|Year : 2008 | Volume
| Issue : 2 | Page : 211-21
Anaesthesia for Tracheo-Bronchial Stenting - A Report of Two Cases
Mariappan Ramamani1, Sahajanandan Raj1, Ponniah Manickam2
1 Lecturer, Department of Anesthesiology, Christian Medical College, Vellore, Tamil Nadu 632004, India
2 Professor, Department of Anesthesiology, Christian Medical College, Vellore, Tamil Nadu 632004, India
|Date of Acceptance||07-Mar-2010|
|Date of Web Publication||19-Mar-2010|
Lecturer, Department of Anesthesiology, Christian Medical College, Vellore, Tamil Nadu 632004
Source of Support: None, Conflict of Interest: None
Endoluminal dilatation and stenting is an alternative management strategy in patients with tracheal stenosis. Providing anaesthesia and maintaining oxygenation during tracheal stenting can be difficult. There are various anaesthetic techniques available for this procedure, based on the characteristics of stenosis and anaesthesiologist experience. A good knowledge about the procedure and communication with the radiologist are essential for the safe conduct of anaesthesia. In patients with near total obstruction and respiratory insufficiency, airway manipulation or coughing can result in complete loss of the airway. Herewith we report the anesthetic management of two cases with tracheal stenosis for stenting.
Keywords: Anaesthesia; Tracheal stenosis; Tracheal dilatation and Tracheal stenting
|How to cite this article:|
Ramamani M, Raj S, Manickam P. Anaesthesia for Tracheo-Bronchial Stenting - A Report of Two Cases. Indian J Anaesth 2008;52:211
| Introduction|| |
The symptoms of tracheal stenosis, regardless of the etiology, are always distressing and the consequences can be life threatening. Hence, these cases need to be treated urgently either surgically or by balloon dilatation and stenting. Providing anaesthesia and maintaining oxygenation for tracheal dilatation and stenting can be difficult and fraught with danger if the segment of stenosis is long and is in close proximity with the carina.
| Case 1|| |
An 18-yr-old lady presented with features of respiratory distress. A diagnosis of right sided consolidation with pneumothorax was made by clinical and radiological examinations [Figure 1]. She was managed with oxygen, intercostal chest drain and antibiotics. On the second day of hospitalization, She developed sudden onset altered sensorium and convulsions for which she was intubated with a 7.5 mm endotracheal tube (ETT) and shifted to ICU. The peak airway pressure was very high at 40 - 45 cm of H2O with low exhaled tidal volume. A size 16 F suction catheter could not be negotiated beyond the tip of endotracheal tube. Acid base analysis showed severe respiratory acidosis. So an emergency CT thorax was done, which revealed distal tracheal and right main bronchial stenosis (tracheal diameter was 2.4mm) at the level of D3-D4 (narrowed length 4.5cm) [Figure 1]. She was scheduled for tracheal dilatation.
| Anaesthetic management|| |
The procedure was carried out in the digital subtraction angiography (DSA) room. ECG, pulse oximetry (SpO2), non-invasive blood pressure (NIBP) and end tidal carbon dioxide (EtCO2) were monitored.Glycopyrrolate 0.2mg was given as premedication. Anaesthesia was induced with oxygen, air and sevoflurane and maintained on assisted spontaneous ventilation. After achieving the adequate depth, an infant feeding tube (8F) was introduced through the self-sealing swivel mount and the trachea was anaesthetized using 4% lidocaine. This was done using a 3 way connector, one end of which was connected to oxygen tubing derived from flow meter attached to the wall outlet (high pressure system), the other side was connected to infant feeding tube and 4% lidocaine was injected intermittently through the side port. [Figure 2]& [Figure 3]. Identification of stenosed segment of trachea was done by fluoroscopy. A guide wire was passed through the selfseal ing swivel mount, over which the balloon dilator was introduced and the stenosed segment was dilated. This was repeated to achieve a satisfactory dilatation. Soon after the dilatation the airway pressures came down from 50 to 23 cm of H2O. The reservoir bag compliance felt very much better on hand ventilation and the EtCO2 came down from 60 to 35 mm Hg. Though the post dilatation ABG and chest X- ray showed significant improvement, she could not be weaned from the ventilator. So stenting was done after the dilatation using the same anaesthetic technique. Post stenting, she was weaned and extubated.
| Case 2|| |
A 51-year-old man presented with history of stridor and dysphagia. A computerized axial tomogram showed features of carcinoma esophagus, with infiltration of trachea, causing narrowing at D2-D3 level [Figure 4]. He was subjected to a diagnostic fiberoptic bronchoscopy, which revealed a proliferative growth in the tracheal lumen. Following bronchoscopy, his stridor worsened, for which he needed emergency intubation. An 8.0 mm ID tube could not be negotiated and after the second attempt he was intubated with 7.5 mm ID endotracheal tube. He was put on pressure-controlled ventilation and planned for elective tracheal dilatation and stenting.
| Anaesthetic management|| |
Monitoring and induction of anaesthesia was carried out with a similar technique as case 1. With the patient breathing spontaneously under sevoflurane anaesthesia, fiberoptic bronchoscopy was done through the self-sealing swivel connector to confirm the extent of lesion. The endotracheal tube (ETT) was withdrawn under fiberoptic guidance, which revealed a moderate stenosis and a large tracheoesophageal fistula. The ETT was pushed back and the plan of tracheal dilatation was abandoned. The infiltration had sloughed out and became a tracheoesophageal fistula. The guide wire was passed distal to the stenosis through the ETT, over which the applicator sheath and the stent was passed. ETT was withdrawn again till the level of vocal cords and a 5 cm covered stent was deployed sealing the fistula. After the stenting, the endotracheal tube was pushed back to the initial position within the stent under fiberoptic guidance. Throughout the procedure patient was maintained on spontaneous ventilation with sevoflurane and intermittent bolus doses of propofol. Later, he was weaned from ventilator and extubated.
| Disscussion|| |
Tracheal stenosis can result from both benign and malignant conditions. Surgical reconstruction has been described as the preferred technique, especially in benign conditions. But, it has a high incidence of morbidity and mortality; also many of the advanced cases are not suitable for surgery. In these cases balloon dilatation and stenting has become an accepted method of palliation ,, .
For the safe conduct of anaesthesia in these patients, it is important to understand the procedure and good communication between the anaesthesiologist and the interventional radiologist is essential.
Patients generally become symptomatic (stridor, tachypnoea) when the tracheal diameter is reduced by 50% and severe respiratory distress and failure occur when the diameter is reduced by 75% . The other important factors in the anaesthetic management are the site and extent of stenosis. Stenosis of the middle and lower trachea are especially worrying, as transtracheal ventilation, tracheostomy, or other surgical airway would not relieve the obstruction  . In cases with near total obstruction and respiratory insufficiency, any airway manipulation or coughing can result in complete loss of the airway. Even, topicalisation of airway can stimulate a bout of cough, resulting in a loss of airway  . It is important not to topicalise the airway in the light planes of anaesthesia, when the reflexes can be exaggerated.
Various anaesthetic techniques have been described for tracheal dilatation and stenting ,,,, . Inhalational induction with preservation of spontaneous breathing, awake fiberoptic intubation after topicalisation of airway and rigid bronchoscopy with controlled jet ventilation under total intravenous anaesthesia have all been described. Each technique has its advantages and disadvantages however, all the methods have been practiced with satisfactory results ,,,.
Although our cases were primarily done under fluoroscopic guidance, the decision to do fiberoptic bronchoscopy for the second case was worthwhile. The endoluminal growth had sloughed out and became a tracheoesphageal fistula. So the balloon dilatation was abandoned and the stent position was adjusted to seal off the fistula.
The technique of anaesthesia should be based on the experience of the anaesthesiologist and characteristics of the tracheal stenosis. The goals of anaesthesia are avoidance of loss of airway control, and maintenance of oxygenation and ventilation with adequate monitoring.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]