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important. In cases where a pneumonectomy is performed, there are also the issues of thoracic volume and shift of the mediastinum, as well as the need for careful fluid management, lower FiO2, and gentle surgical manipulation.32,33

There is little difference in the management of emergence from anesthesia in carinal surgery as opposed to tracheal surgery. Cord swelling is less likely, but obstruction from blood and secretions is more common. Pain control will be a bigger factor; the selection of methods that do not suppress respiratory drive is preferable.

Patients with previous carinal surgery who present for unrelated surgery should not, in general, present particular anesthetic problems. It would be prudent to avoid pushing an endotracheal tube too distally and risk injuring an anastomosis. Most anesthesiologists at centers with experience with these patients would confirm good tube position and an undamaged distal airway with bronchoscopy after intubation. If lung isolation is required for the surgical procedure, the considerations are more involved. As much as possible, it is wise to avoid instrumenting and especially inflating a cuff in a repaired region. The carinal anatomy will be abnormal, with possibly shorter bronchial lengths and different angles of departure for the bronchi. The use of an endobronchial tube may be necessary. In any case, all tube positionings should be done under fiber-optic guidance to avoid the risks of malpositioning.

figure 18-2c Intubation and ventilation for carinal resection and reconstruction (continued). Lesion involving carina and an extensive segment of trachea. A, Ventilation as previously indicated. B, Mobilization and anastomosis of right main bronchus to proximal trachea is performed first while ventilation is effected across the operative field in the left main bronchus. C, After completion of the first anastomosis, a jet catheter may be passed to provide oxygenation in the right lung. Dotted line indicates location of orifice in bronchus intermedius for implantation of left main bronchus. D, Endotracheal tube across the field in the left main bronchus may be intermittently removed as sutures are placed. As anastomosis is being completed, a jet catheter may be substituted to provide high frequency ventilation of the left lung.

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