Anesthetic management for tracheal resection and reconstruction: conventional principles and emerging innovations

PURPOSE OF REVIEW: Tracheal resection and reconstruction (TRR) surgery is one of the most challenging procedures in thoracic anesthesia because it requires continuous coordination between the anesthesiologist and surgeon while sharing the airway throughout surgery. This review aims to provide a clinically useful framework for anesthesia management in patients undergoing tracheal surgery. It integrates traditional principles of managing shared airways with novel developments in anesthesia, including robot-assisted non-intubation surgery, flow-controlled ventilation (FCV) with ultrathin tubes, and high-flow nasal oxygenation (HFNO) to assist anesthesiologists in choosing the best management strategy for each patient. RECENT FINDINGS: The recent developments in TRR anesthesiology are related to the use of robotically non-intubated surgery with spontaneous breathing and oxygen insufflation into the thoracic cavity, FCV with an ultrathin tube with an Evone ventilator with continuous gas exchange during the resection process without tube change, spontaneous breathing with distal oxygen insufflation through a simple catheter for cervical lesions, and HFNO for apneic oxygenation in the open airway period for a tubeless surgical environment. SUMMARY: Preoperative planning is essential for TRR, along with individualized airway management. Ventilation methods include conventional cross-field techniques and advanced ones such as non-intubated robotic surgery, FCV using the Tritube device, and HFNO. The key factors to ensure success include minimizing anastomotic tension and cough-free emergence.