Anaesthesia for laryngo-tracheal surgery, including tubeless field techniques

Abstract

Laryngo-tracheal surgery presents the anaesthetist with numerous challenges including a shared airway with potential for airway compromise pre-, intra-or postoperatively. Surgical desire for a tubeless field in patients with acute or chronic laryngeal or tracheal pathology can be a daunting prospect for anaesthetists unfamiliar with these techniques. With careful preoperative planning and multidisciplinary communication, the most appropriate strategy for oxygenation and anaesthesia can be agreed. Although frequently the domain of the 'head and neck' specialist, all grades of anaesthetist may be faced with these challenging cases, particularly urgent scenarios, out of hours and in non-tertiary centres. Furthermore, proficiency in techniques such as airway topicalization, high-flow nasal oxygenation, and jet ventilation are beneficial in other areas of clinical practice. Lessons learned NAP4 The 2011 4th National Audit Project (NAP4) of the Royal College of Anaesthetists and the Difficult Airway Society investigated major complications of airway management in the United Kingdom. More than one-third of cases detailed in NAP4 involved an airway problem in association with an acute or chronic disease process in the head, neck, or trachea. 1 Approximately 70% of these patients presented with airway obstruction, with the majority requiring either anaesthesia for diagnostic and resective surgery or intervention to maintain airway patency. Expert reviewers considered airway management to have been poor in many of these reported cases, with inadequate patient assessment, planning, and team communication repeatedly cited failings. Recurring themes included airway deterioration following inhalational induction and repeated failure in direct laryngoscopy attempts. Major complications of high-pressure source ventilation A 2008 national survey exploring major complications during anaesthesia for elective laryngeal surgery in the United Kingdom found that this type of surgery was being performed in 62% of responding hospitals. 2 Across these sites, 67% were using high-pressure source ventilation (HPSV) with supraglottic, subglottic, and transtracheal routes being chosen by 86, 50, and Key points • Providing anaesthesia for surgery to the larynx and trachea is associated with a higher risk of airway complications and a need for skills in a variety of specialist techniques.

The simultaneous use of three ventilatory techniques to maintain oxygenation in a patient undergoing tracheal laser resection of tumour

“…Airway surgery can be complex and high risk, and there have been various techniques described in the past for oxygenating and ventilating patients while also allowing an unobstructed surgical field . On occasion one technique alone is not enough and combinations are used, but despite this, oxygen desaturation does occasionally occur.…”

Imaging in head and neck cancers

“…It is important to recognise that CT and MRI are static images undertaken in the supine position, that narrowing of the airway can be affected by both posture and the phase of respiration and that further endoscopic assessment with fibreoptic nasal endoscopy (FNE) will allow a dynamic assessment of the airway. 6…”

Anesthetic considerations for tracheobronchial surgery

“…Anatomically, the trachea consist of an intra-and an extrathoracic part. Stenosis of the intrathoracic trachea or main bronchi present with a more expiratory than inspiratory stridor, while narrowing of the extrathoracic airway leads to inspiratory stridor (3,4).…”