Ann Thorac Surgery 2010;89:387-91.

Tracheal resection with regional anesthesia.

A 52-year-old man underwent tracheal resection during regional anesthesia with sedation. The patient had a prior history of tracheostomy resulting in ...
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