Laryngectomy with a Tritube ® and flow‐controlled ventilation

Canbaz

et al. 2023

Preprint

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.

Section: Discussionmentioning

confidence: 61%

Airway management during unusual tracheal stenosis: A Clinical Feasibility Trial

Canbaz

et al. 2023

Preprint

“…Advancement of the Tritube under direct bronchoscopic guidance, with the tube railroaded over the bronchoscope, was impossible because of the Tritube ID of 2.4 mm. In contrast to cases of single subglottic airway stenosis, where successful unguided advancement of Tritube past the stenosis has been described [4, 5], this was considered unsafe in this case of sequential tracheal stenoses because of the potential risk of injury to the trachea caused by the tip of the tube proximal to the second stenosis. Binding the Tritube tip to the bronchoscope, as described by Jeyarajah et al [6], was also not an option in our case because the composite diameter of the Tritube and bronchoscope in combination would have exceeded the internal diameter of the stenosis.…”

Section: Discussionmentioning

confidence: 95%

Bronchoscope‐assisted Tritube® placement for resection of sequential tracheal stenosis

Meierhans

Gelpke

Hetzel

et al. 2022

Anaesthesia Reports

Symptomatic tracheal stenosis is a rare but significant complication of long-term tracheal intubation and mechanical ventilation. Airway management for tracheal resection in severe tracheal stenosis, especially sequential stenoses, requires multidisciplinary planning. A valuable method of airway management is the insertion of a small-bore, cuffed tracheal tube (Tritubeâ, Ventinova Medical B.V., Eindhoven, The Netherlands) in combination with flow-controlled ventilation. In this case, a patient with tracheal stenosis following prolonged ventilation required resection of the stenosed tissue. A Tritube was placed via a J-tipped guidewire inserted through the working channel of a bronchoscope. Bronchoscopic cuff visualisation along the tube in severe stenosis is impossible because of the outer diameter of the tracheal tube. In this case, we therefore estimated the position of the tube tip based on the distance from the vocal cords to the carina measured on pre-operative computed tomography imaging. During completion of the dorsal tracheal anastomosis, cross field ventilation using a conventional tracheal tube had to be started due to impeded ventilation caused by the Tritube protruding distal to the carina. In severe sequential tracheal stenosis, a small-bore tracheal tube can safely be placed by guidance with a J-tipped guidewire. However, it is important to plan a backup method of ventilation, such as cross field ventilation, prior to commencing a critical procedure.

“…During total laryngectomy, it provides safe airway management, without the need for preprocedural tracheostomy. 6 This improves the oncological prognosis. The device also facilitates surgical tracheostomy.…”

Section: Discussionmentioning

confidence: 98%

“…5 The narrow bore of the device is beneficial in the obstructed airway and may be preferable to a 5-mm microlaryngeal tube (outer diameter 6.9 mm). 6 FCV allows normoventilation and eliminates the challenges of conventional ventilation with small microlaryngeal tubes.…”

Section: Discussionmentioning

confidence: 99%

The Tritube: Facilitating Upper Airway Surgery With an Ultrathin Cuffed Airway Device

et al. 2023

The Tritube is a narrow-bore cuffed tracheal tube (outer diameter 4.4 mm and inner diameter ~2.4 mm) that permits effective alveolar gas exchange using flow-controlled ventilation. Constant gas flow delivers physiological minute volumes, within preset pressure limits, and applies suction to the airway during expiration. The technique has attracted interest for laryngotracheal microsurgery as it provides superior surgical exposure and avoids many of the complications associated with high-frequency jet ventilation. Cuff inflation protects the lower airway and produces a motionless operating field. We describe the structure of the device, discuss its benefits, and suggest how it should be used clinically.