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An Alternative Method for Airway Management With Combined Tracheal Intubation and Rigid Bronchoscope

2019; Elsevier BV; Volume: 107; Issue: 6 Linguagem: Inglês

10.1016/j.athoracsur.2018.12.058

1552-6259

Francesco Puma, Mattia Meattelli, Miroslawa Kolodziejek, M. Properzi, Rosanna Capozzi, Alberto Matricardi, Lucio Cagini, Jacopo Vannucci,

Anesthesia and Sedative Agents

An innovative technique for airway management, using a small-diameter, short-cuffed orotracheal tube for assisting rigid bronchoscopy in critical airway obstruction is reported. The device, part of the translaryngeal tracheostomy kit, “Fantoni method” (DAR TLT, Covidien, Minneapolis, MN), was placed beyond the stenosis and used in combination with the rigid bronchoscope. This procedure improves safety during the management of critical tracheal stenoses because the airway is constantly under the anesthesiologist’s control. Consequently, inhalation anesthesia is feasible, use of neuromuscular blockade is possible, end-tidal carbon dioxide monitoring is reliable, and the distal airway is protected from blood and debris soilage during tumor debulking. Surgery is faster because it is uninterrupted. An innovative technique for airway management, using a small-diameter, short-cuffed orotracheal tube for assisting rigid bronchoscopy in critical airway obstruction is reported. The device, part of the translaryngeal tracheostomy kit, “Fantoni method” (DAR TLT, Covidien, Minneapolis, MN), was placed beyond the stenosis and used in combination with the rigid bronchoscope. This procedure improves safety during the management of critical tracheal stenoses because the airway is constantly under the anesthesiologist’s control. Consequently, inhalation anesthesia is feasible, use of neuromuscular blockade is possible, end-tidal carbon dioxide monitoring is reliable, and the distal airway is protected from blood and debris soilage during tumor debulking. Surgery is faster because it is uninterrupted. The Videos can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2018.12.058] on http://www.annalsthoracicsurgery.org. The Videos can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2018.12.058] on http://www.annalsthoracicsurgery.org. Airway management in rigid bronchoscopy can be challenging in patients with severe tracheal or carinal stenosis with intraluminal bleeding tumors. The endoscopic debulking of such stenoses may be hazardous because of inadequate distal airway control through the rigid bronchoscope. The two most commonly used ventilation methods are spontaneous assisted ventilation and high-frequency jet ventilation (HFJV). The first technique is not always suitable for patients with significant airway stenosis, whereas HFJV is the preferred ventilation method in such circumstances [1Putz L. Mayné A. Dincq A.S. Jet ventilation during rigid bronchoscopy in adults: a focused review.Biomed Res Int. 2016; 2016: 4234861Crossref PubMed Scopus (28) Google Scholar]. However, HFJV may produce barotrauma if the gas egress pathway is not ensured [1Putz L. Mayné A. Dincq A.S. Jet ventilation during rigid bronchoscopy in adults: a focused review.Biomed Res Int. 2016; 2016: 4234861Crossref PubMed Scopus (28) Google Scholar, 2Goudra B.G. Singh P.M. Borle A. Farid N. Harris K. Anesthesia for advanced bronchoscopic procedures: state-of-the-art review.Lung. 2015; 193: 453-465Google Scholar]. For this reason, we developed a technique aimed at better control of the airway below the stenosis and at safer anesthesia management, for selected patients. We use the tracheal tube supplied in the Fantoni translaryngeal tracheostomy kit (DAR TLT kit, Covidien, Minneapolis, MN). Ventilation management is obtained by first positioning the Fantoni orotracheal tube (FOT) below the stenosis and then starting the debulking maneuvers with the rigid bronchoscope alongside the tube. Therefore, the rigid bronchoscope is not used for ventilation, at least during the tumor debulking maneuvers. The FOT was designed to occupy the least amount of tracheal space, to ensure airway control and seal the lower trachea during translaryngeal tracheostomy. Features of this tube are as follows: 4-mm inner diameter, 5.3-mm outer diameter, 40-cm length, a large-volume low-pressure cuff, a very short cuff in its longitudinal axis, and a smooth tip protruding only 15 mm over the distal margin of the cuff (Fig 1). The major steps of this technique are the following:-Preoxygenation at 100% fraction of inspired oxygen for almost 3 minutes with ventilation mask-Induction of anesthesia using intravenous propofol (2 mg/kg, by intravenous bolus) in association with intravenous opioids such as remifentanil (0.02 to 0.5 μg/kg/minute) or fentanyl (2 to 4 μg/kg) while maintaining spontaneous ventilation or assisted manual mask ventilation and nebulizing local lidocaine 2% to 4% through the vocal cords during laryngoscopy-Tracheal intubation with the FOT, carefully placed, proximal to the tumor-Intubation with an 8.5 rigid bronchoscope (Storz Medical AG, Tägerwilen, Switzerland), which is inserted into the proximal trachea, parallel to the FOT-Advancement of the FOT beyond the stenosis under direct visual control. In the case of very tight tracheal stenosis, quick preliminary endoscopic dilation of the lumen is performed through the rigid bronchoscope with a Chevalier-Jackson bougie. In case of further problems, a thin airway exchange catheter can be inserted through the FOT as a guide for its atraumatic positioning.-Inflation of the tube cuff, verifying end-tidal capnography, then maintaining a deep plane of anesthesia with inhalation agents such as sevoflurane 1% to 2%. From this moment the interventional phase of the procedure may begin, using neuromuscular blockade, if it is deemed necessary, preferably with rocuronium at 0.6 to 1.2 mg/kg intravenously.-Completion of the endoscopic airway reopening maneuvers-Removal of blood clots and secretions that have dripped into the interspace between the tracheal tumor and the FOT during the debulking procedure-Deflation of the FOT cuff-Advancement of the rigid bronchoscope beyond the stenosis-Removal of the FOT-End of the procedure, with the preferred ventilation technique through the channel of the rigid bronchoscope and reversal of neuromuscular block with sugammadex (2 to 8 μg/kg intravenously) (Video 1) The technique adopted for carinal tumors is different: the FOT should be positioned in the distal trachea and then, under direct endoscopic control, guided into the patent main bronchus and cuffed. Here, ventilation through the FOT can be maintained up until the end of the endoscopic maneuvers, and even bronchial stent delivery can be carried out with the FOT in place. The distal positioning of the FOT into the left main bronchus can be challenging because the tube generally tends to veer to the right. To remedy this, the rigid bronchoscope needs to be inserted lateral to the FOT, thus leaving the FOT on the same side of the selected bronchus to be intubated (the FOT should be placed on the left side of the bronchoscope whenever the intubation is required for the left main bronchus). In this way, the tip of the FOT can be more easily guided into the patent bronchus with the assistance of rigid bronchoscope forceps. Whenever this is impossible, the FOT can be guided on a thin fiberoptic bronchoscope (Video 2). After intubation of the healthy lung, the rigid bronchoscope can be safely introduced into the obstructed main bronchus with low risks of poor ventilation and contralateral blood flooding (Video 3). Our technique is mainly indicated when a tracheal tumor severely reduces the respiratory space, so that distal airway control cannot be achieved through the proximally placed rigid bronchoscope, thus making spontaneous assisted ventilation unfeasible and HFJV risky. Obstructive carinal tumors are another indication where FOT prevents the exclusion of the healthy lung during the debulking maneuvers. The distal airway control is ensured, even during the initial phase of the procedure before the airway reopening. Indeed, despite the small diameter of the FOT, ventilation control is constantly adequate because of the characteristic cuff, which is suitable for positioning at both the tracheal and the bronchial level At the tracheal level, the FOT is able virtually to bypass any obstruction, and air tightness of the cuff is satisfactory. Distal flooding of blood resulting from tumor debulking is possible with all currently used ventilation techniques, and it can induce respiratory impairment because suction beyond the obstruction is unachievable before the tracheal lumen reopening. At the carinal level, intubation of the unobstructed main bronchus with the long FOT allows for insertion of the rigid endoscope into the contralateral diseased main bronchus without ventilation impairment. This wide-cuffed FOT eliminates the risk associated with contralateral soilage. Anesthetic management is streamlined: neuromuscular blocking is possible, inhalation anesthetic techniques can be used, and fraction of inspired oxygen and end-tidal carbon dioxide levels can be reliably monitored. Airway reopening is uninterrupted, and apneic phases of the procedure to ventilate the patient are not necessary. Disadvantages include the following: the procedure is expensive in part because an entire Fantoni translaryngeal tracheostomy kit must be used, although total costs would be reduced if the FOT was marketed alone; and the concomitant presence of the tube and bronchoscope could slightly limit surgical maneuvering. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjMDA1NDFmNzIyNTg5ZDE4YTFlZWNkZDU2YzczMzZlNyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc5MDMwNjc3fQ.r0mwlrTgSL32IOAzGrsJP0eiFII0vt-lUhyy592_VMi3oXGO7lHeMgLhj5mjC2Hikh3f3LvGFWQt0F-_mBNFc1JmMAWUFxX1dStCp0nQ8fQPRXvXgLx5kVwRnFycDfCysK_IER7maiyiRs7m1MggGnkMh564hMoYTJIOdfJ6_uJncF4hFZFQJEMIG0K6_VTBbBkjDvqMmVXQWMBlks7ekCX8ZbT-MhqsR-7ny7vE3Lv0N8arS-oZ69axEEjNoRr0yGAjxiEFjHWhIB3mAEkFWrP8-VCvzvL1gAyxEgmIy0qdJiv_u-3XXj9R6D-5jrH-D86V-zN1gs28ROIAeO4zHA Download .mp4 (17.43 MB) Help with .mp4 files Video 1The Fantoni orotracheal tube (FOT) is placed into the proximal trachea. A rigid bronchoscope in inserted. Under vision, the FOT is advanced across the stenosis and cuffed. A water-seal test is performed with saline. Lumen patency restoration is carried out. The FOT is uncuffed and pulled back. The rigid scope is advanced beyond the tumor. No distal blood is found.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjYTI2YjMwZGYwODQ3ODc4NWU1MTVjYmI2NjI0NjU4YyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc5MDMwNjc3fQ.Y-bf_qDUjqFmHYRqLKy_TXWuW-1LAS4cZjv5yvXfYwfOq5R8_wRAuWBkU7LlD2Dw3AyzQQehINzFyj625gtVq7CNeeHQXsERfdeg18g8qdK21s4D7sVjX9HkWvYWETqEK9zRbllQByBkienN_hMAp1YKPvFyNTMBMGmsbBudl_0Lg0n6fKlOHiucXFluoVpBpPnyoVSfevwuMwxwbOj2EDXxZaaHMSDJZ-Lt5tZ2tahYXRYYj6gr7oauloPiYr6DHlFiuHEslc83OHc6Ny0H6dvPf5DN1zpaiWVlTHkubpulJEfWw-5_hxsa_AA0duMwkWxuiQZdrMMV_D-17XACPQ Download .mp4 (16.08 MB) Help with .mp4 files Video 2For carinal tumors, the Fantoni orotracheal tube (FOT) in placed into the patent bronchus and cuffed under vision. Airway reopening of the affected side is achieved. Bleeding is controlled before uncuffing and pulling back the FOT.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI1NGUyYTUwNmU4M2MyYTY3MTJkNTIyMzdhZWEzNGQyMSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc5MDMwNjc3fQ.sX3K91vMay-J68z7F7MZq_4AId4tlEuNiw8YzGlkYBmeJ2pTMwwYzIMfy_jwI7K8HV7Eg1uSUTGMQt7NurBt-_m91Fg0bSfNG_XBAsNw5VtYkTyLUHv_La5yd8SzuusI_aG0ubo1dj08MzVjjwag2AJzC61YlykXS70HBIiJCi8FyPB7Wgis3MaQw_XE4Xjuaae-MrpQmE8W6ldm3fc6xfUnMB-9PttaI0PTqwhCEmwrPk6YAnTifqjeLCRBjD2ZMx1zprZEgqqGNQYMpLZatAQFRbo4YpTCW1yvOqOIgoWax1nqBA8KHy2LzcWN6lqwlbr_uMXyRdEP6-0_1nem0w Download .mp4 (14.36 MB) Help with .mp4 files Video 3An exemplifying case of a highly bleeding tumor (atypical carcinoid) arising from the right main bronchus. The Fantoni orotracheal tube is placed on the left side and cuffed. Tumor debulking shows vivid bleeding controlled with laser, epinephrine, cold saline, and mechanical pressure. Purulent secretions are found distally and are collected to prepare the field for a subsequent radical resection. At the end of the procedure, the exploration of the left side shows no blood flooding.