Emergency tracheal resection and reconstruction after severe tracheal stenosis-induced acute respiratory failure: A case report

INTRODUCTION

Post-intubation tracheal stenosis (PITS) is a common and unfortunate complication that can occur after endotracheal intubation or tracheostomy. PITS was first recognised in 1880 as an entity.^[1] Even with the use of high-volume, low-pressure cuffs and growing awareness levels, the incidence is very high following orotracheal intubation(1%–2%) and tracheostomy (1.5%–2.6%) as well.^[1–3] Not measuring the cuff pressure regularly by a manometer and haemodynamic instability in intensive care unit (ICU) patients might also contribute to the mucosal hypoperfusion leading to stenosis.^[4]

Patients usually present 2–3 months later with exertional dyspnoea (tracheal luminal diameter <8 mm) or stridor (diameter <5 mm).^[5,6] Treatment approaches include medical management with steroids and bronchodilators, excision of the fibrous tissue by light amplification by stimulated emission of radiation, rigid bronchoscopy, tracheal dilatation, and tracheal stenting. The definitive management for advanced stenosis includes resection of the stenotic segment and end-to-end anastomosis of the trachea, with a success rate of 71%–97%.^[6,7]

In severe degrees of stenosis, even a slight decrease in airway calibre due to oedema, instrumentation, or infection can lead to cardiorespiratory compromise. This happened recently in one of our patients as he was being evaluated for elective surgery. We treated him with high-flow nasal oxygen, steroids, bronchodilators, and diuretics. Although a tracheostomy tube was kept ready, we wanted to avoid further instrumentation of the trachea and took him up for tracheal resection and reconstruction the same day after stabilisation.

CASE REPORT

A 35-year-old male presented with shortness of breath, stridor, and hoarseness of voice since one month. Approximately 3 months earlier, he had been admitted to a local hospital for exacerbation of viral pneumonia. He had a seizure episode, following which the trachea was intubated, and he was put on ventilatory support for 9 days. Following recovery, he was extubated and discharged from the hospital. Two months later, he developed shortness of breath and stridor. Tracheal stenosis was diagnosed on bronchoscopic examination. Computed tomography (CT) scan of the thorax revealed a stenosed segment of >2.5 cm in the trachea, 2.5 cm below the vocal cords [Figure 1]. Tracheal diameter at the narrowest part as seen in the CT scan was 4 mm. Upon admission to our institute, he was breathing room air with a peripheral oxygen saturation (SpO₂) of 96% and a respiratory rate of 25–30 breaths per minute. Arterial blood gases showed normocarbia with a normal lactate level. A diagnosis of PITS was made. He was scheduled to undergo evaluation followed by tracheal resection and reconstruction. He had mild global left ventricular hypokinesia (left ventricular ejection fraction 45%), normal right ventricular systolic function, and pulmonary artery pressure (26 mmHg) on echocardiography. The patient suddenly developed an acute, severe exacerbation of stridor and respiratory failure with altered sensorium the following morning. The minimum SpO₂ recorded by the floor nurse was 60%. The code blue resuscitation team immediately shifted him to the ICU with bag-mask ventilation and supplemental oxygen. High-flow nasal oxygen was started at 60 l/minute. Intravenous hydrocortisone 200 mg, etofylline with theophylline 110 mg, and frusemide 40 mg were injected. After initial resuscitation, his SpO₂ improved to 90%, his sensorium improved, he started responding to commands, and he was haemodynamically stable. Blood gas analysis revealed the partial pressure of oxygen and carbon dioxide (CO₂) in arterial blood to be 65 mmHg each, a pH of 7.2, and a lactate level of 4.5 mmol/L. Following a multidisciplinary discussion, the decision was made to proceed with emergency tracheal resection and reconstruction, and informed consent was obtained from the attendants.

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Figure 1:

Reconstructed image of the trachea showing the stenotic segment. A: Anterior aspect, FPL: Foot posterior left position, HAR: Head anterior right position

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The operating room (OR) was prepared with emergency airway gadgets like a tracheostomy set, a cricothyroidotomy set, second-generation supraglottic airway devices (SGADs), endotracheal tubes ranging from size 3.5 mm to 8.5 mm, a video laryngoscope, a fibreoptic bronchoscope, a rigid bronchoscope, a jet ventilator and an airway exchange catheter. The patient was shifted to the OR on assisted bag-mask ventilation via a Bain’s circuit with continuous in-transit monitoring of vital parameters. In the OR, an electrocardiogram, a non-invasive blood pressure monitor, a pulse oximeter, an invasive arterial line, and a bispectral (BIS) index monitor were connected to the patient. Preoxygenation was done for five minutes with a fractional concentration of inspired oxygen (FiO₂) of 1. He was premedicated with intravenous fentanyl 50 µg, dexamethasone 6 mg, and palonosetron 75 µg. Anaesthesia was induced with the slow administration of propofol 50 mg. After checking the ability to ventilate, 30 mg of atracurium was administered. Ventilation was initially assisted with synchronous intermittent mandatory ventilation using air, oxygen, and sevoflurane. At three minutes, a 16 G nasogastric tube was inserted. Ventilation was continued for a few more breaths, and an Ambu AuraGain™ SGAD sized 3 was inserted to secure the airway. Ventilation was continued in pressure-controlled mode with tidal volume and respiratory rate adjusted to keep the end-tidal CO₂ below 50 mmHg and peak airway pressure less than 30 mmHg. The nasogastric tube was kept open to air to drain out the possible air that had insufflated the stomach due to the high airway pressure. Propofol and atracurium infusions were connected. The patient was positioned supine with the neck extended by placing a bolster under the upper chest. A horizontal neck (Kocher’s) incision was taken 2 cm above the sternal notch. The trachea and stenotic segment were delineated. The mediastinal part of the trachea was mobilised with blunt dissection using fingers. Supra- and infrahyoid laryngeal drop was performed to attain a length of 3 cm [Figure 2]. The trachea was looped at the stenotic part. Tracheotomy was done and cross-field ventilation was started using number 6 flexometallic tube [Figure 3]. The stenosed upper trachea with stenotic segment starting from the 1st tracheal ring and extending for 3 cm was resected (approximate length of trachea resected was 3.5 cm). The neck was then flexed to bring the cricoid cartilage close to the remaining distal tracheal segment. End-to-end cricotracheal anastomoses were done, first the posterior wall and then the anterior wall after removing the cross field ETT. During this period, oxygentation was maintained via an airway exchange catheter inserted through the SGAD and passed distal to the anastomosis [Figure 4]. Propofol infusion was continued during this period to maintain the depth of anaesthesia as per the BIS monitor. A negative air leak test was performed after the anastomosis was complete. Following skin closure, a ‘guardian suture’ was applied to keep the patient’s neck in the flexed position. A tracheoscopy was performed through the fibreoptic bronchoscope for inspection of the anastomosis site and suction of secretions. Neuromuscular blockade was reversed with neostigmine when the patient was conscious, oriented, and responding to instructions, with a tidal volume greater than 5 ml/kg and a normal, regular respiratory rate. The SGAD was removed, and the patient was shifted to the ICU on room air. He was discharged on the eighth postoperative day.

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Figure 2:

Approximately 3 cm length achieved after supra and infrahyoid drop

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Figure 3:

Cross field tube in place

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Figure 4:

Airway exchange catheter for oxygen insufflation

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DISCUSSION

Our case report highlights that emergency tracheal resection and reconstruction is a feasible option worth exploring, as tracheostomy is not an ideal option in a trachea already stenosed.

Tracheal resection needs meticulous planning and coordination between the operating team and the anaesthesiologists. Every step should be discussed out beforehand. Computed axial, coronal, and sagittal tomography 3-dimensional reconstruction gives a fair idea about the level and extent of stenosis as well as the luminal diameter of the stenotic segment. This can help the anaesthesiologist to plan the airway management. The OR should be prepared with advanced airway gadgets, including a rigid bronchoscope and a jet ventilator if available, and two senior anaesthesiologists with good coordination should be present. Preoxygenation, smooth and slow induction of anaesthesia, and checking for the ability to ventilate are paramount before administering muscle relaxants. Options for the initial part of airway management include, but are not limited to, passing a small-calibre endotracheal tube through the stenosis or keeping it proximal to it, using a second-generation SGAD, catheter-based high-frequency jet ventilation, and others. We used an SGAD in our patient as the stenosis was high up, and the lumen was very narrow. A high airway pressure is expected because of the stenosis and should be titrated with a low tidal volume and higher respiratory rate. Second-generation SGADs can withstand the raised peak airway pressure. We successfully used an Ambu AuraGain™ in our patient. Once the surgeon performs a tracheotomy to resect the stenotic segment, the scenario changes to an open trachea with no communication between the proximal and distal parts. Maintaining oxygenation, depth of anaesthesia, and washing out CO₂ becomes a challenge at this stage. A cross-field flexometallic endotracheal tube can be used for ventilating the lungs, or it can be selectively placed in one bronchus in case of supracarinal or bronchial stenosis. Oxygen can be insufflated into the trachea or a main stem bronchus via a tube exchange catheter inserted retrograde from the surgical side or via a jet ventilation catheter. A BIS-guided titration of propofol infusion maintains the depth of anaesthesia. For anastomosis, the neck needs to be flexed to appose both ends of the trachea. This position of the patient contrasts with the ‘sniffing the morning air’ position described for laryngoscopy and intubation. Following tracheal reconstruction, a protective lung ventilation strategy or driving pressure-guided ventilation should be followed with a reduced peak airway pressure. Extubation is a challenge as the neck needs to be kept flexed, the trachea having been freshly repaired, the presence of airway oedema because of manipulation, and residual mild stenosis at the anastomosis site. The extubation process should be smooth, and the patient should not cough or move vigorously on regaining the airway reflexes. An inadequate plan for extubation should be avoided at all costs, as subsequent airway control will be difficult and intubation will be catastrophic.^[7]

CONCLUSION

Our case report suggests that emergency tracheal reconstruction rather than tracheostomy is a practical therapeutic option for acute respiratory failure in selected patients post-stabilisation. However, patient safety is paramount, and emergency tracheostomy should be performed when the patient’s condition is not improving with conservative measures, noninvasive ventilation and high-flow nasal oxygen.