Complications in Non-intubated Tracheal Resection: What Did We Learn?

Dear Editor, Anaesthetic management of tracheal resection and anastomosis presents unique challenges of a shared airway. Non-intubated spontaneous breathing during tracheal resection is a less-explored technique. In this discussion, we examine the unforeseen complications during non-intubated tracheal resection, which provided us with important lessons. A 39-year-old female with no comorbidities presented with complaints of difficulty breathing for 6 months. A computed tomography scan revealed a well-defined lesion (measuring approximately 2.0 cm × 2.8 cm × 3.4 cm) infiltrating the left anterolateral wall of the upper trachea at the third and fourth tracheal rings [Figure 1]. Tracheal resection and anastomosis using a cervical approach were planned. Preoperative examination revealed mild expiratory stridor, which did not worsen on lying down. Fibreoptic bronchoscopy showed intraluminal growth, 3 cm from the vocal cords, occupying 75% of the tracheal diameter. Flexometallic tubes of smaller diameter, sterile breathing circuit, paediatric bronchoscope and difficult airway trolley were prepared. After preoxygenation with 100% oxygen, anaesthesia was induced with an intravenous injection of propofol (1.5 mg/kg), fentanyl (2 μg/kg) and midazolam (1 mg). Following atracurium (40 mg), an Ambu Auragain No. 3.0 cuffed tube was inserted and controlled ventilation initiated. The depth of anaesthesia was maintained with an intravenous infusion of propofol at 100–150 μg/kg/min. By the time the surgeons were ready to cut open the trachea, the effect of the muscle relaxant had worn off, and the patient was breathing spontaneously through the cut end of the trachea, maintaining saturation between 90% and 94%.Figure 1: CECT Thorax transverse viewHalfway through the tracheal resection, disconnection of the propofol infusion was noted at the intravenous cannula, leading to tachypnoea and movement of the patient. Immediately, an intravenous bolus of propofol 40 mg and midazolam 1 mg was administered to deepen the anaesthesia plane. This resulted in apnoea, followed by rapid desaturation to 30%. Cross-field controlled ventilation was promptly instituted, which improved the saturation. As the patient regained spontaneous breathing, cross-field ventilation was discontinued. Another episode of desaturation occurred when the surgeons began closing the posterior tracheal wall. Cross-field ventilation was resumed; however, high peak pressures (>45 cm of water) were noted, and chest expansion was not observed on the right side. After a brief discussion with the surgeons, a bronchoscopic examination of the distal trachea revealed blood clots in the right mainstem bronchus and bronchus intermedius. Following the evacuation of the clots, oxygen saturation improved. Subsequently, spontaneous breathing ensured uninterrupted anastomosis of the tracheal ends. Postprocedure, the laryngeal mask airway was removed once the patient regained consciousness. The patient did not report any awareness during the surgery. Non-intubated tracheal resections have been reported in the literature recently. Spontaneous breathing through the cut ends of the trachea maintains oxygenation and carbon dioxide removal without interrupting the surgical procedure. This method prevents interference with intratracheal lesion,[1] reduces the risk of bleeding in the airway and enables monitoring of the recurrent laryngeal nerve during surgery. Negative effects of positive pressure ventilation (e.g. barotrauma and volutrauma) are avoided using this technique. The use of a second-generation supraglottic device allows leak-free ventilation at high peak airway pressure, especially in cases with critically obstructive lesions in the upper trachea. Despite its advantages, this technique carries inherent risks. Patients with poorly compliant lungs and obesity may not maintain oxygen saturation in a supine position under intravenous sedation.[2] Total intravenous anaesthesia is necessary for non-intubated techniques. Interrupting intravenous infusion for a short period can lead to a lighter plane of anaesthesia and intraoperative awareness. Therefore, monitoring the depth of anaesthesia with the bispectral index (BIS) is essential.[3,4] In our case, accidental disconnection of the propofol infusion could have been easily detected had we employed BIS monitoring.[4] Furthermore, sudden deepening of the anaesthetic plane can cause apnoea and rapid desaturation. Cross-field ventilation provides rescue ventilation in such situations. It is also important to note that the distal end of the trachea remains unprotected during the tubeless technique. Aspiration of blood clots can obstruct the airway, leading to rapid desaturation. Vigilant monitoring, repeated suctioning of the distal airways and constant communication between surgical and anaesthesia teams can help prevent this complication. We hope this information will enlighten readers about the less-explored anaesthesia technique during tracheal resection surgeries. Eternal vigilance, careful selection of patients, closed-loop communication with the surgeons and preparation for rescue ventilation hold the key to success in non-intubated anaesthesia for tracheal resection. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.