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* From the Department of Anesthetics, Bristol Royal Infirmary, and the
Department of ENT, Southmead Hospital, Bristol, United Kingdom.
Address correspondence to: Dr. Edmund A.J. Morris, Department of Anesthetics, Southmead Hospital, Bristol, United Kingdom - BS10 5NB. Phone: +44 117 9595114; Fax: +44 117 9595075; E-mail: edmund.morris{at}nbt.nhs.uk
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Clinical features: A 19-yr-old man weighing 85 kg was scheduled for tracheal resection surgery following postintubation tracheal stenosis. He had a relatively long segment (4 cm) of his trachea resected and anastomosed. Postoperatively, he was sedated and electively ventilated for four days in a chin to chest position by stay sutures. In order to reduce any risk of traumatic disruption to the tracheal anastomosis, we planned to extubate his trachea under light general anesthesia. Attempts to extubate his trachea using propofol and alfentanil infusions failed. We used propofol and remifentanil infusions to achieve a state of sedate cooperation and extubated his trachea with fibreoptic bronchoscope guidance.
Conclusion: Propofol and remifentanil infusions in combination can facilitate successful extubation of the surgically resected airway with high risk of disruption.
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) were of a tight (2 cm long and < 0.5 cm diameter) circumferential tracheal stenosis 2 cm above the site of his tracheostomy. As the patient was not keen to have a long-term tracheostomy, he elected to undergo resection of the stenosed segment.
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). He was sedated with propofol and alfentanil infusions and his lungs were ventilated in the intensive care unit. A plan was made to extubate his trachea three days later, but to leave the stay sutures in place for up to a week longer to allow healing of the anastomosis.
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Several attempts to awaken the patient by reducing the rate of infusion of alfentanil and propofol were unsuccessful. Attempts to change the anesthetic to sevoflurane to establish a spontaneously breathing patient who would be compliant and allow airway assessment also failed: with each attempt he awoke suddenly and with some distress. He had to be immediately restrained and resedated to prevent his sutures from tearing and putting the anastomosis at risk.
We had previously used remifentanil to achieve a state of sedate cooperation in patients undergoing awake fibreoptic intubation and decided to use this opioid to achieve the same effect before attempting to extubate this patient’s trachea again. With a background infusion of propofol (100 mg·hr–1), we replaced the alfentanil infusion with a remifentanil infusion at an initial rate of 0.2 µg·kg–1·min–1. Over the next 20 min the remifentanil infusion was decreased to 0.05 µg·kg–1·min–1, by which time the patient was awake, calm, and obeying commands. He was able to communicate that he understood the need to keep his head still. Extubation of the trachea was achieved with the surgeon examining the anastomosis through a fibreoptic endoscope passed through the lumen of the tracheal tube. The patient breathed spontaneously throughout, did not cough, and maintained a patent airway after tracheal extubation without extending his head. Throughout this period his oxygen saturations remained at 99%, heart rate remained between 80 and 90 beats·min–1 and systolic blood pressure was between 140 and 160 mmHg. The patient subsequently made a full recovery.
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Discussion |
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Intraoperative anesthetic management of tracheal resection is well described.1,2 Following tracheal resection with primary anastomosis, the trachea is subjected to tension. Various releasing maneuvers have been described to increase the length of trachea that can be safely resected to reduce the tension.7 Tracheal transplants have also been tried.8 In the postoperative period the neck is usually kept under flexion to reduce the tension. This is normally achieved by placing sutures between the chin and the chest. Alternatively, neck flexion can be achieved by placing external splints.9 Despite these precautions, anastomotic complications still occur in 9% of patients undergoing this type of surgery; risk factors for complication include a resection of > 4 cm of trachea and the need for tracheostomy before the operation.3 As our patient had these two risk factors he was considered to be at relatively high risk of developing anastomotic complications. Though poor vascularity of the tissues and superadded infection are described as the common reasons for dehiscence of a tracheal anastomosis, the presence of the inflated cuff of the tracheal tube, coughing or bucking and any trauma during extubation or reintubation can potentially cause tracheal rupture. Emergency intubation is a known cause for tracheal injury even in the normal trachea.10
Extubation of the trachea is found to be associated with more complications than intubation in a normal trachea.11 The American Society of Anesthesiologists Task Force on Difficult Airway Management has published recommendations for the management of extubation in a difficult airway.12 An algorithm for extubation of the difficult airway is also available in the review by Miller et al.13 These algorithms describe the airway equipment available to facilitate extubation, and the advantages and limits of each. The guidelines contain no specific advice for extubation after airway surgery and do not suggest the use of iv anesthetic agents such as propofol and remifentanil in such situations.
Traditional teaching suggests that patients with a difficult airway should be fully awake and cooperative before extubation, although there are certain circumstances in airway surgery where a decision is made to perform extubation under deep inhalational anesthesia to allow smoother awakening.14 Such "deep extubation" can be used, for example, to avoid extubation laryngospasm or to reduce coughing and straining after airway or other head and neck surgery, particularly in patients in whom reintubation would not be particularly difficult. Sevoflurane and desflurane have been found to be useful for deep extubation.15,16 However, an increased incidence of airway obstruction has been reported with concentrations of more than one minimum alveolar concentration.16 We tried to use sevoflurane not to perform deep extubation but to provide a compliant patient prior to awake extubation: as we have reported, this was not possible. Nevertheless, inhalational agents can be useful for planned extubation under appropriate circumstances.
Propofol and remifentanil either in combination or alone have been used to provide or supplement anesthesia during awake fibreoptic intubation or airway surgery.17–19 Both of these drugs can suppress the cardiovascular response during emergence.20,21 A continuous infusion of remifentanil between 0.05 to 0.075 µg·kg–1·min–1 has been demonstrated to provide good intubating conditions.18,19 When remifentanil was used alone, a high incidence of recall was reported.18 However, neither propofol nor remifentanil have been described to facilitate tracheal extubation after airway surgery.
Several airway adjuncts can be used to aid the safe extubation of the difficult airway such as Cook’s exchange catheter, the endotracheal ventilation catheter and the fibreoptic bronchoscope.12,13 We used the fibreoptic bronchoscope because of the added advantage (and the surgeon’s request) that the airway could be assessed during extubation.22,23 In the event of failed extubation due to the fixed flexion of the patient’s neck we planned to insert a laryngeal mask airway. The laryngeal mask airway has been shown to be useful in securing the airway and maintaining anesthesia whilst the airway is further evaluated and during the creation of a surgical airway should this be necessary.24,25 Should control of the airway have been lost below the level of the glottis our surgeon would have performed immediate tracheostomy through the site of the previous surgery.
This case demonstrates that infusion of remifentanil in association with low dose propofol can facilitate extubation of the trachea following airway surgery, providing wakeful compliance in a patient before the tracheal tube is removed. Patients who have undergone airway resection surgery present a particular challenge to the anesthesiologist, and we believe this anesthetic approach should be considered when performing extubation in such patients.
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Footnotes |
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Accepted for publication October 28, 2005. Revision accepted December 16, 2005.
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2 Pinsonneault C, Fortier J, Donati F. Tracheal resection and reconstruction. Can J Anesth 1999; 46: 439–55.
3 Wright CD, Grillo HC, Wain JC, et al. Anastomotic complications after tracheal resection: prognostic factors and management. J Thorac Cardiovasc Surg 2004; 128: 731–9.
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9 Mueller DK, Becker J, Schell SK, Karamchandani KM, Munns JR, Jaquet B. An alternative method of neck flexion after tracheal resection. Ann Thorac Surg 2004; 78: 720–1.
10 Chen EH, Logman ZM, Glass PS, Bilfinger TV. A case of tracheal injury after emergent endotracheal intubation: a review of the literature and causalities. Anesth Analg 2001; 93: 1270–1.
11 Asai T, Koga K, Vaughan RS. Respiratory complications associated with tracheal intubation and extubation. Br J Anaesth 1998; 80: 767–75.
12 Caplan RA, Benumof JL, Berry FA, et al. Practice guidelines for management of the difficult airway. A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 1993; 78: 597–602.[Medline]
13 Miller KA, Harkin CP, Bailey PL. Postoperative tracheal extubation. Anesth Analg 1995; 80: 149–72.[Medline]
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15 Valley RD, Freid EB, Bailey AG, et al. Tracheal extubation of deeply anesthetized pediatric patients: a comparison of desflurane and sevoflurane. Anesth Analg 2003; 96: 1320–4.
16 Inomata S, Yaguchi Y, Taguchi M, Toyooka H. End-tidal sevoflurane concentration for tracheal extubation (MACEX) in adults: comparison with isoflurane. Br J Anaesth 1999; 82: 852–6.
17 Donaldson AB, Meyer-Witting M, Roux A. Awake fibreoptic intubation under remifentanil and propofol target-controlled infusion. Anaesth Intensive Care 2002; 30: 93–5.[Medline]
18 Puchner W, Egger P, Puhringer F, Lockinger A, Obwegeser J, Gombotz H. Evaluation of remifentanil as single drug for awake fiberoptic intubation. Acta Anaesthesiol Scand 2002; 46: 350–4.[Medline]
19 Machata AM, Gonano C, Holzer A, et al. Awake naso-tracheal fiberoptic intubation: patient comfort, intubating conditions, and hemodynamic stability during conscious sedation with remifentanil. Anesth Analg 2003; 97: 904–8.
20 Kulkarni A, Price G, Saxena M, Skowronski G. Difficult extubation: calming the sympathetic storm. Anaesth Intensive Care 2004; 32: 413–6.[Medline]
21 Shajar MA, Thompson JP, Hall AP, Leslie NA, Fox AJ. Effect of remifentanil bolus dose on the cardiovascular response to emergence from anaesthesia and tracheal extubation. Br J Anaesth 1999; 83: 654–6.
22 Nakagawa H, Komatsu R, Hayashi K, Isa K, Tanaka Y. Fiberoptic evaluation of the difficult extubation. Anesthesiology 1995; 82: 785–6.[Medline]
23 Popat MT, Dravid RM, Watt-Smith SR. Use of the flexible intubating fibrescope for tracheal re-intubation in a patient with difficult extubation. Anaesthesia 1999; 54: 359–61.[Medline]
24 Asai T. Use of the laryngeal mask after tracheal extubation (Letter). Can J Anesth 1999; 46: 997–8.[Medline]
25 Dob DP, Shannon CN, Bailey PM. Efficacy and safety of the laryngeal mask airway vs Guedel airway following tracheal extubation. Can J Anesth 1999; 46: 179–81.
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