Anaesthesia, 1976, Volume 31, pages 1076-1080 CASE R E P O R T
Management of anaesthesia during tracheal resection
R I C H A R D H . ELLIS, C H A R L E S J . H I N D S L A W R E N C E T. G A D D
AND
One of the main problems during anaesthesia for tracheal resection is the provision of a clear airway during the period of tracheal division without impairing the good surgical access required for constructing the anastomosis. Recently Lee and English have described an ingenious method of ventilation using a bronchoscopic injector and a narrow catheter during an operation for the resection of a tracheal stenosis.’ This communication reports the use of a similar system and confirms the adequacy of the ventilation achieved.
Case history
The patient was a boy aged 13 years. He was a healthy boy weighing 23 kg who was buried alive when a large sand pit in which he was playing collapsed around him. On admission to hospital he had a considerable amount of sand in his upper airway and was in severe respiratory distress. He was intubated and ventilated for two days by which time his condition had improved sufficiently to allow extubation although he had to be intubated twice more before being discharged, apparently healthy, from hospital. Two months after the initial episode he was re-admitted to hospital having developed increasingly severe signs of tracheal obstruction. Tomograms revealed the presence of a 3 cm long stricture involving the cricoid cartilage and the upper trachea. He was transferred to the Cardiothoracic Unit at St Bartholomew’s Hospital for further management and, shortly after admission, required urgent tracheoscopic dilatation. Fivc days later elective surgery to resect the tracheal obstruction was carried out. Richard H. Ellis, MB, FFA, RCS, Consultant; Charles J. Hinds, MB, BS, Registrar; and Lawrence T. Gadd, MB, FFA, RCS, Senior Registrar, Department of Anaesthesia, St Bartholomew’s Hospital London E.C.I. The present address of Dr Gadd is: Department of Anaesthesia, Royal Childrens’ Hospital, Sydney, Australia. Correspondence to Dr Richard H. Ellis, Department of Anaesthesia, St Bartholomew’s Hospital, London ECl A 7BE.
1076
Anaesthesia during tracheal resection
1077
Anaesthetic technique The patient was premedicated with omnopon 10 mg and scopolamine 0.2 mg. Anaesthesia was induced with nitrous oxide, oxygen and halothane and the larynx carefully anaesthetised with 4% lignocaine. It was then possible to pass a 5.5 mm uncuffed endotracheal tube through the larynx and beyond the stricture: with the airway thus secured the halothane was discontinued, the patient paralysed with pancuronium and anaesthesia maintained with nitrous oxide and oxygen, supplemented by intravenous increments of pethidine and relaxants. An intravenous infusion was set up and a cannula inserted into a radial artery. The trachea was then mobilised and the extent of the stricture defined. Two minutes before the trachea was incised ketamine (1 mg/kg) was given intravenously. The trachea was opened immediately distal to the lower end of the stricture and a fine catheter passed down the lumen of the endotracheal tube until it appeared at the tracheal incision. The catheter was 20 cm long and was fashioned from a disposable polythene manometer line with an internal diameter of 1.52 mm and an external diameter of 2.54 mm.* The proximal end of the catheter was connected to the outlet of the manual control valve of a bronchoscopic injector’ and ventilation carried out with 100% oxygen delivered by the injector together with air entrained through the tracheal incision
Fig. 1. The operative field after resection of the tracheal stenosis. The injector tube appears immediately distal to the cricoidcartilage (A) and passes for 1.5 cm into the distal tracheal segment (B). There is virtually unrestricted surgical access. The Pco, was 34 mmHg and the Po, 380 mmHg when this photo was taken.
* Portex Ltd, Hythe, Kent CT21 6JL. Catalogue No. 200/490/060.
1078
R. H . Ellis, C.J . Hinds and L. T. Gadd
(Fig. 1). The injector control valve was depressed regularly for one second 12 times a minute and the patient's chest appeared to inflate satisfactorily. The endotracheal tube was withdrawn until its tip was above the upper margin of the stricture. Ventilation was maintained with the injector for just over one hour, during which time the tracheal stenosis was resected and the cut ends anastomosed. Satisfactory ventilation was difficult to achieve for part of this procedure because the catheter was displaced repeatedly from the distal tracheal segment. This problem was readily overcome by the surgeon stitcning the catheter in place with a retaining suture. Increments of ketamine (0.5-1 mg/kg) were given at 20 minute intervals to maintain anaesthesia during this period. Regular suction by the surgeon and his assistant was required to prevent the aspiration of blood into the trachea and lung. Apart from this the anaesthetic technique did not hamper the surgery and the operating conditions were excellent (Fig. I). The catheter was withdrawn when the anastomosis was completed and ventilation was continued through the endotracheal tube, the tip of which lay just above the cricoid cartilage; the patient once more received nitrous oxide and oxygen until the surgery was finished, when the anaesthetic was discontinued and the relaxant reversed with atropine and prostigmine. Recovery of consciousness occurred five minutes later and the child was extubated and breathed spontaneously without difficulty. At intervals throughout the procedure arterial blood was sampled for estimation of acid-base and blood-gas state. The samples were analysed immediately using an ABL 1 blood-gas analyser (Radiometer Ltd, Copenhagen), the calibration of which was checked using tonometered blood for oxygen tension (Poz),carbon dioxide tension (Pco2)and serum for pH. Discussion
Lee & English' administered thiopentone intermittently to ensure narcosis during the time when no inhalational anaesthetic was given. Ketamine has been recommended for use under similar condition^^.^ and we preferred it to thiopentone because of the ease and convenience of its administration at a time when the anaesthetist's main preoccupation is the provision of a clear airway. Ketamine has other properties which make it a suitable agent in these circumstances, namely its lack of harmful effects on the tracheo-bronchial tree,5 its beneficial actions on the cardiovascular system especially when used with pancuronium6 and its provision of a degree of protection from arrhythmias.' The patient had no recollection of the procedure and did not suffer any unpleasant sensation on recovery from anaesthesia. It is often misleading to assess the adequacy of ventilation from the chest movements and clinical signs of hypercarbia are inconstant,* but the blood-gas measurements (Fig. 2) show that adequate ventilation can be achieved using this technique. The higher levels of Pcoz during part of the period of injector ventilation were related to the difficulty in keeping the tip of the catheter within the distal tracheal segment. Once this had been secured with a retaining suture the Pco, readily fell to a more satisfactory level. In the interests of asepsis the technique described should be modified to allow the surgeon to pass the catheter up through the endotracheal tube to the anaesthetist. The outstanding advantage of this technique is the minimal intrusion of anaesthetic apparatus into the surgical field. Operating conditions are thus far superior to those
Anaesthesia during tracheal resection
1079
I
-FE
o
ventilation
Hours
Fig. 2. The variations in Po2and Pcol during the various stages of the operation (see text). (The high levels of Pco, during the middle third of the period of injector ventilation coincided with difficulty in keeping the catheter securely in the trachea.)
provided by the more usual methods of maintaining anaesthesia, in which the construction of the anastomosis is often hindered by an endotracheal tube which has been passed across the operative field, either through the larynx' or directly into the incision." The technique should be of especial benefit during the resection of low tracheal strictures which are near to or involving the carina. In these circumstances cardiopulmonary bypass has been used to maintain oxygenation" although the more usual management involves deliberate endobronchial intubation and light clamping of the pulmonary artery on the unventilated side to minimise arterial desaturation.12 The technique described above can easily be modified to provide ventilation to both lungs simply by using separate catheters for each bronchus. Summary Recently Lee & English have described an ingenious method of ventilation using a bronchoscopic injector and a narrow catheter during an operation for the resection of a tracheal stenosis. We report the use of a similar system and confirm the adequacy of ventilation achieved by serial blood-gas estimations. References 1. LEE,P. & ENGLISH, I.C.W. (1974) Management of anaesthesia during tracheal resection. Anaesthesia, 29, 305. 2. BETHUNE, D.W., COLLIS, J.M., BURBRIDGE, N.J. & FORSTER, D.M. (1972) Bronchoscope injectors. A design for use with pipeline oxygen supplies. Anaesthesia, 27, 81. 3. DUNDEE, J.W. & WYANT, G.M. (1974) Intracenous anaesthesia, 1st edn, p. 240. Churchill Livingstone, London. 4. HEIFETZ,M. (1974) Management of anaesthesia during tracheal resection. Anaesthesia, 29, 760. 5. CORSSEN,G., GUTIERREZ, J., REVES,J.G. & HUBER,F.C. (1972) Ketamine in the anesthetic management of asthmatic patients. Anaesthesia and Analgesia; Current Researches, 51, 588.
1080
R . H . Ellis, C. J . Hinds and L. T. Gadd
6. DUNDEE, J.W. (1971) Selective indications for ketamine anaesthesia discussion. Proceedings of the Royal Society of Medicine, 64, 11 59. 7. DOWDY,E.G. & KAYA,K. (1968) Studies of the mechanism of cardiovascular responses to CI-581. Anesthesiology, 29,931. 8. NUNN,J.F. (1969) Applied respiratory physiology with special reference to anaesthesia, 1st edn, p. 322. Butterworths, London. 9. MUSHIN, W.W. (1963) Thoracic anesthesia, 1st edn, p. 373. Blackwell Scientific Publications,
Oxford. 10. PAYNE, W.S., LEONARD, P.F., MILLER, R.D., ROSENOW, E.C. & DESANTO, L.W. (1973) Physio-
logically based assessment and management of tracheal strictures. Surgical Clinics of North America, 53, 875. I I . HARLEY, H.R.S. (1971) Laryngotracheal obstruction complicating tracheostomy or endotracheal intubation with assisted respiration : a critical review. Thorax, 26, 493. 12. GEFFIN, B., BLAND,J. & GRILLO, H.C. (1969) Anesthetic management of tracheal resection and reconstruction. Anesthesia and Analgesia; Ciirrent Researches, 48, 884.
Management of anaesthesia during tracheal resection
R I C H A R D H . ELLIS, C H A R L E S J . H I N D S L A W R E N C E T. G A D D
AND
One of the main problems during anaesthesia for tracheal resection is the provision of a clear airway during the period of tracheal division without impairing the good surgical access required for constructing the anastomosis. Recently Lee and English have described an ingenious method of ventilation using a bronchoscopic injector and a narrow catheter during an operation for the resection of a tracheal stenosis.’ This communication reports the use of a similar system and confirms the adequacy of the ventilation achieved.
Case history
The patient was a boy aged 13 years. He was a healthy boy weighing 23 kg who was buried alive when a large sand pit in which he was playing collapsed around him. On admission to hospital he had a considerable amount of sand in his upper airway and was in severe respiratory distress. He was intubated and ventilated for two days by which time his condition had improved sufficiently to allow extubation although he had to be intubated twice more before being discharged, apparently healthy, from hospital. Two months after the initial episode he was re-admitted to hospital having developed increasingly severe signs of tracheal obstruction. Tomograms revealed the presence of a 3 cm long stricture involving the cricoid cartilage and the upper trachea. He was transferred to the Cardiothoracic Unit at St Bartholomew’s Hospital for further management and, shortly after admission, required urgent tracheoscopic dilatation. Fivc days later elective surgery to resect the tracheal obstruction was carried out. Richard H. Ellis, MB, FFA, RCS, Consultant; Charles J. Hinds, MB, BS, Registrar; and Lawrence T. Gadd, MB, FFA, RCS, Senior Registrar, Department of Anaesthesia, St Bartholomew’s Hospital London E.C.I. The present address of Dr Gadd is: Department of Anaesthesia, Royal Childrens’ Hospital, Sydney, Australia. Correspondence to Dr Richard H. Ellis, Department of Anaesthesia, St Bartholomew’s Hospital, London ECl A 7BE.
1076
Anaesthesia during tracheal resection
1077
Anaesthetic technique The patient was premedicated with omnopon 10 mg and scopolamine 0.2 mg. Anaesthesia was induced with nitrous oxide, oxygen and halothane and the larynx carefully anaesthetised with 4% lignocaine. It was then possible to pass a 5.5 mm uncuffed endotracheal tube through the larynx and beyond the stricture: with the airway thus secured the halothane was discontinued, the patient paralysed with pancuronium and anaesthesia maintained with nitrous oxide and oxygen, supplemented by intravenous increments of pethidine and relaxants. An intravenous infusion was set up and a cannula inserted into a radial artery. The trachea was then mobilised and the extent of the stricture defined. Two minutes before the trachea was incised ketamine (1 mg/kg) was given intravenously. The trachea was opened immediately distal to the lower end of the stricture and a fine catheter passed down the lumen of the endotracheal tube until it appeared at the tracheal incision. The catheter was 20 cm long and was fashioned from a disposable polythene manometer line with an internal diameter of 1.52 mm and an external diameter of 2.54 mm.* The proximal end of the catheter was connected to the outlet of the manual control valve of a bronchoscopic injector’ and ventilation carried out with 100% oxygen delivered by the injector together with air entrained through the tracheal incision
Fig. 1. The operative field after resection of the tracheal stenosis. The injector tube appears immediately distal to the cricoidcartilage (A) and passes for 1.5 cm into the distal tracheal segment (B). There is virtually unrestricted surgical access. The Pco, was 34 mmHg and the Po, 380 mmHg when this photo was taken.
* Portex Ltd, Hythe, Kent CT21 6JL. Catalogue No. 200/490/060.
1078
R. H . Ellis, C.J . Hinds and L. T. Gadd
(Fig. 1). The injector control valve was depressed regularly for one second 12 times a minute and the patient's chest appeared to inflate satisfactorily. The endotracheal tube was withdrawn until its tip was above the upper margin of the stricture. Ventilation was maintained with the injector for just over one hour, during which time the tracheal stenosis was resected and the cut ends anastomosed. Satisfactory ventilation was difficult to achieve for part of this procedure because the catheter was displaced repeatedly from the distal tracheal segment. This problem was readily overcome by the surgeon stitcning the catheter in place with a retaining suture. Increments of ketamine (0.5-1 mg/kg) were given at 20 minute intervals to maintain anaesthesia during this period. Regular suction by the surgeon and his assistant was required to prevent the aspiration of blood into the trachea and lung. Apart from this the anaesthetic technique did not hamper the surgery and the operating conditions were excellent (Fig. I). The catheter was withdrawn when the anastomosis was completed and ventilation was continued through the endotracheal tube, the tip of which lay just above the cricoid cartilage; the patient once more received nitrous oxide and oxygen until the surgery was finished, when the anaesthetic was discontinued and the relaxant reversed with atropine and prostigmine. Recovery of consciousness occurred five minutes later and the child was extubated and breathed spontaneously without difficulty. At intervals throughout the procedure arterial blood was sampled for estimation of acid-base and blood-gas state. The samples were analysed immediately using an ABL 1 blood-gas analyser (Radiometer Ltd, Copenhagen), the calibration of which was checked using tonometered blood for oxygen tension (Poz),carbon dioxide tension (Pco2)and serum for pH. Discussion
Lee & English' administered thiopentone intermittently to ensure narcosis during the time when no inhalational anaesthetic was given. Ketamine has been recommended for use under similar condition^^.^ and we preferred it to thiopentone because of the ease and convenience of its administration at a time when the anaesthetist's main preoccupation is the provision of a clear airway. Ketamine has other properties which make it a suitable agent in these circumstances, namely its lack of harmful effects on the tracheo-bronchial tree,5 its beneficial actions on the cardiovascular system especially when used with pancuronium6 and its provision of a degree of protection from arrhythmias.' The patient had no recollection of the procedure and did not suffer any unpleasant sensation on recovery from anaesthesia. It is often misleading to assess the adequacy of ventilation from the chest movements and clinical signs of hypercarbia are inconstant,* but the blood-gas measurements (Fig. 2) show that adequate ventilation can be achieved using this technique. The higher levels of Pcoz during part of the period of injector ventilation were related to the difficulty in keeping the tip of the catheter within the distal tracheal segment. Once this had been secured with a retaining suture the Pco, readily fell to a more satisfactory level. In the interests of asepsis the technique described should be modified to allow the surgeon to pass the catheter up through the endotracheal tube to the anaesthetist. The outstanding advantage of this technique is the minimal intrusion of anaesthetic apparatus into the surgical field. Operating conditions are thus far superior to those
Anaesthesia during tracheal resection
1079
I
-FE
o
ventilation
Hours
Fig. 2. The variations in Po2and Pcol during the various stages of the operation (see text). (The high levels of Pco, during the middle third of the period of injector ventilation coincided with difficulty in keeping the catheter securely in the trachea.)
provided by the more usual methods of maintaining anaesthesia, in which the construction of the anastomosis is often hindered by an endotracheal tube which has been passed across the operative field, either through the larynx' or directly into the incision." The technique should be of especial benefit during the resection of low tracheal strictures which are near to or involving the carina. In these circumstances cardiopulmonary bypass has been used to maintain oxygenation" although the more usual management involves deliberate endobronchial intubation and light clamping of the pulmonary artery on the unventilated side to minimise arterial desaturation.12 The technique described above can easily be modified to provide ventilation to both lungs simply by using separate catheters for each bronchus. Summary Recently Lee & English have described an ingenious method of ventilation using a bronchoscopic injector and a narrow catheter during an operation for the resection of a tracheal stenosis. We report the use of a similar system and confirm the adequacy of ventilation achieved by serial blood-gas estimations. References 1. LEE,P. & ENGLISH, I.C.W. (1974) Management of anaesthesia during tracheal resection. Anaesthesia, 29, 305. 2. BETHUNE, D.W., COLLIS, J.M., BURBRIDGE, N.J. & FORSTER, D.M. (1972) Bronchoscope injectors. A design for use with pipeline oxygen supplies. Anaesthesia, 27, 81. 3. DUNDEE, J.W. & WYANT, G.M. (1974) Intracenous anaesthesia, 1st edn, p. 240. Churchill Livingstone, London. 4. HEIFETZ,M. (1974) Management of anaesthesia during tracheal resection. Anaesthesia, 29, 760. 5. CORSSEN,G., GUTIERREZ, J., REVES,J.G. & HUBER,F.C. (1972) Ketamine in the anesthetic management of asthmatic patients. Anaesthesia and Analgesia; Current Researches, 51, 588.
1080
R . H . Ellis, C. J . Hinds and L. T. Gadd
6. DUNDEE, J.W. (1971) Selective indications for ketamine anaesthesia discussion. Proceedings of the Royal Society of Medicine, 64, 11 59. 7. DOWDY,E.G. & KAYA,K. (1968) Studies of the mechanism of cardiovascular responses to CI-581. Anesthesiology, 29,931. 8. NUNN,J.F. (1969) Applied respiratory physiology with special reference to anaesthesia, 1st edn, p. 322. Butterworths, London. 9. MUSHIN, W.W. (1963) Thoracic anesthesia, 1st edn, p. 373. Blackwell Scientific Publications,
Oxford. 10. PAYNE, W.S., LEONARD, P.F., MILLER, R.D., ROSENOW, E.C. & DESANTO, L.W. (1973) Physio-
logically based assessment and management of tracheal strictures. Surgical Clinics of North America, 53, 875. I I . HARLEY, H.R.S. (1971) Laryngotracheal obstruction complicating tracheostomy or endotracheal intubation with assisted respiration : a critical review. Thorax, 26, 493. 12. GEFFIN, B., BLAND,J. & GRILLO, H.C. (1969) Anesthetic management of tracheal resection and reconstruction. Anesthesia and Analgesia; Ciirrent Researches, 48, 884.
