Canadian Journal of Anesthesia 47:261-264 (2000)
© Canadian Anesthesiologists' Society, 2000
Brief Report
An unusual cause of tracheal stenosis
Lakshmi Vas, MD*,
Savita Sanzgiri , MD DNB*,
Bharati Patil, MD* and
Vikram Sanghvi, MS
* From the Department of Anesthetics, Bai Jerbai Wadia Hospital For Children, and
Tata Memorial Hospital for Oncology, Bombay, India.
Address Correspondence to: Dr. Lakshmi Vas, Department of Anesthetics, Bai Jerbai Wadia Hospital for Children, Acharya Donde Marg, Parel Bombay - 12, India.
 |
Abstract
|
|---|
Purpose: To report a large chronic tracheal foreign body, causing tracheal stenosis in an 11-yr-old girl.
Clinical Features: The history was suggestive of obstructive airways disease with secondary bronchiectasis. Physical findings were crepitations and rhonchi all over the chest. Blood gases were normal. Chest X-ray showed bronchiectasis and a ventilation perfusion scan identified a tracheo-esophageal fistula. During anesthesia to confirm this, intubation and ventilation were difficult because of tracheal stenosis. The hypoventilation resulted in severe hypercarbia and acidosis. A subsequent CT scan showed a stenosis of 2 mm diameter and 1 cm length in the middle third of trachea, bronchiectasis, and an air filled pocket between the trachea and esophagus. PFT showed a severe obstruction. Antitubercular treatment which was started on the presumptive diagnosis of tuberculous stenosis and tracheoesophageal fistula caused a delay with deterioration of patient from intermittent dyspnea to orthopnea with severe hypecarbia and acidosis. The anesthetic management of the tracheal reconstruction was difficult due to her moribund condition even after medical treatment, the short length of the trachea above the obstruction, its severity and lack of resources for alternative techniques. A large foreign body was found lying obliquely in the trachea dividing it into an anterior narrow airway mimicking a stenosed trachea , and a wider posterior blind passage.
Conclusion: The anesthetic consequences were peculiar to the unexpected etiology of the stenosis and poor general condition of the patient. Minor details like the tracheal tube bevel and ventilatory pattern became vitally important.
|
Introduction
|
|---|
SUCCESS of tracheal reconstruction1–10 depends on careful planning. We anesthetized a patient twice for severe tracheal stenosis. The relevant findings when the stenosis was unexpectedly diagnosed during the first anesthetic and anesthetic management for delayed tracheal reconstruction follow.
|
Case Report
|
|---|
An 18 kg 11-yr-old girl was admitted for intermittent breathlessness with normal activities between attacks, for a year. The onset had been sudden. She had been unsuccessfully treated for asthma, aspiration pneumonitis and tuberculosis. Physical findings, airway grading, exercise tolerance (she could climb two floors with ease), blood chemistry and blood gases were normal. Chest X-ray showed bilateral bronchiectasis. Pulmonary function testing was not done. A ventilation - perfusion scan suggested an H - shaped tracheo-esophageal fistula. During esophagoscopy to confirm this, tracheal intubation, even with a 4 mm id tube was impossible due to an obstruction 1.5-2 cm below the cords. An uncuffed 6 mm tube placed above the obstruction enabled adequate chest excursion, audible breath sounds and oxygen saturation. The PETCO2 could not be recorded because of a large leak around the tube. It returned after resumption of spontaneous ventilation at the end of esophagoscopy showing a PETCO2 > 100 mmHg, PaCO2 -127 mmHg and pH 6.9. However, 10 min of spontaneous respiration restored normalcy and the trachea was extubated.
A CT scan showed stenosis of 2 mm diameter and 1 cm length in the middle third of the trachea, bronchiectasis and an air filled pocket, between the trachea and esophagus. Flow volume loops showed severely flattened inspiratory and expiratory curves. Spirometry was < 40% of predicted values. Surgery was delayed to allow antitubercular therapy. Two months later she was admitted with severe breathlessness, upper respiratory tract infection and 3 kg weight loss. Chest X-ray was same as before. Blood counts, renal and liver function tests were normal. Arterial blood gases are shown in the Table
. After 15 dy of antibiotics, mucolytics, bronchodilators and physiotherapy, she was posted for tracheal reconstruction.
After 5 µg•kg–1 glycopyrrolate im and EMLA, preoxygenation in sitting position, ECG, NIBP, pulse oximeter and capnograph nasal sampling line were attached (Table
). Intermittent trilene inhalation facilitated placement of arterial and central venous lines, bilateral superior laryngeal nerve blocks and superficial cervical plexus blocks with bupivacaine 0.5%. The upper airway was sprayed with 1 ml lidocaine 4%. She was awake during these procedures. The systolic blood pressure range was 140 to 110 mmHg and heart rate was 120-140 bpm. Perioperative blood gases are shown in the Table.
Propofol 1 mg•kg–1 bolus followed by 1 mg•kg–1•min–1 infusion and halothane 0.5% in oxygen were given. After a glossopharygeal nerve block with 1 ml lidocaine 1% and succinylcholine 2 mg•kg–1 a cuffed 6 mm id armoured nasotracheal tube was passed into the trachea above the stenosis. Part of the inflated cuff was above the vocal cords. Spontaneous ventilation, on its return, was uneven so ventilation was controlled with atracurium 0.5 mg•kg–1 bolus followed by infusion of 0.5 mg•kg–1•hr–1 and isoflurane in oxygen. The stenosis was sectioned and the trachea reanastomosed around a 7.5 mm id nasotracheal tube. After 1 mg neostigmine and 0.6 mg atropine spontaneous respiration maintained normal blood gases.
The excised segment of the trachea showed an anterior narrow passage for ventilation and a posterior blind pouch. (Figures 1 a,b). Between them, there was a middle mobile part of two thick septa enclosing a foreign body, a thin circular plastic disk of 1 cm diameter with serrated edges and multiple perforations (Figure 2). Recovery was uneventful after trachea extubation at 72 hr.
View larger version (21K):
[in this window]
[in a new window]
|
FIGURE 1A A line diagram showing the retrospective representation of the foreign body enclosed in grannulomatous tissue the trachea. Note the narrow airway anteriorly, the grannuloma in the middle and the posterior blind passage mistaken for a tracheo esophageal fistula.
The long bevel of a PVC tube is obstructed by the septum.
|
|
View larger version (22K):
[in this window]
[in a new window]
|
FIGURE 1B A representation of a tracheal armoured tube with a short bevel, the bevel staying unobstructed above the blind passage.
|
|
View larger version (88K):
[in this window]
[in a new window]
|
FIGURE 2 The foreign body, a plastic disc which is a part of `RAKHI' tied on the wrist for religious reasons.
|
|
|
Discussion
|
|---|
Observation of the foreign body in this patient, suggested that when lying vertically it would not have obstructed the trachea but, when horizontal, it could block most of the trachea causing severe breathlessness and explained the intermittent attacks. Development of septae around the foreign body in response to continued irritation probably led to a gradual division of the trachea into an anterior stenosed airway and a posterior blind passage.
As tuberculosis is endemic in India, the posterior blind passage was mistaken for a tuberculous tracheoesophageal fistula, with recurrent pulmonary aspirations to explain the fever with respiratory distress and bronchiectasis. In retrospect, this delay for antitubercular therapy in the absence of a tissue diagnosis coinciding with the critical phase in the progression of the obstruction resulted in gross deterioration of the patient's condition.
When the patient was agitated, her breathlessness was alarming. In retrospect, the mobile upper end of the septum enclosing the foreign body probably moved anteriorly to narrow the airway to the 2 mm shown in the CT, and this explains the swings between normalcy and severe stridor. Also, obstruction of the tracheal tube by the septum (Figure 1a) explains the need for a high inspiratory pressure during the first anesthetic. (Figure 1a) In addition, the type of endotracheal tube bevel was important (Figure 1c) because the 1 cm bevel of a 6 mm tube in a 1.5 cm airway worsened the leak and increased hypoventilation.
During the second anesthetic, controlled ventilation using a cuffed armoured tube with a short bevel, ensured the maximum length of tube in the trachea whilst avoiding intubation of the blind passage (Figure 1b) and leak. The unavailability of a fibreoptic bronchoscope, HFO HFJ and risks of rigid bronchoscopy precluded their use. The use of local and topical anesthesia and trilene analgesia avoided the agitation which may have precipitated severe stridor.
|
Conclusion
|
|---|
The anesthetic management of a patient with foreign body tracheal stenosis is described. The intermittent sever obstruction was caused by realignment of the foreign body within the trachea. Attention was paid to minute details of anesthetic management such as the length of the bevel of the tracheal tube, steps to safely minimize anesthesia, the choice of ventilatory pattern and the judicious use of anesthetic agents assumed great importance.
Accepted for publication November 26, 1999.
|
References
|
|---|
1
Concha M, González J, González A, Dagnino J, Molina R. Epidural anaesthetic for ureteral reimplatation in infant with congenital tracheal stenosis. Can J Anaesth 1997; 44: 666–8.[Abstract/Free Full Text]
2
Sutcliffe N, Remington SAM, Ramsay TM, Mason C. Severe tracheal stenosis and operative delivery. Anaesthesia 1995; 50: 26–9.[Medline]
3
Frelich J, Eagle CJ. Anaesthetic management of a patient with myastheina gravis and tracheal stenosis. Can J Anaesth 1996; 43: 84–9.[Abstract/Free Full Text]
4
Salama DJ, Body SC. Management of a patient with tracheal stenosis. Br J Anaesth 1994; 72: 354–7.[Abstract/Free Full Text]
5
Theman TE, Kerr JH, Nelems JM, Pearson FG. Carinal resection. A report of 2 cases and description of the anesthetic technique. J Thorac Cardiovasc Surg 1975; 71: 314–20.[Abstract]
6
Geffin B, Bland J, Grillo HC. Anesthetic management of tracheal resection and reconstruction. Anesth Analg 1969; 48: 884–90.[Free Full Text]
7
Lee P, English ICW. Management of anaesthetic during tracheal resection. Anaesthesia 1974; 29: 305–6.[Medline]
8
Kryger M, Bode F, Antic R. Diagnosis of obstruction of the upper and central airways. Am J Med 1976; 61: 85–93.[Medline]
9
Gothard JWW, Stutton BA. Anesthetic for Thoracic Surgery, 2nd ed. London: Blackwell Scientific Publications, 1993: 204–13.
10
Mansour KA, Lee RB, Miller J. Tracheal resections: lessons learned. AnnThorac Surg 1994; 57: 1120–5.[Abstract]
TOP
Abstract
Introduction
