CASE REPORT www.ijcmr.

com Section: Anesthesiology

Airway Management of a Case of Severe Upper Tracheal Stenosis-

An Arduous Task Well Accomplished
Priyanka Bansal1, Kiranpreet Kaur2, Suresh Singhal3, Mamta Bharadwaj4

CASE REPORT
ABSTRACT
A 23 years old male, present with previous H/O tracheotomy
Introduction: Tracheal stenosis is rare but a fatal condition. after traumatic head surgery and following which patient
Tracheal resection and reconstruction, although a rare
was kept on a ventilator in ICU for 7 days. Decannulation
procedure, but because of the fact that it is lifesaving. It is
was done on 10th day post tracheostomy. The patient was
important to know the etiology, characteristic and exact
location of tracheal lesion and a thorough preoperative discharged home from ICU. Fifteen day post-decannulation
evaluation of the patient. patient presented with complaint of progressive dyspnoea
Case report: A 23 years male, present with previous H/O and stridor which aggravated on lying down. On examination
tracheotomy after traumatic head surgery, complained of patient was tachypneic with a respiratory rate of 24/minute,
progressive dyspnoea and stridor which aggravated on bilateral wheeze was present and the patient was using his
lying down. A sucessful tracheal ressection and anastomosis accessory muscles of respiration. Room air SpO2 was 92%.
performed. The immediate ABG report showed a PO2 76mm Hg and
Conclusion: We conclude that the key to the successful PCo2 of 84 mm Hg.
management in such patients is that appropriate method Computed tomography (CT) scan showed a short segment
of a safe and efficient gas exchange should be established.
(approx. 1.2 cm) having 80% stenosis with lumen diameter
Any respiratory distress should always be approached with
5-6 mm, at D1 vertebral level. Bronchoscopy was done and
caution. Proper extubation should be our primary goal because
mechanical ventilation postoperatively may be associated
revealed severe tracheal stenosis at the level of third and
with anastomotic dehiscence. fourth tracheal ring. Emergency surgery for tracheal resection
with end to end anastomosis was planned. The patient was
Keywords: Airway Management, Severe Upper Tracheal shifted in the operation theatre, all monitors including NIBP,
Stenosis, Arduous Task ECG, and pulse oximetry was attached. An 18 G cannula
was secured.
We assessed the patient for ventilation by administering 20
INTRODUCTION mg of propofol prior to induction. We were able to ventilate
the patient and proceeded for induction. Fentanyl100mcg
Tracheal stenosis is known to be rare, but one of the grievous
and 0.2 mg of glycopyrrolate was given. Induction was
and fatal condition which can compromise patient’s life.
done using injection propofol (2 mg kg-1), the patient was
The leading cause of tracheal stenosis is trauma, followed
reassessed for ventilation, and after successful ventilation
by prolonged tracheal intubation or tracheostomy. Other but
injection suxamethonium 50 mg given for relaxation.
rare causes could be tracheal tumors, chronic inflammatory
Anaesthesia was further maintained with N20and sevoflurane
diseases and collagen vascular diseases. All these conditions
in O2 and IPPV started. Anticipating a critical tracheal
results in narrowing of tracheal diameter, which further
stenosis and with the aim of securing the airway with the
compromise oxygenation and ventilation of the patient.
largest diameter of endotracheal tube, we started with 5mm
Tracheal resection and reconstruction is the treatment of
(ID) micro laryngeal surgery (MLS) tube (extra-long tube,
choice for most patients with tracheal stenosis.1-5
with the aim of securing the tip beyond the lesion), but was
Airway management in such cases is a challenge to the
not successful. MLS tube 4 mm was tried as a next step,
anaesthetist as well as the surgeon. Perioperative risk
increases with the severity and the site of the stenosis.
The sharing of an abnormal airway as well as securing for
1
Assistant Professor, Department of Anaesthesiology, 2Professor,
maintenance of oxygenation and ventilation throughout Department of Anaesthesiology, 3Senior Professor, Department
of Anaesthesiology, 4Associate Professor, Department of
the procedure is an arduous task. Tracheal resection and
Anaesthesiology PGIMS Rohtak, Haryana, India
reconstruction, although a rare procedure, but because of
the fact that it is lifesaving, the importance of anticipating Corresponding author: Dr Kiranpreet Kaur, Professor, Department
the course of surgery and designing an approved anesthetic of Anaesthesiology, PGIMS Rohtak, Haryana, India
plan cannot be overruled. It is important to know the
How to cite this article: Bansal P, Kaur K, Singhal S, Bharadwaj
etiology, characteristic and exact location of tracheal lesion
M. Airway management of a case of severe upper tracheal stenosis-
and a thorough preoperative evaluation of the patient. We
an arduous task well accomplished. International Journal of
report a successful emergency anaesthetic management of
Contemporary Medical Research 2020;7(9):I26-I27.
case presenting with critical upper tracheal stenosis post
tracheostomy. DOI: http://dx.doi.org/10.21276/ijcmr.2020.7.9.48

I26
Section: Anesthesiology International Journal of Contemporary Medical Research
Volume 7 | Issue 9 | September 2020 | ISSN (Online): 2393-915X; (Print): 2454-7379
Bansal, et al. Airway Management of a Case of Severe Upper Tracheal Stenosis

but encountered a resistance with it also. We planned to such patients, as attempts to insert a small ETT may cause
remove the cuff of 4 mm MLS tube, and finally we were complete obstruction of the airway. In these patients, the
successful in negotiating the tube beyond the stenotic lesion anatomy allows ventilation when breathing spontaneously.5,6,9
with slight difficulty. A confirmation with fiberscope was We were successful in inserting 4.0 mm ID MLS tube beyond
done to rule out major trauma. IPPV begun, but ventilator the stenosis and were able to ventilate the patient but with
pressures were very high. After adequate tracheal resection, resistance.
a sterile flexo-metallic ETT with ID, 7mm, was passed distal Proper arrangement for ventilatory support and ICU
to the tracheal lesion. Ventilation commenced with separate monitoring should be done in post operative period. If ETI is
sterile bains circuit. The distal endotracheal tube was taken to kept for post-operative period than it must be positioned
care of to prevent endobrochial migration or inadequate so that the cuff does not rest on any suture line.3,6 Our patient
oxygenation and ventilation. After a successful anastomosis was extubated on operation table but was shifted to ICU for
was achieved, the patient was re-intubated orally with 7 mm further monitoring and observation.
ID ETT, distal tube was removed and oral tube gradually CONCLUSION
secured in position, pass the tracheal anastomotic sutures.
We conclude that the key to the successful management in
Guardian sutures from chin to chest were placed to maintain such patients is that appropriate method of a safe and efficient
the flexion of the head. The patient was extubated fully gas exchange should be established. Any respiratory distress
awake, but cooperative and counselled about the posture and should always be approached with caution.The periods of
sutures. Rest of postoperative period was uneventful and the hypoxia and apnea should be avoided. Proper extubation
patient was shifted back to ward on second postop day. should be our primary goal because mechanical ventilation
DISCUSSION postoperatively may be associated with anastomotic
dehiscence. We finally recommend constant vigilance of
Surgery and airway management in a patient with tracheal
tenuous inflammatory airway, throughout the perioperative
stenosis is an extremely challenging job. Surgeon and
period for a better outcome.
anaesthetist both share common airway for tracheal
reconstruction, hence it is considered as complex and REFERENCES
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Submitted: 01-08-2020; Accepted: 12-09-2020; Published: 08-10-2020
conventional anesthetic technique would be catastrophic in

International Journal of Contemporary Medical Research Section: Anesthesiology I27

ISSN (Online): 2393-915X; (Print): 2454-7379 | Volume 7 | Issue 9 | September 2020