Airway management during unusual tracheal stenosis: A Clinical Feasibility Trial

Abstract

Background While actual figures are still lacking, this incidence of laryngotracheal stenosis (LTS) is expected to increase because of the high COVID-19 patient numbers requiring (prolonged) invasive mechanical ventilation. While prolonged intubation is a known risk factor of LTS, LTS related to COVID-19 may be result in a different phenotype: pronation affects the location of stenosis and COVID-19 pneumonia can decline lung mechanics. Therefore, airway management in patients with COVID-19 related LTS has unique challenges for both anesthesiologists and surgeons for its location and severity. This prospective observational feasibility trial aims to evaluate the use of a novel thin, cuffed, endotracheal tube (Tritube) in combination with flow_controlled ventilation (FCV) in the management of patients with LTS secondary to COVID-19 related LTS undergoing laryngeal surgery. Methods 20 patients suffering from COVID-19 related LTS, as diagnosed by CT, requiring endolaryngeal surgery were included. Ultrathin endotracheal tube Tritube, together with FCV was used for airway management and ventilation. Feasibility, ventilation efficiency and surgical exposure were evaluated. Results Median duration of mechanical ventilation during their ICU stay was 17 days, [range (7-27] and the prone position was used in all patients. In 18/20 patients endoscopic diagnosis, confirmed the initial CT diagnosis: posterior subglottic stenosis. Visual Analogue Scale (VAS) score was 9 out of 10 (range 7-10). FCV ventilation was performed with or without CO2 laser. All hemodynamic and respiratory variables were within the normal clinical range. In 1 patient a respiratory complication occurred, meaning that the SpO2 temporarily dropped to 89 %. Note that this patient had SpO2 of 90 % before induction of anesthesia. Conclusion This study shows that it is feasible to use Tritube with FCV in patients with unusual location of tracheal stenosis, namely a subglottic posterior location, undergoing laryngotracheal surgery. Tritube provides a good surgical field and FCV provided highly adequate ventilation especially in patients with compromised lung mechanics. Trial registration Clinical trial registration was done prospectively (NCT05317923) on 08/04/2022.