ANESTHESIA AND ANALGESIA . . . Current Researches VOL.56, NO.3, MAY-JUNE, 1977
429
Oxygen-let Ventilation Dur ng Tracheal Reconstruction in Patients with Tracheal Stenosis ANIS BARAKA, MD*
Intermittent jets of 0, a t 60 psi via a smallbore (5 mm), cuffed tracheal tube have been used with relaxants to ventilate adult patients with tracheal stenosis undergoing surgical resection and reconstruction. Before resection, the tube was maintained proximal to the stenosis. During resection and reconstruction, the
tube bypassed the resected gap into the distal tracheal segment. The technic allows the surgeon to mobilize, resect, and reconstruct the trachea around the small tube in an unhurried manner, and provides adequate ventilation and oxygenation throughout the procedure.
T
The patient was scheduled for tracheal reconstruction. After premedication with atropine (0.6 mg) IM, she was oxygenated with 100 percent 0, for 5 minutes; anesthesia was then induced with propanidid (500 mg) followed by succinylcholine (100 mg) and was maintained with an IV drip of 1 percent propanidid and 0.1 percent succinylcholine at a rate of 0.1 ml/kg/min. After topical laryngeal spray, she was intubated with a long, sterile cuffed tracheal tube ( 5 mm I D ) , with a Y adapter fitted to the proximal end. One sidearm of the adapter was connected by high-pressure tubing to the piped-in 02,delivered at 60 psi, while the other arm was kept unoccluded (fig 1).
stenosis, a serious complication, may follow prolonged tracheostomy or tracheal intubation. Circumferential resection and primary end-to-end anastomosis is considered the ideal method of reconstruction of mediastinal tracheal stenosis.1.2 RACHFAL
The present investigation confirms previous reports334 showing that intermittent O., jets can be used successfully to ventilate patients with tracheal stenosis undergoing reconstructive surgery. However, in the present report, jets are flushed via a small-bore cuffed tracheal tube, rather than by the injector and/or narrow catheters previously used, resulting in a higher 0, concentration with minimal air entrainment.+
CASE REPORTS The first patient was a 38-year-old woman with tetanus. A Portex cuffed tracheotomy tube was inserted and the patient was curarized and kept on IPPV with an Emerson respirator for 4 weeks. However, after removal of the tracheotomy tube, the patient developed progressive dyspnea. Tomography revealed stenosis of the trachea 5 cm above the carina at the site of the cuff. ?Baraka A: 0, jet ventilation in patients with tracheal stenosis. Presented at 6th World Congress of Anesthesiology, Mexico City, DF, Mexico, 1976.
The 0, concentration delivered from the distal end of the tube varied between 65 and 75 percent, as checked by a gas-0, analyzer (Mira Corporation). The tube was introduced proximal to the stricture, and the patient was ventilated via the sidearm of the adapter by intermittent jets of O., of l-second duration at a rate of lO/min, exhaling via the unoccluded second arm. The patient was placed in the lateral position and a right thoracotomy was performed because the site of stenosis was too low for a cervical incision. After adequate mediastinal mobilization, the stenotic segment of the trachea
"Chairman, Department of Anesthesiology, American University of Beirut. Lebanon. Paper received: 6/9/76 Accepted for publication: 8/31/76
ANESTHESIAA N D ANALGESIA. . Current Researches VOL.56, No. 3, MAY-JUNE, 1977
430
by a Boyle I11 circuit, using N,O-0, supplemented by pancuronium. At the end of the procedure, neuromuscular block was reversed and the patient was extubated. Adequate spontaneous respiration was resumed and recovery was uneventful. The same technic of 0,-jet ventilation was used successfully in 2 other adult patients with mediastinal tracheal stenosis including thoracotomy which followed prolonged intubation with a cuffed tracheostomy tube. Both patients also underwent surgical tracheal reconstruction. Anesthesia was induced, following preoxygenation, by I V injection of 2 mglkg of ketamine and 100 mg of succinylcholine and was maintained by intermittent ketamine and pancuronium. Intermittent 0,-jet ventilation was continued throughout the procedure, and the resultant blood-gas changes were monitored before, during, and after the tracheal reconstruction (table).
FIG 1. Setup for 0, jet ventilation in patients with tracheal stenosis undergoing surgical reconstruction. The patient is intubated with the long W5 orotracheal tube. The sidearm of the Y adapter is connected by high pressure tubing to the pipeline 0, delivered a t 60 psi. The O2 flow is interrupted by the manually operated valve (Blow Gun, Norgren #17-004-304).
was excised and the tracheal tube was guided into the distal segment of the trachea and, for a short period, into the left main bronchus. After tracheal reconstruction, the small tube was withdrawn above the suture line (fig 2 ) .
DISCUSSION Prospective studies predict a 16 to 20 percent incidence of stenosis following prolonged cuffed-tube intubation. The lesion occurs either a t the stoma or the site of the cuff, the lesion usually involving several rings of the trachea. Ulcerations, necrosis, and infection may be followed by formation of fibrous strictures that usually appear within 40 days after tube removal.j.6
Ventilation was maintained throughout the procedure by intermittent O2 jets until end-to-end anastomosis was completed. Blood-gas values achieved by 0.)jet ventilation before, during, and after tracheal reconstruction are shown in the table. The small tube was then replaced by a #8 orotracheal tube and anesthesia was maintained
ll
II
The treatment of tracheal stenosis varies from simple transbronchoscopic dilation and
A
l
: % k 1:; C
B
D
I1
-
7
A
7
7
A
FIG 2. Diagram depicting the steps of 0, jet ventilation during tracheal reconstruction. ( A ) : The orotracheal tube is kept above the stenosis until the stenotic segment is resected. ( B ) : After resection, the tube is pushed down into the distal segment of the trachea or (C) kt0 the left main bronchus. When end-to-end anastomosis is completed, the tube is pulled above the suture line (D) and can be replaced by a normal-sized tube.
Oxygen Jet Ventilation
. . . Baraka
431 TABLE
Arterial Blood-Gas Values Under O,-Jet Ventilation for Tracheal Reconstruction (torr) Patient 1 Position of tube
Paoz
Pacoz
Pa02
Above stenosis
430
40
500
Distal trachea
310
45
Left bronchus
70 400
Above suture line
Patient 2 Pacan
Patient 3 Paoz
Pacoz
42
450
38
270
44
350
45
62
65
65
70
50
40
430
41
450
35
excision to surgical resection and end-to-end anastomosis. Circumferential resection and primary end-to-end anastomosis is considered to be the ideal method of reconstruction of mediastinal tracheal stenosis. This is made possible by the adequate mobilization of mediastinal structures. Anesthetic management of the patient with tracheal stenosis is a challenge to the anesthesiologist, who must achieve adequate ventilation in the face of the marked inspiratory and expiratory resistance resulting from the stenosis.7 Induction of general anesthesia is usually hazardous. Attempts at intubation under local anesthesia through the stricture may be risky, since bleeding and edema can cause complete obstruction. Also, a tube small enough to pass through the stricture may not improve the airway because the thickness of the tube may encroach on the available stenotic cross-sectional area.* Different technics, such as hypothermia or even cardiopulmonary bypass, have been recommended to maintain oxygenation during tracheal resection and reconstruction. However, these technics increase the risk and duration of anesthesia and operative procedures. Intubation of the distal tracheal segment or the left main bronchus by a Tovell tube, which crosses the operative field and is linked by sterile connecting tubes to the anesthesia machine, has been successful during reconstructive surgery. However, distal tracheal intubation can be established only after a critical induction of inhalational anesthesia, thoracotomy, and division of the trachea. Also, the distal tube tends to obscure the posterior suture line and distort the lower tracheal segment.Q~l0 The present report shows that intermittent 0, jets, via a small-bore, cuffed tracheal tube, with relaxant technics of anesthesia,
can be safely used from the start to ventilate patients with tracheal stenosis. The flow rate through an orifice is proportional to the square of the diameter of the orifice and the square root of the pressure difference.ll Oxygen jets at a pressure of 60 psi produce a pressure gradient sufficient to achieve an adequate flow rate across the stenosis. Before resection, the tube is maintained proximal to the stenosis, and intermittent jet ventilation via the tube results, despite the stenosis, in adequate Pao, (430 to 500 torr) and Paco, (38 to 42 torr) levels. During resection and reconstruction, the tube bypasses the resected gap into the distal tracheal segment. When the distal tracheal stump is short, the endotracheal tube can be advanced into the left main bronchus. However, bronchial intubation and jet ventilation of one lung can result in hypoventilation and shunting, resulting in low Pao, and high Paco, levels. Therefore, patients should have an inspired O2 concentration as near to 100 percent as possible, to avoid hyp0xia.12,~~ The refinement of temporarily eliminating perfusion of the unventilated lung by clamping the pulmonary artery (transitory physiologic pneumonectomy) might be physiologically beneficial and help to diminish the shunt effect.lo Intermittent 0, jets have been initially used to ventilate patients undergoing bronchoscopy. Sandersl4 adapted a Venturi injector attachment to the unoccluded head of the bronchoscope. The jet via the injector entrains a high flow of room air, which provides enough pressure and volume to ventilate the patient. The principle of 0%jets via a bronchoscope injector and/or a narrow catheter has been applied to ventilate patients with tracheal s t e n o ~ i s . ~However, .~ direct O2 jets via a small-bore tracheal tube,
432
ANESTHESIA AND ANALGESIA
as opposed to injectors and narrow cathIn the eters, result in higher Pao, levels.1~:~ present investigation, jet ventilation via a small-bore tracheal tube resulted in a high inspired 0, concentration ranging from 65 to 75 percent, and, provided both lungs are ventilated, can give Pao, levels as high as 500 torr.
The potential problems associated with the use of a small-bore, cuffed tracheal tube for jet ventilation are mainly related to expiratory resistance. Harmful sequelae can be minimized by ventilation a t a slow rate (about 10jniin) in order to prolong exhalation time, and by deflating the cuff, if necessary, to allow exhalation around the tube. The principle of 0,-jet ventilation can be applied successfully to ventilate patients with tracheal stenosis whether undergoing transbronchoscopic management or surgical resection and reconstruction. ‘i; The technic allows the surgeon to mobilize, resect, and reconstruct the trachea in an unhurried manner. The jet produces a pressure gradient sufficient for ventilation and ensures a high inspired 0, concentration with minimal air entrainment. *Baraka: op cit supra.
REFERENCES 1. Grillo HC: Circumferential resection and reconstruction of the mediastinal and ceivical trachea. Ann Surg 162:375-388, 1965
2. Pearson FG. Andrews MeJ: Detection and management of tracheal stenosis following cuffed tube tracheostomy. Ann Thorac Surg 12:359-374, 1971
Current Researches VOL.56, No. 3, MAY-JUNE. 1977 3. Leep P, English ICW: Management of anaesthesia during tracheal resection. Anaesthesia 29:305-306, 1974
4. Macnaughton FI: Catheter inflation ventilation and tracheal stenosis. Br J Anaesth 47: 12251227, 1975 5. Coulson AS. Rossiter SJ, Guernsey JM: Progressive tracheal obstruction. J Thorac Cardiovasc Surg 67:733-743, 1974 6. Lefemine A, MacDonnell K. Moon H : Tracheal stenosis following cuffed tube tracheostomy. Ann Thorac Surg 15:456-462, 1973
7. Miller R, Hyatt R: Evaluation of obstructing lesions of the trachea and larynx by flow-volume loops. Am Rev Respir Dis 108:475-481, 1971 8. Payne W. Leonard P, Miller R, et al: Physiologically based assessment and management of tracheal strictures. Surg Clin North Am 53:875884, 1973
9. Geffin B, Bland J, Grillo HC: Anesthetic management of tracheal resection and reconstruction. Anesth Analg 48.884-894, 1969 10. Grillo HC, Bendixen HH. Gephart T : Resection of the carina and lower trachea. Ann Surg 158: 889-893, 1963 11. MacIntosh R, Mushin W, Epstein HG: Physics for the Anaesthetist. Third edition. Oxford. Blackwell Scientific Publication, 1963 12. Kerr JK, Crompton-Smith A: Observations during endobronchial anaesthesia. 11: Oxygenation. Br J Anaesth 46:84-92, 1974
13. Khanam T , Branthwaite MA: Arterial oxygenation during one lung anaesthesia. Anaesthesia 28:280-290, 1973 14. Sanders RD: Two ventilating attachments for bronchoscopes. Del Med J 39:170-175, 1967 15. El-Naggar M, Keh E. Stemmers A. et al: Jet ventilation for microlaryngoscopic procedures: a further simplified technic. Anesth Analg 53: 797804, 1974
429
Oxygen-let Ventilation Dur ng Tracheal Reconstruction in Patients with Tracheal Stenosis ANIS BARAKA, MD*
Intermittent jets of 0, a t 60 psi via a smallbore (5 mm), cuffed tracheal tube have been used with relaxants to ventilate adult patients with tracheal stenosis undergoing surgical resection and reconstruction. Before resection, the tube was maintained proximal to the stenosis. During resection and reconstruction, the
tube bypassed the resected gap into the distal tracheal segment. The technic allows the surgeon to mobilize, resect, and reconstruct the trachea around the small tube in an unhurried manner, and provides adequate ventilation and oxygenation throughout the procedure.
T
The patient was scheduled for tracheal reconstruction. After premedication with atropine (0.6 mg) IM, she was oxygenated with 100 percent 0, for 5 minutes; anesthesia was then induced with propanidid (500 mg) followed by succinylcholine (100 mg) and was maintained with an IV drip of 1 percent propanidid and 0.1 percent succinylcholine at a rate of 0.1 ml/kg/min. After topical laryngeal spray, she was intubated with a long, sterile cuffed tracheal tube ( 5 mm I D ) , with a Y adapter fitted to the proximal end. One sidearm of the adapter was connected by high-pressure tubing to the piped-in 02,delivered at 60 psi, while the other arm was kept unoccluded (fig 1).
stenosis, a serious complication, may follow prolonged tracheostomy or tracheal intubation. Circumferential resection and primary end-to-end anastomosis is considered the ideal method of reconstruction of mediastinal tracheal stenosis.1.2 RACHFAL
The present investigation confirms previous reports334 showing that intermittent O., jets can be used successfully to ventilate patients with tracheal stenosis undergoing reconstructive surgery. However, in the present report, jets are flushed via a small-bore cuffed tracheal tube, rather than by the injector and/or narrow catheters previously used, resulting in a higher 0, concentration with minimal air entrainment.+
CASE REPORTS The first patient was a 38-year-old woman with tetanus. A Portex cuffed tracheotomy tube was inserted and the patient was curarized and kept on IPPV with an Emerson respirator for 4 weeks. However, after removal of the tracheotomy tube, the patient developed progressive dyspnea. Tomography revealed stenosis of the trachea 5 cm above the carina at the site of the cuff. ?Baraka A: 0, jet ventilation in patients with tracheal stenosis. Presented at 6th World Congress of Anesthesiology, Mexico City, DF, Mexico, 1976.
The 0, concentration delivered from the distal end of the tube varied between 65 and 75 percent, as checked by a gas-0, analyzer (Mira Corporation). The tube was introduced proximal to the stricture, and the patient was ventilated via the sidearm of the adapter by intermittent jets of O., of l-second duration at a rate of lO/min, exhaling via the unoccluded second arm. The patient was placed in the lateral position and a right thoracotomy was performed because the site of stenosis was too low for a cervical incision. After adequate mediastinal mobilization, the stenotic segment of the trachea
"Chairman, Department of Anesthesiology, American University of Beirut. Lebanon. Paper received: 6/9/76 Accepted for publication: 8/31/76
ANESTHESIAA N D ANALGESIA. . Current Researches VOL.56, No. 3, MAY-JUNE, 1977
430
by a Boyle I11 circuit, using N,O-0, supplemented by pancuronium. At the end of the procedure, neuromuscular block was reversed and the patient was extubated. Adequate spontaneous respiration was resumed and recovery was uneventful. The same technic of 0,-jet ventilation was used successfully in 2 other adult patients with mediastinal tracheal stenosis including thoracotomy which followed prolonged intubation with a cuffed tracheostomy tube. Both patients also underwent surgical tracheal reconstruction. Anesthesia was induced, following preoxygenation, by I V injection of 2 mglkg of ketamine and 100 mg of succinylcholine and was maintained by intermittent ketamine and pancuronium. Intermittent 0,-jet ventilation was continued throughout the procedure, and the resultant blood-gas changes were monitored before, during, and after the tracheal reconstruction (table).
FIG 1. Setup for 0, jet ventilation in patients with tracheal stenosis undergoing surgical reconstruction. The patient is intubated with the long W5 orotracheal tube. The sidearm of the Y adapter is connected by high pressure tubing to the pipeline 0, delivered a t 60 psi. The O2 flow is interrupted by the manually operated valve (Blow Gun, Norgren #17-004-304).
was excised and the tracheal tube was guided into the distal segment of the trachea and, for a short period, into the left main bronchus. After tracheal reconstruction, the small tube was withdrawn above the suture line (fig 2 ) .
DISCUSSION Prospective studies predict a 16 to 20 percent incidence of stenosis following prolonged cuffed-tube intubation. The lesion occurs either a t the stoma or the site of the cuff, the lesion usually involving several rings of the trachea. Ulcerations, necrosis, and infection may be followed by formation of fibrous strictures that usually appear within 40 days after tube removal.j.6
Ventilation was maintained throughout the procedure by intermittent O2 jets until end-to-end anastomosis was completed. Blood-gas values achieved by 0.)jet ventilation before, during, and after tracheal reconstruction are shown in the table. The small tube was then replaced by a #8 orotracheal tube and anesthesia was maintained
ll
II
The treatment of tracheal stenosis varies from simple transbronchoscopic dilation and
A
l
: % k 1:; C
B
D
I1
-
7
A
7
7
A
FIG 2. Diagram depicting the steps of 0, jet ventilation during tracheal reconstruction. ( A ) : The orotracheal tube is kept above the stenosis until the stenotic segment is resected. ( B ) : After resection, the tube is pushed down into the distal segment of the trachea or (C) kt0 the left main bronchus. When end-to-end anastomosis is completed, the tube is pulled above the suture line (D) and can be replaced by a normal-sized tube.
Oxygen Jet Ventilation
. . . Baraka
431 TABLE
Arterial Blood-Gas Values Under O,-Jet Ventilation for Tracheal Reconstruction (torr) Patient 1 Position of tube
Paoz
Pacoz
Pa02
Above stenosis
430
40
500
Distal trachea
310
45
Left bronchus
70 400
Above suture line
Patient 2 Pacan
Patient 3 Paoz
Pacoz
42
450
38
270
44
350
45
62
65
65
70
50
40
430
41
450
35
excision to surgical resection and end-to-end anastomosis. Circumferential resection and primary end-to-end anastomosis is considered to be the ideal method of reconstruction of mediastinal tracheal stenosis. This is made possible by the adequate mobilization of mediastinal structures. Anesthetic management of the patient with tracheal stenosis is a challenge to the anesthesiologist, who must achieve adequate ventilation in the face of the marked inspiratory and expiratory resistance resulting from the stenosis.7 Induction of general anesthesia is usually hazardous. Attempts at intubation under local anesthesia through the stricture may be risky, since bleeding and edema can cause complete obstruction. Also, a tube small enough to pass through the stricture may not improve the airway because the thickness of the tube may encroach on the available stenotic cross-sectional area.* Different technics, such as hypothermia or even cardiopulmonary bypass, have been recommended to maintain oxygenation during tracheal resection and reconstruction. However, these technics increase the risk and duration of anesthesia and operative procedures. Intubation of the distal tracheal segment or the left main bronchus by a Tovell tube, which crosses the operative field and is linked by sterile connecting tubes to the anesthesia machine, has been successful during reconstructive surgery. However, distal tracheal intubation can be established only after a critical induction of inhalational anesthesia, thoracotomy, and division of the trachea. Also, the distal tube tends to obscure the posterior suture line and distort the lower tracheal segment.Q~l0 The present report shows that intermittent 0, jets, via a small-bore, cuffed tracheal tube, with relaxant technics of anesthesia,
can be safely used from the start to ventilate patients with tracheal stenosis. The flow rate through an orifice is proportional to the square of the diameter of the orifice and the square root of the pressure difference.ll Oxygen jets at a pressure of 60 psi produce a pressure gradient sufficient to achieve an adequate flow rate across the stenosis. Before resection, the tube is maintained proximal to the stenosis, and intermittent jet ventilation via the tube results, despite the stenosis, in adequate Pao, (430 to 500 torr) and Paco, (38 to 42 torr) levels. During resection and reconstruction, the tube bypasses the resected gap into the distal tracheal segment. When the distal tracheal stump is short, the endotracheal tube can be advanced into the left main bronchus. However, bronchial intubation and jet ventilation of one lung can result in hypoventilation and shunting, resulting in low Pao, and high Paco, levels. Therefore, patients should have an inspired O2 concentration as near to 100 percent as possible, to avoid hyp0xia.12,~~ The refinement of temporarily eliminating perfusion of the unventilated lung by clamping the pulmonary artery (transitory physiologic pneumonectomy) might be physiologically beneficial and help to diminish the shunt effect.lo Intermittent 0, jets have been initially used to ventilate patients undergoing bronchoscopy. Sandersl4 adapted a Venturi injector attachment to the unoccluded head of the bronchoscope. The jet via the injector entrains a high flow of room air, which provides enough pressure and volume to ventilate the patient. The principle of 0%jets via a bronchoscope injector and/or a narrow catheter has been applied to ventilate patients with tracheal s t e n o ~ i s . ~However, .~ direct O2 jets via a small-bore tracheal tube,
432
ANESTHESIA AND ANALGESIA
as opposed to injectors and narrow cathIn the eters, result in higher Pao, levels.1~:~ present investigation, jet ventilation via a small-bore tracheal tube resulted in a high inspired 0, concentration ranging from 65 to 75 percent, and, provided both lungs are ventilated, can give Pao, levels as high as 500 torr.
The potential problems associated with the use of a small-bore, cuffed tracheal tube for jet ventilation are mainly related to expiratory resistance. Harmful sequelae can be minimized by ventilation a t a slow rate (about 10jniin) in order to prolong exhalation time, and by deflating the cuff, if necessary, to allow exhalation around the tube. The principle of 0,-jet ventilation can be applied successfully to ventilate patients with tracheal stenosis whether undergoing transbronchoscopic management or surgical resection and reconstruction. ‘i; The technic allows the surgeon to mobilize, resect, and reconstruct the trachea in an unhurried manner. The jet produces a pressure gradient sufficient for ventilation and ensures a high inspired 0, concentration with minimal air entrainment. *Baraka: op cit supra.
REFERENCES 1. Grillo HC: Circumferential resection and reconstruction of the mediastinal and ceivical trachea. Ann Surg 162:375-388, 1965
2. Pearson FG. Andrews MeJ: Detection and management of tracheal stenosis following cuffed tube tracheostomy. Ann Thorac Surg 12:359-374, 1971
Current Researches VOL.56, No. 3, MAY-JUNE. 1977 3. Leep P, English ICW: Management of anaesthesia during tracheal resection. Anaesthesia 29:305-306, 1974
4. Macnaughton FI: Catheter inflation ventilation and tracheal stenosis. Br J Anaesth 47: 12251227, 1975 5. Coulson AS. Rossiter SJ, Guernsey JM: Progressive tracheal obstruction. J Thorac Cardiovasc Surg 67:733-743, 1974 6. Lefemine A, MacDonnell K. Moon H : Tracheal stenosis following cuffed tube tracheostomy. Ann Thorac Surg 15:456-462, 1973
7. Miller R, Hyatt R: Evaluation of obstructing lesions of the trachea and larynx by flow-volume loops. Am Rev Respir Dis 108:475-481, 1971 8. Payne W. Leonard P, Miller R, et al: Physiologically based assessment and management of tracheal strictures. Surg Clin North Am 53:875884, 1973
9. Geffin B, Bland J, Grillo HC: Anesthetic management of tracheal resection and reconstruction. Anesth Analg 48.884-894, 1969 10. Grillo HC, Bendixen HH. Gephart T : Resection of the carina and lower trachea. Ann Surg 158: 889-893, 1963 11. MacIntosh R, Mushin W, Epstein HG: Physics for the Anaesthetist. Third edition. Oxford. Blackwell Scientific Publication, 1963 12. Kerr JK, Crompton-Smith A: Observations during endobronchial anaesthesia. 11: Oxygenation. Br J Anaesth 46:84-92, 1974
13. Khanam T , Branthwaite MA: Arterial oxygenation during one lung anaesthesia. Anaesthesia 28:280-290, 1973 14. Sanders RD: Two ventilating attachments for bronchoscopes. Del Med J 39:170-175, 1967 15. El-Naggar M, Keh E. Stemmers A. et al: Jet ventilation for microlaryngoscopic procedures: a further simplified technic. Anesth Analg 53: 797804, 1974
