An airway can always be established promptly in a patient with neoplastic obstruction of the trachea or of the carina. Bleeding studies should be done. If any portion of the tracheal circumference is free of tumor, a rigid bronchoscope will pass beyond the obstruction. Cartilages and tumor yield to the bronchoscope. In the uncommon situation where tumor is completely circumferential, a bronchoscope may be insinuated through the residual tiny lumen with a corkscrewing motion. Blood or tumor debris is removed with a wide-

bore suction tip and the patient stabilized with respect to oxygenation and partial pressure of carbon dioxide (PCO2).The tumor is initially assessed with a Hopkins magnifying telescope to be certain it is not unduly vascular. Excessively vascular lesions, such as a hemangiomatous malformation, are very rare. Initial minimal biopsy can test vascularity if there is concern. Biopsy in any case is needed if a diagnosis has not previously been established. Excessively vascular lesions or the rare arteriovenous malformations should not be biopsied. Limited tumors can be resected and diagnosis established by frozen section from the specimen.

A coring technique is used to remove obstructing tumor of the trachea, carina, or main bronchus.3 A rigid bronchoscope of adult size (7 to 9 mm) is passed through the tumor with a rotary notion. The bevelled tip of the Jackson bronchoscope is favored. The axis of the airway must be kept in mind to avoid penetrating the tracheal wall, which may be completely replaced by tumor. Special care must be taken at the carinal spur. Potential exists, as with a laser, for injury to the pulmonary artery or other major structures. Detached pieces of tumor are quickly removed with suction. Coring is continued until a satisfactory airway is obtained (Figure 19-4). The bronchoscope is periodically occluded for ventilation between coring and suctioning. After a major amount of tumor has been removed, the biopsy forceps are used to further trim the tumor, to establish a satisfactory airway. If a very large chunk of tumor is detached, it can be held against the tip of the bronchoscope with the suction tip, and the bronchoscope withdrawn along with the suction tube and tumor. The bronchoscope is reinserted. Bleeding is not often a problem, but it can usually be controlled by broncho-scopic pressure. Saline irrigation clears the field as necessary. If bleeding seems excessive, the following may also be useful: epinephrine-soaked pledgets (0.l mg/mL) on long applicators, to stop oozing. Coagulation with long insulated electrodes or a laser has not been necessary, nor has an endotracheal tube with a tamponading balloon. These have not been required in our practice. A Foley venous occlusion catheter can also be used for bleeding distally in the bronchial tree. Coring would be inadvisable in an anticoagulated patient. Insertion of an endotracheal tube would be appropriate until coagulation levels are controlled.

At conclusion, the airway is carefully aspirated, checked for bleeding, and the patient is awakened. If anesthesia is profound, the patient should awaken with an endotracheal tube in place. The airway can be easily suctioned or irrigated. The tube is removed when the patient is sufficiently awake to demonstrate a normal protective cough reflex. The patient is best observed in a respiratory care unit for a few hours.

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