Thoracic

Anaesthesia for tracheal and Aetiology of adult laryngotracheal stenosis

airway surgery Post-tracheal intubation Cuff-related circumferential stricture

Granuloma, arytenoid injury
Alistair Macfie Post tracheostomy Stomal stenosis
Trauma Penetrating or blunt external trauma
Irradiation and burns
Benign neoplasm Respiratory papillomatosis
Carcinoid tumour
Malignant neoplasm Primary: adenoid cystic and
squamous carcinoma
Abstract Secondary: thyroid carcinoma
Major surgery on the trachea and airway is an anaesthetic challenge Metastatic
which necessitates the simultaneous control of the airway, maintenance Chronic inflammatory Amyloidosis
of gas exchange and good surgical exposure. Advance planning, good disease Sarcoidosis
communication and teamwork among surgeon, anaesthetist and theatre Relapsing polychondritis
nurses are never more important. This is one of the few areas of surgery Collagen vascular diseases Wegeners granulomatosis
where the management of the airway is shared at times between the Bilateral vocal cord Bilateral recurrent laryngeal nerve
anaesthetist and surgeon. A major indication for laryngeal and tracheal dysfunction injury
surgery is laryngotracheal stenosis, a rare condition which can cause Infection Tuberculosis, diphtheria
significant morbidity and life-threatening airway obstruction. In the era Idiopathic Idiopathic progressive subglottic
of modern medicine, post-intubation injury has superseded infection and stenosis
external trauma as the commonest aetiology. The incidence of post-in-
tubation stenosis has been estimated at 4.9 cases per million per year. Table 1
Definitive surgery is usually carried out in tertiary specialist centres;
the surgical technique depends on the site and pathological process.
Segmental resection of the trachea with primary end-to-end anastomotic c ontribute to the development of stenoses. Suprastomal stricture
reconstruction has demonstrated a high level of successful decannula- is a recognized late complication of both open surgical and per-
tion and is usually the technique of choice for tracheal stenosis. cutaneous tracheostomy. A summary of the features of presenta-
tion of tracheal stenosis are listed in Table 2.
Keywords airway; anaesthesia; stenosis; surgery; trachea
Investigation
A previous history of tracheal intubation or tracheostomy should
alert the clinician to the possibility of tracheal stenosis, which is
Tracheal anatomy
often not evident on plain posteroanterior and lateral radiographs.
This is described elsewhere (see pages 54244, in this issue). Computed tomography (CT) or magnetic resonance imaging
(MRI) scans demonstrate tracheal narrowing but may not accu-
rately determine the exact length and position. Three-dimensional
Traumatic laryngotracheal stenosis
reconstructions of the tracheobronchial anatomy are providing
The major causes of laryngotracheal stenosis are listed in Table1. surgeons with additional information to guide surgery.
Post-intubation benign stricture is the commonest indication for Spirometric flowvolume loops (see pages 52326, in this
tracheal resection and is typically a consequence of prolonged tra- issue) were historically important in the diagnosis of intratho-
cheal intubation or tracheostomy. When the cuff of the tracheal racic airway obstruction. They are now generally not instrumen-
tube exerts a tracheal wall pressure in excess of the capillary tal in making a definitive diagnosis but may be helpful to monitor
perfusion pressure of the tracheal mucosa then ischaemic injury the progression of airway obstruction after treatment.
will result. Severe or recurrent tissue injury results in ulceration, Endoscopy is critically important for evaluation of both the
chondritis, granulation tissue formation and, over time, con- larynx and trachea (Figure 1). The larynx may be assessed
centric fibrotic contraction and airway narrowing. Direct injury
from the tracheal tube wall may also result in granuloma for-
mation and arytenoid cartilage damage. Modern high-volume, Presentation of tracheal stenosis
low-pressure cuffs have lowered the risk of tracheal stricture,
and the total number of patients surviving prolonged intuba- Presents weeks to months after intubation
tion has increased. Traction on the tube and local infection also Slowly progressive dyspnoea
Cough and wheeze easily mistaken for asthma
Inspiratory stridor
Alistair Macfie, FRCA, is a Consultant in Cardiothoracic Anaesthesia and Recurrent pneumonias
Critical Care at the West of Scotland Regional Heart and Lung Centre,
West Dunbartonshire, UK. Table 2

ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12 534 2008 Published by Elsevier Ltd.
 Thoracic

lesions usually provides temporary relief only and restenosis

occurs. Results of endoscopic resection of granulomas and other
non-circumferential lesions are somewhat better.

Anaesthesia for tracheal and bronchial stenting

Airway stents are inserted to provide symptomatic relief for
obstructing non-resectable primary airway tumours. Stents may
also be of benefit in the management of central airway obstruc-
tion as a result of extrinsic compression from goitres, mediastinal
masses, thyroid tumours or lymphomas. Stenting may be used as
a bridge to curative or palliative treatment. Self-expandable air-
way stents can be deployed under fluoroscopic control through
an orotracheal tube. Rigid bronchoscopy provides better visual-
ization and more room within the airway, which allows deploy-
ment of all types of stents. General anaesthesia is often required
for stent insertion as control of airway reflexes and maintenance
of a patent airway are essential.

Laser therapy
Laser treatment of tracheal strictures has variable results and, as
Figure 1 Subglottic tracheal stenosis. with dilatation, the result is usually a temporary measure prior
to definitive treatment. A carbon dioxide laser can be used to
by indirect mirror examination and flexible nasolaryngeal palliate unresectable airway tumours that are causing central
endoscopy. obstruction. Care must be taken to avoid ignition of tracheal
Because severe tracheal stenosis may deteriorate into com- tubes within the airway in the oxygen-rich environment. Laryn-
plete obstruction during awake flexible bronchoscopy, tracheal geal lesions and subglottic lesions may require the use of laser-
stenosis should be defined by rigid bronchoscopy under general resistant tubes.
anaesthesia. Passage of a rigid bronchoscope can be life saving
in cases of central obstruction or extrinsic compression of the
Tracheal reconstruction
airway following induction of anaesthesia. Rigid bronchoscopy
also allows full assessment of the lesion, biopsy, if appropriate, Surgical techniques
and assessment of the health of the surrounding mucosa. Tracheal resection and primary anastomotic reconstruction
is the preferred surgical treatment of severe tracheal stenosis.
Anaesthesia for bronchoscopy The number of rings resected depends on the pathology and the
Either inhalational or intravenous anaesthesia can be used for length of the lesion. Modern surgical techniques have produced
induction of anaesthesia. Inhalational induction maintains spon- good results with resection of up to half the tracheal rings. The
taneous ventilation and avoids muscle relaxation until the air- surgical approach can be cervical, cervicomediastinal or postero-
way is secured. However, coughing and instrumentation can lateral thoracotomy. A cervical approach to the subglottic and
precipitate complete obstruction in patients with central airway upper trachea is performed through a collar incision. In addition,
obstruction. In practice, intravenous anaesthesia and muscle a partial or full sternotomy may be necessary for access to the
relaxation with suxamethonium (succinyl choline) are gener- intrathoracic portion of the trachea, whereas for good surgical
ally used to rapidly provide surgical anaesthesia to facilitate the exposure of the lower trachea a right thoracotomy is required.
passage of a rigid bronchoscope. Administration of short-acting Major complications of the surgery include restenosis, dehis-
intravenous agents such as propofol and remifentanil ensures a cence, innominate artery erosion and damage to the recurrent
rapid and complete recovery of consciousness. Atmospheric pol- laryngeal nerves. Excessive anastomotic tension and devascular-
lution from escape of volatile gases from the open airway dur- ization are generally responsible for restenosis and dehiscence
ing anaesthesia is also avoided. Ventilation is provided through and should be avoided. Surgical release procedures such as the
the bronchoscope with a Venturi-type injector. The rigid bron- release of the anterior and posterior tracheal tissues, pulmonary
choscope thereafter ensures a clear airway and ventilation with ligaments and the larynx can be performed to ease approxima-
oxygen-enriched air. tion of the tracheal margins. A guardian suture may be placed at
the end of surgery that passes from the skin over the mandible
Treatment of tracheal stenosis to the anterior chest. The suture remains in situ for up to a week
Severe respiratory difficulty may be treated initially with ster after reconstructive surgery and discourages neck extension,
oids, nebulized racemic adrenaline, and diuretics which tempo- thereby limiting tracheal anastomotic tension.
rarily improve mucosal oedema and airway obstruction while
antibiotics may be required to treat bronchopulmonary infection. Airway management
Often, benign tracheal stenosis will be dilated to relieve stridor The airway management should be planned in advance. A
and to allow assessment and optimization of the respiratory sta- variety of sizes of armoured tubes and microlaryngeal tubes
tus before definitive surgery occurs. Dilatation of circumferential (MLTs) may be required. The airway management of an upper

ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12 535 2008 Published by Elsevier Ltd.
 Thoracic

or middle tracheal resection is described in Figure 2. A lower

tracheal resection can present additional difficulties. These are The airway management of a lower tracheal resection
often approached through right thoracotomy and may require
endobronchial intubation and collapse of the right lung to facili-
tate surgical access. The presence of a double lumen tube would
make surgical repair of the trachea impossible. The two com-
monest techniques of airway management for lower tracheal
resection are described in Figure 3. These are endobronchial
intubation across the surgical field and the use of bilateral jet
ventilation catheters placed into the main bronchi, which allows
good surgical access during the critical phase of surgical repair
of the trachea. Cardiopulmonary bypass can be utilized to allow
full cessation of ventilation; however, the risks of anticoagula-
tion and the harmful effects of cardiopulmonary bypass on the
lungs are best avoided. The ventilation of both bronchi with two
separate ventilators has been described for carinal surgery. Fol-
low-up rigid bronchoscopy is required to assess tracheal suture a b
line healing and airway patency. It may also be indicated for
oncological surveillance. a Endobronchial intubation with an armoured tube across the surgical field.
b Jet ventilation through bilateral endobronchial catheters placed into the
main bronchi allows good surgical access during the critical phase of
Anaesthetic technique surgical repair of the trachea. This may be achieved with two long suction
A key objective of tracheal surgery is for the patient to be extu- catheters and jet ventilation, which may be either automated or manual
with a Venturi-type injector
bated awake, warm, well oxygenated and cardiovascularly stable
at the end of the surgery. Early extubation is preferable as the
presence of an endotracheal tube cuff at the tracheal anastomosis Figure 3
may compromise healing. The patient is initially positioned in
an extended neck position, which is usually changed at the time and may result in significant blood and heat loss. Attention to
of the anastomosis to a more neutral position that reduces the fluid balance and maintenance of normothermia with warmed
tension on the tracheal anastomosis. The operation may be pro- fluids and heated blankets is essential for successful extubation.
longed, particularly if laryngeal release procedures are required, The anaesthetic technique must ensure that the risk of residual
hypnosis, muscle relaxation and excessive opiate-related narcosis
is minimized. Adequate analgesia must, however, be provided.
The anaesthetic technique may at times be required to accommo-
The airway management of an upper or middle date an unprotected open airway, although these periods should
tracheal resection with end-to-end anastomosis be minimized. For these reasons the author considers total intra-
venous anaesthesia with propofol and remifentanil as the tech-
nique of choice. Epidural analgesia may be used for pain relief
after thoracotomy or sternotomy but is not essential.
At the end of surgery, the patient is awakened and, where
possible, the trachea is extubated. A guardian suture is often
used to restrict neck extension. The patient is monitored in a
critical care environment, which allows early detection of airway
difficulties. Intensive physiotherapy and early mobilization are
important ways of minimizing the risk of postoperative respira-
tory complications. Steroids are not routinely used as they may
impair healing of the tracheal anastomosis.

Anaesthesia for removal of an inhaled foreign body

a b c d
The inhalation of a foreign body generally occurs in small
a The trachea is intubated beyond the tumour or stricture, if possible with a children and vulnerable adults with either disabilities or drug-
smaller tube, and the tip is positioned with a fibrescope above the carina.
induced depression of conscious level. Presenting symptoms may
Some strictures can be dilated to facilitate distal intubation. b After surgical
incision of the trachea, the sterile armoured tube is inserted directly into be stridor, cough, recurrent pneumonias or respiratory difficulty.
the cut lower end of the trachea by the surgeon and secured or continu- Chest radiograph may reveal collapse consolidation distal to the
ously held in position. c After the posterior anastomosis is completed, the obstructed bronchus or emphysematous distension due to a ball-
endotracheal tube can be readvanced from above and is placed below the
suture line and above the carina. d Then the anastomosis is completed
valve effect of the obstructing foreign body. Rigid bronchoscopy
under general anaesthesia is undertaken for investigation and
removal of any foreign body. If the respiratory status allows, in
Figure 2 children, spontaneous ventilation should be maintained with the

ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12 536 2008 Published by Elsevier Ltd.
 Thoracic

Conclusion
A ventilating Storz paediatric bronchoscope with
Jackson Rees modification of the Ayres T piece Tracheal and airway surgery presents a unique anaesthetic chal-
lenge. This type of surgery will generally be performed in spe-
cialist centres; however, the principles of airway management
are universal. Rigid bronchoscopy is of crucial importance for
airway management and assessment. The commonest indication
for tracheal resection is now post-intubation and tracheostomy
stenosis.

Further reading
Conacher ID. Anaesthesia and tracheobronchial stenting for central
airway obstruction in adults. Br J Anaesth 2003; 90: 36774.
Grillo HC, Donahue DM, Mathisen DJ, et al. Postintubation tracheal
stenosis. Treatment and results. J Thorac Cardiovasc Surg 1995;
109: 48693.
Lorenz RR. Adult laryngotracheal stenosis: etiology and surgical
management. Curr Opin Otolaryngol Head Neck Surg 2003; 11:
There are two bungs. One is a simple occluder for the oblique channel, 46772.
which usually takes the injector cannula for jet ventilation as the scope is
multipurpose. The larger end bung is inserted after the bronchoscope is
Nouraei SAR, Ma E, Patel A, et al. Estimating the population incidence
inserted into the trachea and is a self-sealing bung which allows passage of of adult post-intubation laryngotracheal stenosis. Clin Otolaryngol
optical forceps for removal of foreign bodies and/or biopsy 2007; 32: 41112.

Figure 4

ventilating bronchoscope and Jackson Rees T piece to avoid dis-

lodging any foreign body distally (Figure 4). If necessary, con- Acknowledgements
trolled ventilation can be provided with this attachment also.
The alternative school of thought is that any foreign body that My thanks to Mr Ken MacKenzie MB ChB FRCS, Consultant
requires bronchoscopic removal is impacted and unlikely to be Otolaryngologist and Honorary Senior Lecturer, Glasgow Royal
displaced by controlled ventilation. In adults, Venturi-type jet Infirmary, for Figure 1, and to Michelle McNichol for help with
ventilation such as the Sanders injector is used. Postoperative Figures 2 and 3.
mucosal oedema and secretion clearance may be problematic.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12 537 2008 Published by Elsevier Ltd.