Anesthesia Bronchoscopy Intubation

The patient is usually induced with inhalation anesthesia and a rigid bronchoscope passed. Even if a tumor nearly occludes the trachea, it usually arises only from a portion of the tracheal circumference. The bronchoscope may be passed beyond the tumor beside that portion of the trachea not involved by tumor base, even against cartilaginous wall. In the case of the rare circumferentially based tumor, the rigid bron-choscope may be inserted through the residual central lumen initially, using the dilation technique described in Chapter 19, "Urgent Treatment of Tracheal Obstruction." If the airway in a patient with benign stenosis measures less than 6 mm in diameter, then it is routinely dilated under direct vision at this point, using the technique described. The airway must be adequate from the start to avoid retention of CO2 and possible arrhythmia during early phases of operation. An endotracheal tube is passed either beside a high or obstructing tumor, through the tumor or, in the case of stenosis, through the lesion. Apparent near-occlusion of the trachea is never an indication for cardiopulmonary bypass. If the lesion is lower and the obstruction is not critical or has been previously dilated, then the endotracheal tube may initially reside above the lesion. Management of an obstructing tumor that is very low in the trachea or at the carina is discussed in Chapter 19, "Urgent Treatment of Tracheal Obstruction." A critically obstructed airway must be opened in a rapid but wholly systematic way to avoid risking fatality. The special problem of critical sub-glottic stenosis in the larynx is also discussed in Chapter 25, "Laryngotracheal Reconstruction."

If the lesion is high or in midtrachea, then a standard full-length endotracheal tube is used. If the lesion lies low in the trachea, then the patient is intubated with a proximally extended tube with an armored flexible distal component (Figure 24-1). This allows the tube to be advanced into the left main bronchus, if needed. If a stoma is present, then intubation is still often carried out perorally as the most convenient technique for managing a tracheal lesion. In cases of tight stenoses that involve the subglottic intralaryngeal airway in addition to the uppermost trachea, and in patients in whom there is discontinuity of the airway due to stenosis between the larynx and the trachea, and where the stoma resides below the obstruction, intubation is done with a standard flexible armored tube through the stoma and induction carried out in this way. The tube is removed to permit rigid bronchoscopic examination of the distal trachea and then replaced. The operative field is prepared around such a tube, which is held vertically so that it will not contaminate the field, and the field is draped. A sterile endotracheal tube and necessary equipment are made ready at the operative field. The inlying tube is then removed, the sterile adhesive drape applied, and then the fresh sterile tube with sterile connecting tubing is placed through the sterile adhesive drape and the ends of the anesthesia tubing are handed off the field to the anesthetist (Figure 24-2). This anticipates the same arrangement of cross-field ventilatory tubing, which ordinarily follows tracheal division intraoperatively.

figure 24-1 Top of photograph is an extended endotracheal tube designed by Dr. Roger Wilson, which reaches from the mouth into the left main bronchus, if necessary. Its components are 1) a segment ofRusch tube for added length, 2) a metal sleeve connector, which hardly diminishes the lumen, and 3) a Tovell flexible armored tube, which has the advantages of a short balloon cuff. An extension is usually added to the sidearm for ease in cuff inflation and deflation. The tube is positioned with a flexible bronchoscope, sometimes aided intraoperatively by the surgeon. Other versions of an elongated tube are pictured in Figures 18-3 and 18-4 in Chapter 18, "Anesthesia for Tracheal Surgery." Pictured below is a flexible armored tube used for intubation of the distal trachea across the operative field.

figure 24-1 Top of photograph is an extended endotracheal tube designed by Dr. Roger Wilson, which reaches from the mouth into the left main bronchus, if necessary. Its components are 1) a segment ofRusch tube for added length, 2) a metal sleeve connector, which hardly diminishes the lumen, and 3) a Tovell flexible armored tube, which has the advantages of a short balloon cuff. An extension is usually added to the sidearm for ease in cuff inflation and deflation. The tube is positioned with a flexible bronchoscope, sometimes aided intraoperatively by the surgeon. Other versions of an elongated tube are pictured in Figures 18-3 and 18-4 in Chapter 18, "Anesthesia for Tracheal Surgery." Pictured below is a flexible armored tube used for intubation of the distal trachea across the operative field.

figure 24-2 Intubation for operation through existing stoma. Note the sterile anesthesia tubing. The field is prepared for upper tracheal resection. Access is available to the hyoid bone above, and for partial or complete sternotomy below, if any of these extensions are necessary.

The anterior approach has limited physiologic impact on the patient, but pneumothorax occurs rarely intraoperatively. It must be considered if a patient abruptly develops unexplained physiologic problems during operation, such as hypotension, diminished compliance, or falling oxygen saturation.

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