Anesthesia For Tracheal Surgery - Specific Procedures - UpToDate

24/12/2020 Anesthesia for tracheal surgery: Specific procedures - UpToDate
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Anesthesia for tracheal surgery: Specific procedures

Author: Vicki E Modest, MD
Section Editors: Peter D Slinger, MD, FRCPC, Carin A Hagberg, MD, FASA
Deputy Editor: Nancy A Nussmeier, MD, FAHA
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2020. | This topic last updated: Oct 20, 2020.
INTRODUCTION
Elective or emergency tracheal surgical procedures are typically performed to improve tracheal
patency or repair loss of tracheal integrity. Anesthetic challenges can include abnormal airway
anatomy and physiology, requirements for specialized endotracheal tubes (ETTs) and additional
airway devices to meet evolving intraoperative needs, and changes to alternative modes of
ventilation (eg, jet ventilation [JV], intermittent ventilation) if the trachea is open or obstructed.
This topic will discuss anesthetic management of adult patients undergoing specific procedures
involving the trachea from the distal edge of the larynx to the tracheal bifurcation at the carina.
General considerations for anesthetic management of tracheal surgery (eg, preoperative

assessment and planning; anesthetic techniques for induction, maintenance, and emergence
from general anesthesia; options for oxygenation and ventilation; management of
postoperative pain) are discussed in a separate topic (see "Anesthesia for tracheal surgery:
General considerations"). Considerations for patients with novel coronavirus disease 2019
(COVID-19) who require tracheostomy are also addressed in that topic. (See "Anesthesia for
tracheal surgery: General considerations", section on 'Tracheal surgery in COVID-19 patients'.)
Other topics discuss anesthetic management of patients undergoing surgical or other invasive
procedures involving the larynx, bronchi, or esophagus:
● (See "Anesthesia for head and neck surgery".)

● (See "Anesthesia for adult bronchoscopy".)
● (See "Anesthesia for esophagectomy and other esophageal surgery".)
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TRACHEOSTOMY
A tracheostomy is performed to bypass pathology that compromises upper airway patency, or

to provide access for ventilation support by creating a tracheal stoma with insertion of a
tracheostomy tube (cuffed or uncuffed) below the larynx. The surgical approach is midline at
the neck approximately midway between the cricoid cartilage and the sternal notch, usually
through the second and third tracheal rings. The patient is placed in a supine position with the
upper back slightly elevated and the head extended in order to stabilize the trachea and
improve surgical exposure. (See "Overview of tracheostomy", section on 'Technical aspects'.)
Open tracheostomy
General considerations — Important aspects of anesthetic management during a

tracheostomy procedure include:
● Protection of the patient's eyes with tape before surgical prepping and draping. (See
"Postoperative visual loss after anesthesia for nonocular surgery", section on 'Corneal
abrasion'.)
● Confirmation that the endotracheal tube (ETT) cuff pressure is adequate for airway
protection prior to surgical incision.
● Suctioning of potentially copious secretions that may pool in the oropharynx prior to
draping and again before deflation of cuff and withdrawal of the ETT.
● Appropriate control of oxygen and ignition source, particularly during open

tracheostomies, which carry the highest risk of intraoperative airway fire (see "Fire safety in
the operating room", section on 'Preventive measures in high-risk procedures' and
"Anesthesia for tracheal surgery: General considerations", section on 'Preoperative team
planning'):
• Ensure that the oxygen concentrations within the airway (both the fraction of inspired
oxygen concentration [FiO2] and the fraction of expired oxygen concentration [FeO2])
are <30 percent once the closed trachea is exposed in the presence of an ignition
source (eg, the electrosurgery [ESU] unit) [1]. Often three to five minutes are necessary
to allow the FeO2 to be reduced to <30 percent. (See "Fire safety in the operating
room", section on 'Oxygen during airway surgery'.)
Medical air should be used to dilute the oxygen concentration. Since nitrous oxide
(N2O) supports combustion similar to oxygen, it is never an appropriate diluent for
oxygen.
The oxygen analyzer is monitored to ensure that a FiO2 <30 percent is the actual
delivered oxygen concentration and the expired concentration goal of <30 percent is
met. We never simply reduce flow of 100 percent oxygen delivered through an open
source such as a facemask or nasal cannula, as this will result in nonhomogeneous
zones of oxygen concentrations, and is not condoned by the Anesthesia Patient Safety
Foundation (APSF) or the Emergency Care Research Institute (ECRI).
• Other precautions to avoid airway fire in this setting include minimizing oxygen
buildup by configuring the surgical drapes to be "open" to prevent accumulation of
oxygen underneath them, flushing the surgical field with medical air, and scavenging
the operating field with a suctioning device when an ESU is being used. (See "Fire
safety in the operating room", section on 'Management of drapes, towels, sponges,
and gauzes'.)
• Prior to opening the trachea, the surgeon, nurses, and anesthesiologist must verify
that the ESU has been handed off the surgical field. Then the FiO2 is increased to 1.0
prior to manipulation of the ETT (but only after the ESU is no longer on the surgical
field). (See "Safety in the operating room", section on 'Timeouts'.)
• Clear communication with the surgeon is necessary, particularly while pulling back the
ETT to allow surgical insertion of the tracheostomy tube, as well as after connection of
the new tracheostomy tube to the circuit to verify adequacy of ventilation. (See "Safety
in the operating room", section on 'Structured communication'.)
A quiet and nondistracting operating room is essential. (See "Safety in the operating
room", section on 'Techniques to minimize distractions and disruptions'.)
• If correct positioning of the tracheostomy tube is uncertain, flexible bronchoscopy is

employed to verify its position within the trachea before initiating ventilation.
Patient-specific considerations — Open tracheostomy is typically performed for one of the

following situations (see "Overview of tracheostomy", section on 'Percutaneous versus
operative'):
● Elective tracheostomy for a patient who is currently intubated with likely need for
prolonged controlled ventilation, including those with novel coronavirus disease 2019
(COVID-19). (See "Anesthesia for tracheal surgery: General considerations", section on
'Tracheal surgery in COVID-19 patients'.)
● Elective tracheostomy for anticipated airway compromise at or above the vocal cords due
to existing tracheal pathology or as an expected result of planned surgery
● Emergency tracheostomy for critical airway occlusion at or above the vocal cords
Need for prolonged intubation — Patients who are currently intubated and ventilator-
dependent typically have respiratory insufficiency and are critically ill. Elective tracheostomy
should be postponed if the patient is hemodynamically unstable and cannot be safely
transported from the intensive care unit (ICU) to the operating room.
Anesthetic management involves continuing or adjusting baseline intravenous (IV) sedative-

analgesic agents and/or adding additional anesthetic agents to maintain sedation/anesthesia.
It may also be necessary to adjust baseline vasoactive infusions to maintain hemodynamic
stability. For example, during ETT removal and tracheostomy tube insertion, augmentation of
anesthetic depth may beneficially blunt hemodynamic responses to this intense noxious
stimulation of the airway. Doses of IV anesthetic agents may be used, or addition of an
inhalation anesthetic is a reasonable option during certain portions of the procedure. However,
when the trachea is temporarily open, escape of volatile anesthetic agent and consequent
pollution of the operating room atmosphere will occur.
Although administration of a neuromuscular blocking agent (NMBA) is common and typically

useful, this is not always necessary and may be unwise if there is concern regarding patient
related surgical or anatomic challenges.
Anticipated airway compromise above the vocal cords — Selection of local or general

anesthesia for planned tracheostomy due to existing or impending upper airway compromise is
based on the likelihood that the airway would be lost if the patient is sedated or anesthetized.
(See "Anesthesia for tracheal surgery: General considerations", section on 'Selection of
anesthetic technique'.)
● If general anesthesia is selected, an ETT may be passed through the cords, either directly or
through a supraglottic airway (ie, laryngeal mask airway [LMA]). If upper airway
compromise allows for ventilation from above the cords, the ETT can be inserted after
induction, then the surgeon may proceed with the tracheostomy with the precautions
noted above. (See 'General considerations' above.)
● If a general anesthetic is to be avoided and the patient will remain awake then the airway
and neck must be made insensate. Use local anesthetic to topicalize the airway with
optional sedation. The goal is a comfortable patient who is sedated and not moving but
breathing spontaneously. (See "Anesthesia for tracheal surgery: General considerations",
section on 'Use of local anesthetic for selected procedures'.)

● Oxygen may be delivered via a facemask or nasal cannula as needed. With oxygen delivery
via such open systems, use of the ESU is avoided if possible. However, if the surgeon will
use an ESU and the patient needs supplemental oxygen, attach the facemask or nasal
tubing to a 5 mm ETT connector attached to the Y-piece of the breathing circuit of the
anesthesia machine so that a precise preset blending of oxygen and air at a FiO2 <30
percent can be delivered (the lower the better). Notably, several minutes may be required
for FeO2 to be reduced to <30 percent, as noted above [1]. (See 'General considerations'
above and "Fire safety in the operating room", section on 'Open oxygen delivery system'.)
Emergency tracheostomy for critical airway occlusion — Emergency surgical entry

directly into the subglottic larynx (ie, cricothyrotomy) may be necessary to treat critical airway
occlusion. Jet ventilator equipment should be immediately available for any patient with critical
tracheal stenosis especially those that are unstable. (See "Anesthesia for tracheal surgery:
General considerations", section on 'Jet ventilation'.)
Indications and technical aspects for this procedure are discussed separately. (See "Emergency
cricothyrotomy (cricothyroidotomy)".)
Percutaneous "mini" tracheostomy — A percutaneous tracheostomy is typically performed in

the ICU between the second and fourth tracheal rings, with sequential dilations over a guide
wire to allow for transcutaneous placement of a small diameter tracheostomy tube [2,3]. A
modified technique employing a tube exchanger has been employed [4]. Typically, this
procedure is performed under local anesthesia, often at the bedside. (See "Anesthesia for
tracheal surgery: General considerations", section on 'Use of local anesthetic for selected
procedures'.)
Indications and surgical techniques for percutaneous tracheostomy are presented separately.
(See "Overview of tracheostomy", section on 'Percutaneous versus operative'.)
BRONCHOSCOPIC EVALUATION BEFORE TRACHEAL SURGERY
Flexible bronchoscopy — Before beginning some elective tracheal surgical procedures, such as

stent placement or open repair or reconstruction, the surgeon usually inspects the glottis and
trachea via a flexible bronchoscope. This preprocedural examination is useful to define current
anatomy and pathology, confirm that the planned surgical procedure is appropriate, and rule
out the presence of a new acute process that could be improved with therapy. In some cases, a
decision to reschedule elective surgery is appropriate.

Depending on the goal of the bronchoscopic examination and patient-specific factors, the
anesthetic technique may involve local anesthetic topicalization of the vocal cords and trachea
with optional sedation, rather than general anesthesia. (See "Anesthesia for adult
bronchoscopy", section on 'Topical airway anesthesia with sedation'.)
If a general anesthetic technique is selected, support of ventilation will be necessary. The

flexible bronchoscope may be inserted through a supraglottic airway (ie, laryngeal mask airway
[LMA]) device or endotracheal tube (ETT) that has an inner diameter (ID) that is ideally ≥7.5 mm.
Adequate ventilation is usually achieved by ventilating around the scope after its passage
through the LMA or ETT. The breathing circuit from the anesthesia machine is attached to a side
port of a bronchoscope adapter. (See "Anesthesia for adult bronchoscopy", section on 'Airway
control'.)
Either an inhalation anesthetic technique or total intravenous anesthesia (TIVA) may be

employed to produce general anesthesia during flexible bronchoscopy. We typically select a
TIVA technique if significant suctioning of the trachea is anticipated since suctioning causes
interruptions in inhalation anesthetic delivery. Patient immobility and absent cough reflex may
be achieved with or without administration of a neuromuscular blocking agent (NMBA). Details
regarding anesthetic techniques and agents are discussed separately. (See "Anesthesia for adult
bronchoscopy", section on 'Anesthetic techniques'.)
Rigid bronchoscopy — Rigid bronchoscopy may be employed in selected patients to

accomplish airway evaluation, dilation, or placement of a tracheal T-tube or stent. The rigid
bronchoscope is a straight metal tube available in a range of calibers with a beveled distal end
that is inserted into the trachea through the mouth (or tracheostomy stoma) in order to
visualize the trachea, and, in some cases, the mainstem bronchi.
Typically, deep general anesthesia is necessary during rigid bronchoscopy due to noxious
airway stimulation and extreme discomfort. Details regarding specific anesthetic techniques
and agents used during rigid bronchoscopy are discussed separately. (See "Anesthesia for adult
bronchoscopy", section on 'General anesthesia for rigid bronchoscopy'.)
Advantages and disadvantages of different ventilation methods that may be employed during
rigid bronchoscopy are discussed separately (see "Anesthesia for adult bronchoscopy", section
on 'Ventilation techniques'). These include:
● Standard positive pressure ventilation (PPV) – PPV is accomplished by attaching the

anesthesia circuit to the side port of the rigid bronchoscope ( picture 1). Ventilation is
typically controlled by hand to accommodate the bronchoscopist's need for periods of
apnea. (See "Anesthesia for adult bronchoscopy", section on 'Positive pressure ventilation'.)
In patients with tracheal narrowing, conditions for ventilation may vary. For example, a
small-caliber rigid bronchoscope may be passed through a tracheostomy stoma, and
ventilation is accomplished through the side-port of the bronchoscope. The tight fit of the
rigid bronchoscope against the narrowed segment of the trachea allows PPV. However,
leakage of gases around the bronchoscope occurs when it is not fully engaged with the
stricture, or as the stenotic tracheal segment becomes progressively dilated. It may then be
necessary to administer high flows of oxygen to compensate for lost airway gases, with
continuous monitoring of pulse oximetry and observation of chest rising to ensure
adequacy of PPV and oxygenation [5]. Since gas flows are high in this setting, capnography
is not a useful monitor.
● Jet ventilation (JV) – JV is accomplished via a purpose-built port that has a Luer-Lock
connector for the JV tubing ( picture 2). (See "Anesthesia for adult bronchoscopy", section
on 'Jet ventilation'.)
● Intermittent ventilation with an ETT – If necessary to ensure adequacy of ventilation, the

bronchoscope may be intermittently removed and replaced by an ETT. In such cases, a
flexible kink-resistant ETT (eg, a wire-reinforced "armored" ETT) is preferred ( picture 3).
(See "Anesthesia for tracheal surgery: General considerations", section on 'Endotracheal
tube selection'.)
We usually select a TIVA technique to maintain general anesthesia, including administration of a

NMBA to induce complete muscle relaxation. This prevents patient movement and facilitates
exposure of the glottis for the bronchoscopist. We typically avoid inhalation anesthesia with a
volatile anesthetic agent since leakage of anesthetic gases around and through the
bronchoscope will contaminate the operating room during interventions performed by the
bronchoscopist. Furthermore, measurements of the end-tidal anesthetic agent will be
inaccurate. In addition, if JV is employed, TIVA is the only anesthetic choice since inhalation
anesthetics cannot be administered via a JV system. (See "Anesthesia for adult bronchoscopy",
section on 'Total intravenous anesthesia'.)
Occasionally, we may use an inhalation anesthetic technique with sevoflurane if the surgeon
requests a period of spontaneous negative pressure ventilation for observation of dynamic
pathology such as movement of the membranous backwall of the trachea with respiratory
variations that occur in patients with tracheomalacia. (See "Anesthesia for adult bronchoscopy",
section on 'Inhalation anesthesia'.)
INSERTION OF AN ENDOTRACHEAL STENT

An endotracheal stent provides tracheal support to improve or maintain airway patency in

patients with a tracheal mass, stenosis, or collapse [6]. Urgent or emergency stenting may be
employed to treat critical tracheal stenosis. In such cases, ventilation strategies are
individualized depending on the location (and cause) of tracheal narrowing [7]. Less commonly,
placement of a stent may be necessary to occlude a tracheal laceration or fistula.
Orally placed tubes are straight and situated distal to the vocal cords. In some cases, the distal
end bifurcates to travel for a distance down the mainstem bronchi. Stents placed via a tracheal
stoma are "T" shaped, with a limb extending through the tracheostomy site and the proximal
and distal limbs positioned in the trachea. These stents may be straight or bifurcated at the end
[6]. (See "Airway stents".)
The stent or T-tube is deployed through a rigid or flexible bronchoscope inserted and/or forceps
via a transoral or stomal route (see 'Bronchoscopic evaluation before tracheal surgery' above)
[6]. If placement is through a mature stoma into an intact trachea, the airway will be reliably
accessible throughout the procedure.
● Local anesthesia – In selected cases it is possible to place a stent via a flexible

bronchoscope with local anesthetic applied to the airway plus optional sedation. Examples
include silicone or expandable metal stents that can be gently and quickly deployed into
position and do not need removal for sizing ( table 1) [8]. (See "Anesthesia for adult
bronchoscopy", section on 'Topical airway anesthesia with sedation'.)
● General anesthesia – Deep general anesthesia is usually necessary for stent insertion,
particularly if the device is deployed via a rigid bronchoscope (see 'Rigid bronchoscopy'
above). In one randomized study of 64 patients undergoing airway stenting, controlled
ventilation with administration of a neuromuscular blocking agent (NMBA) resulted in a
lower incidence of desaturation events (ie, percutaneous oxygen saturation [SpO2] <95
percent) compared with allowing spontaneous respiration (10 versus 75 percent) [9].
Typically, the bronchoscope and stent are inserted, then repeatedly repositioned or
removed to adjust limb lengths for an optimal tracheal fit. This technique requires periods
of intermittent ventilation (see "Anesthesia for tracheal surgery: General considerations",
section on 'Intermittent ventilation'). If transoral ventilation can be used, we employ an
oxygen mask, supraglottic airway (ie, laryngeal mask airway [LMA]), or endotracheal tube
(ETT). In patients with a tracheostomy, manual occlusion of the tracheal stoma may be
required to achieve adequate ventilation via a transoral airway device. If ventilation via a
tracheal stoma becomes necessary during the procedure, a wire-reinforced "armored" ETT
is selected for insertion into the stoma to minimize the risk of ETT kinking ( picture 3).

(See "Anesthesia for tracheal surgery: General considerations", section on 'Endotracheal

tube selection'.)
We prefer a total intravenous anesthesia (TIVA) technique since delivery and end-tidal
measurements of inhalation anesthetic gases are unreliable during these periods, and we
also use a neuromuscular blocking agent (NMBA) to prevent patient movement. (See
"Anesthesia for tracheal surgery: General considerations", section on 'Maintenance'.)
Before extubation, possible administration of dexamethasone 8 to 10 mg to reduce airway

and vocal cord swelling is discussed with the surgeon. We avoid administration of any long-
acting opioid since insertion of an endotracheal stent or T-tube produces little or no
postoperative pain, and to avoid harm from oversedation when airway patency may be
tenuous in the postoperative period (see "Anesthesia for tracheal surgery: General
considerations", section on 'Pain management'). For example, airway obstruction may be
caused by accumulation of secretions or clot, or by a dynamic tracheal lesion that allows a
stent to drift into malposition. Continued close observation is necessary during and after
emergence to ensure airway patency. (See "Anesthesia for tracheal surgery: General
considerations", section on 'Emergence and extubation'.)
Some patients cough repeatedly postemergence with their primary complaint being the
feeling of a foreign body in the trachea. If the patient's airway is patent, low doses of a
short-acting opioid (eg, fentanyl 25 to 50 mcg) may be judiciously administered to blunt the
cough reflex.
OPEN REPAIR OR STENT OCCLUSION OF A TRACHEOESOPHAGEAL FISTULA
Tracheoesophageal fistulae (TEF) are patent connections between the respiratory and upper
gastrointestinal (GI) tract ( picture 4). A TEF may be present at birth due to a genetic variant,
or may form later in life as a result of an inflammatory process, neoplasm, or trauma to the
respiratory tract and/or esophagus ( table 2). The precise location of a TEF varies. Most
acquired TEFs are proximal (ie, at the cervicothoracic junction). TEFs due to motor vehicle
accidents with a crush injury to the chest are typically located at the carina. Other etiologies
may occur anywhere along the trachea. (See "Tracheo- and broncho-esophageal fistulas in
adults".)
An occlusive tracheal stent (silicone or self-expanding metallic) may be deployed for palliation of
a TEF due to a malignant tracheal or esophageal lesion or to serve as a bridge if surgery must
be deferred ( picture 5). Tracheal stents are positioned via flexible or rigid bronchoscopy, and
may be combined with an esophageal "kissing stent" placed via esophagoscopy ( picture 6).
(See 'Bronchoscopic evaluation before tracheal surgery' above and "Anesthesia for
esophagectomy and other esophageal surgery", section on 'Repair of tracheoesophageal
fistula'.)
For open repair, a transverse low "collar" incision that may be extended via a partial sternotomy
is typically accomplished in the supine position. However, a right thoracotomy in the left lateral
decubitus position may be selected for a distally located TEF. A long endotracheal tube (ETT)
may be necessary for a distally located TEF.
Preoperative preparation
Preoperative assessment and planning — General anesthesia is necessary for open repair

of TEF or for stent occlusion via a rigid bronchoscope. As noted above, when flexible
bronchoscopy is employed, stent placement may be possible using local anesthesia plus
sedation in selected patients. (See 'Insertion of an endotracheal stent' above.)
In addition to standard assessment and planning for tracheal surgery, the following
preoperative considerations are important (see "Anesthesia for tracheal surgery: General
considerations", section on 'Preoperative assessment and planning'):
● Confirm optimal medical condition, particularly whether treatment of pulmonary infection

and nutritional status are adequate.
● Confirm administration of usual medications on the morning of surgery, particularly proton

pump inhibitors and acid suppression therapy.
● Understand the patient's anatomy (precise location and size and patency of the lesion) and
confirm the surgical approach and planned interventional sequence (eg, positioning, use of
flexible or rigid bronchoscopy, location of incision[s]).
● Achieve consensus during the preoperative team briefing regarding techniques for
anesthetic induction, endotracheal intubation and positioning of the tip positioning, and
maintenance of oxygenation and ventilation. (See "Anesthesia for tracheal surgery: General
considerations", section on 'Key points for surgical briefings'.)
● If a right thoracotomy is planned, insertion of a thoracic epidural (TEA) or paravertebral

block (PVB) catheter is typically accomplished before induction of general anesthesia. (See
"Anesthesia for tracheal surgery: General considerations", section on 'Planning for
postoperative analgesia'.)
Operating room setup — In addition to standard equipment for airway management, the
following specific equipment should be available (see "Anesthesia for tracheal surgery: General
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considerations", section on 'Operating room setup'):
● Flexible bronchoscopes in both adult and pediatric sizes immediately available in the
operating room throughout the surgical procedure.
● Dedicated suction for the bronchoscope and a second setup with a Yankauer suction tip
available at the head of the bed.
● An assortment of regular, extra-long, and a wire-reinforced "armored" ETTs in all sizes from
7.0 mm ID down to the smallest available cuffed sizes ( picture 3). If the fistula is close to
the carina or involves a bronchus, a long ETT, double-lumen endotracheal tube (DLT),
and/or a bronchial blocker may be needed. The selected tube will be advanced over the
flexible bronchoscope beyond the fistula into the opposite bronchus so that one lung
ventilation (OLV) can be initiated. Then, the nonventilated lung can be isolated from the
fistula by a bronchial blocker, if necessary. (See "Anesthesia for tracheal surgery: General
considerations", section on 'Endotracheal tube selection' and "Lung isolation techniques".)
● An assortment of supraglottic airway devices (ie, laryngeal mask airway [LMA]) may be used
as another option to facilitate fiberoptic bronchoscopic examination and tracheal
suctioning. (See "Anesthesia for tracheal surgery: General considerations", section on
'Supraglottic airway devices'.)
Induction and initial airway management — Patients with TEF are at high risk for pulmonary
aspiration of gastric contents that have seeped through the fistula tract. Applying cricoid
pressure during induction is not protective. The following strategies may be beneficial:
● Preinduction strategies are employed to minimize gastric insufflation and risk for soilage of
the trachea via the fistula tract include:
• Elevation of the head of the bed to a 30 degree angle to both reduce the risk and
improve the functional residual capacity of lungs that may be chronically damaged by
pulmonary aspiration.
• Preoxygenation with 100 percent oxygen to increase oxygen reserve and provide
additional time to secure the airway before positive pressure ventilation (PPV) is
initiated [10]. (See "Rapid sequence induction and intubation (RSII) for anesthesia",
section on 'Preoxygenation'.)
• Preinduction stomach evacuation via an esophagoscope after numbing the

oropharynx. However, blind instrumentation of the esophagus is avoided. Typically, the
surgeon will use an esophagoscope to evacuate gastric contents under direct

visualization, and, in some cases, may position a nasogastric or orogastric tube for
later evacuation of stomach contents.
● Induction strategies emphasize avoiding blind intubation as this may result in inadvertently
traversing the fistula tract and intubating the esophagus or mediastinum. Thus, intubation
and ETT positioning are always accomplished with fiberoptic bronchoscopic guidance.
Isolation of the TEF while avoiding soiling of the trachea with gastric contents may be
accomplished by:
• Awake intubation of a spontaneously breathing patient after topical anesthesia and/or

nerve blocks, as described separately (see "Flexible scope intubation for anesthesia",
section on 'Topical anesthesia'). However, the airway must be exceptionally well
anesthetized during intubation since coughing increases abdominal and epigastric
tone, thereby increasing risk of spillage of gastric contents into the trachea and
copious tracheal secretions may present a tropicalizing challenge. General anesthesia
is induced only after the ETT has been properly positioned.
• Induction of general anesthesia with efficient endotracheal intubation and avoidance

of PPV until the fistula is isolated by placement of the ETT cuff beyond the TEF (see
"Anesthesia for tracheal surgery: General considerations", section on 'Induction and
airway management'). Specific techniques for induction of general anesthesia and
placement and positioning of the ETT via a flexible bronchoscope include:
- Rapid sequence induction and intubation (RSII). If succinylcholine is used, we

administer a defasciculating dose of a nondepolarizing neuromuscular blocking
agent (NMBA) before succinylcholine to reduce the intragastric pressure increase
that would otherwise occur [11,12]. We prefer RSII if it is likely that the airway can
be easily secured in a patient with unambiguous airway anatomy. (See "Rapid
sequence induction and intubation (RSII) for anesthesia" and "Rapid sequence
induction and intubation (RSII) for anesthesia", section on 'Defasciculation'.)
- Inhalation induction to avoid PPV by maintaining negative pressure spontaneous

breathing until the fistula has been isolated by a properly positioned ETT.
Potentially difficult airway anatomy should be anticipated (eg, patients with severe
tracheal inflammation or copious secretions). This can create challenges in
distinguishing the trachea from the fistula tract or esophagus during
bronchoscopic examination. For such patients, an inhalation induction or awake
intubation is a safer choice than RSII since these techniques allow the patient to

continue ventilating during the additional time that may be required to adequately
visualize anatomical structures.
- Awake intubation after numbing the airway with topically applied local anesthetic
or use of airway nerve blocks, with optional sedation when appropriate. Notably,
patients with copious secretions may interfere with adequacy of topical anesthetic
techniques.
● Verification of correct ETT position ensures that its tip is within the tracheal lumen (and not
out through the fistula tract), and that it has been advanced far enough to allow the cuff to
be distal to the fistula and above the carina. In some cases, the surgeon may opt to
perform flexible bronchoscopic inspection of the fistula while the patient is awake or may
request that an LMA be inserted immediately after induction of general anesthesia to allow
a quick inspection before insertion of the ETT (which may cover up the pathology). In such
cases, the ETT can subsequently be inserted over the flexible bronchoscope for proper
positioning.
● Patients with a TEF near the carina require special management. Either a DLT or a long
single lumen tube may be employed. If it is not possible to inflate the tracheal cuff of the
DLT due to proximity to the TEF, a bronchial blocker is used to isolate the nonventilated
lung from the TEF. (See "Anesthesia for tracheal surgery: General considerations", section
on 'Endotracheal tube selection' and "Lung isolation techniques".)
● PPV is avoided until the fistula has been isolated by a properly positioned ETT, in order to
prevent gastric insufflation and pressurization. If the trachea is grossly soiled, the flexible
bronchoscope can be used for suctioning and cleaning the distal airways prior to initiating
PPV.
● Initiation of controlled PPV is with low pressure settings. Start at 10 to 15 cm H2O for a
target tidal volume (TV) of 4 to 6 mL/kg using either one or two lungs. Typically, the fraction
of inspired oxygen (FiO2) is set at 100 percent initially, then reduced to the lowest level that
maintains adequate oxygen saturation (measured with pulse oximetry). Controlled
ventilation and oxygenation may be facilitated by administration of a NMBA and/or lung
recruitment maneuvers. Further details are available in separate topics. (See "Anesthesia
for tracheal surgery: General considerations", section on 'Standard positive pressure
ventilation' and "One lung ventilation: General principles", section on 'Ventilation
strategies'.)
Maintenance and intraoperative airway management — After general anesthesia has been

induced and the airway has been secured, the surgeon will reevaluate airway and esophageal
pathology using both bronchoscopy and esophageal endoscopy. In some cases, the surgeon
may opt to place an esophageal stent that at least partially isolates the TEF. Repair of the
esophagus and trachea (or stent placement) is subsequently completed after the distal airway
has been suctioned and cleaned via a flexible bronchoscope and after maneuvers to facilitate
alveolar recruitment.
If the ETT is positioned beyond the fistula, it is pulled back intermittently during the surgical
repair in order to visualize and access the TEF. PPV is avoided whenever the fistula is exposed;
instead, intermittent ventilation is employed during these periods (see "Anesthesia for tracheal
surgery: General considerations", section on 'Intermittent ventilation').
Since inhalation anesthetic delivery and end-tidal measurements of exhaled concentration are
unreliable during intermittent ventilation, we employ a TIVA technique to ensure maintenance
of adequate anesthetic depth. (See "Anesthesia for tracheal surgery: General considerations",
section on 'Maintenance' and "Maintenance of general anesthesia: Overview", section on 'Total
intravenous anesthesia'.)
Extubation and recovery
● Extubation – Typically, tracheal extubation is planned at the end of the surgical procedure
in the operating room [13,14]. The surgeon must be present.
Just before emergence, the surgeon may inspect and further clean the airway with a
flexible bronchoscope inserted via the existing ETT or through an LMA that is placed at the
end of the case. If an LMA is selected, bronchoscopic examination of the vocal cords can
address any concerns regarding vocal cord swelling or injury to the recurrent laryngeal
nerve. (See "Respiratory problems in the post-anesthesia care unit (PACU)", section on
'Vocal cord paralysis'.)
Other prerequisites for extubation are described separately. (See "Anesthesia for tracheal
surgery: General considerations", section on 'Emergence and extubation'.)
● Recovery – Following extubation, positive pressure airway support is used judiciously after
any tracheal repair. Although reintubation is avoided if possible, this is accomplished over a
flexible bronchoscope using a small diameter ETT when necessary.
Patients undergoing TEF repair are transported to the intensive care unit (ICU) for
postoperative observation and management, as discussed separately. (See "Anesthesia for
tracheal surgery: General considerations", section on 'Transfer to intensive care unit'.)

Postoperative pain after isolated stent insertion or a transverse cervical incision is typically
minimal. (See "Anesthesia for tracheal surgery: General considerations", section on 'Pain
management'.)
TRACHEAL RESECTION AND RECONSTRUCTION
Tracheal pathology requiring tracheal resection and reconstruction may be malignant or

benign. The surgical approach depends on lesion location [15]:
● Upper or midtracheal lesions such as postintubation injuries are typically approached

through a cervical transverse collar incision.
● Lower tracheal or carinal lesions, as well as hilar or carinal releases are typically
approached via either a sternal split or a right thoracotomy.
Preoperative assessment and preparation — Preoperative preparations are generally similar

to those for repair of a tracheoesophageal fistula (TEF) (see 'Preoperative assessment and
planning' above). Additional considerations include [15] (see "Anesthesia for tracheal surgery:
General considerations", section on 'Preoperative assessment and planning'):
● Since tracheal pathology may be dynamic, reevaluation just before surgery is particularly
important to check for changes in status, and to select the most appropriate induction and
airway management techniques.
● The patient is informed that there will be retention "chin" stitches running from their chin
to upper chest to hold their head and neck in flexion during the postoperative period (to
offload the trachea tension), and that they should not pull these stitches by attempting to
extend the head and neck when they awaken from anesthesia.
● An intra-arterial catheter is inserted in all patients undergoing tracheal resection and

reconstruction; this is particularly important for postoperative management.
● Intravascular access via two reliable peripheral or other IV catheters is preferred, since the
arms will be tucked and inaccessible. (See "Anesthesia for tracheal surgery: General
considerations", section on 'Monitoring'.)
Induction and initial airway management — Anesthetic induction requires careful planning

[15]. (See "Anesthesia for tracheal surgery: General considerations", section on 'Induction and
airway management'.)

An endoscopic airway evaluation with flexible or rigid bronchoscopy, or both, is typically

performed before surgical incision to finalize the to finalize the operative plan [6]. A flexible
bronchoscope may be inserted transorally with the patient awake, or through an endotracheal
tube (ETT) or a supraglottic airway (ie, laryngeal mask airway [LMA]) with the patient asleep (see
'Flexible bronchoscopy' above). Some surgeons may elect to insert a rigid bronchoscope
immediately after anesthetic induction, but before ETT intubation (see 'Rigid bronchoscopy'
above). Furthermore, if the patient has critical airway stenosis, the surgeon may need to dilate
the trachea using the rigid bronchoscope to allow subsequent passage of a 5.5 or 6.0 mm
cuffed ETT though the stenotic area.
An LMA may be considered for use as the primary airway until cross-table or jet ventilation (JV)
is established [15-18] (see "Anesthesia for tracheal surgery: General considerations", section on
'Supraglottic airway devices' and 'Maintenance and intraoperative airway management' below),
especially if the patient has a friable mid- to proximally-located subglottic stenosis. The LMA is
placed during induction of general anesthesia and used until the trachea is resected distal to
the pathology. By avoiding traversing the tracheal pathology with an ETT, risks for mechanical
trauma, swelling, bleeding, or tumor fragmentation, with resultant airway occlusion, are
minimized. An LMA may also serve as a rescue airway if the trachea cannot be intubated after
anesthetic induction agents are administered [7,18]. Potential disadvantages of LMA use
include managing an airway that is not secured and potential difficulty in performing an
anastomotic leak test (at 20 cm H2O and maybe higher) using a brief Valsalva maneuver after
completion of the tracheal reconstruction [15].
Maintenance and intraoperative airway management — We typically select a total

intravenous anesthesia (TIVA) technique (eg, with propofol and remifentanil titrated to maintain
adequate anesthetic depth) and add a nondepolarizing NMBA to maintain anesthesia [6,15].
Intermittent manipulation of the airway during surgery is highly stimulating, necessitating
careful titration of the anesthetic agents used for a TIVA technique. (See "Anesthesia for
tracheal surgery: General considerations", section on 'Maintenance' and "Maintenance of
general anesthesia: Overview", section on 'Total intravenous anesthesia'.)
Once the trachea is exposed, the FiO2 should be reduced to <0.3 if any ignition source (eg, an
electrosurgery unit [ESU]) is being used (see "Fire safety in the operating room", section on
'Oxygen during airway surgery'). Immediately prior to transection of the trachea, all ESU
devices must be handed off the surgical field. This allows administration of 100 percent oxygen
for preoxygenation. When the trachea is transected, the oral ETT is retracted so that the tip is
just proximal to the transected portion of the trachea. The surgeon then directly intubates the
main conducting airway distal to the affected tracheal area and directly connects the ETT
(typically a wire-reinforced ETT ( picture 3)), connected to sterile breathing circuit tubing (or
jet ventilator tubing) on the surgical field [16]. The proximal end of such tubing is passed over
the surgical drapes to non-sterile extension tubing, which is immediately connected to the
anesthesia machine or jet ventilator by the anesthesiologist to establish cross-field ventilation.
Subsequent ventilation is accomplished with well-timed hand-delivered breaths via the distal
tracheal ETT, alternating with periods of intermittent ventilation (see "Anesthesia for tracheal
surgery: General considerations", section on 'Intermittent ventilation'), or with JV (see
"Anesthesia for tracheal surgery: General considerations", section on 'Jet ventilation'). This
cross-field ventilation technique ensures continued oxygenation and ventilation, potentially for
a prolonged period of time, while the trachea is being reconstructed. An alternative technique
to achieve JV is by advancing the jet ventilator tubing through the oral airway (ie, an LMA or ETT)
or by retrograde passage of the proximal end of the jet ventilator tubing from the surgical field
up into the oropharynx (or the lumen of an LMA), thereby allowing the anesthesiologist to
grasp and connect it to a jet ventilator, while the surgeon places the distal tip of the tubing into
the distal trachea [18].
After reconstruction of the trachea, the oral ETT is carefully readvanced through the new
anastomosis. Circumferential tracheal sutures are then tightened so that controlled positive
pressure ventilation (PPV) may be employed without significant leaking. Typically, an
anastomotic leak test is performed. The repair is completed with the patient's head flexed and
supported on blankets to reduce tension on the fresh tracheal suture lines. (See "Anesthesia for
tracheal surgery: General considerations", section on 'Key points for surgical briefings'.)
Extubation and recovery — After completion of the repair, the surgeon often repeats flexible
bronchoscopy to inspect and clean the upper airway and trachea, either via the retracted ETT or
through an LMA that is inserted shortly before emergence.
Most patients undergoing tracheal resection and reconstruction are then allowed to emerge
from general anesthesia with the ETT or LMA in place, and are extubated in the operating room
[6,15]. In the rare case that reintubation becomes necessary while the patient is still in the
operating room or in the immediate postoperative period, a small ETT is selected and placed
over a fiberoptic bronchoscope [15]. Compared with endotracheal extubation, use of an LMA
may cause less coughing and mechanical stress on the freshly sutured airway during
emergence [15,18].
Patients undergoing tracheal resection and reconstruction are transported to the intensive care
unit (ICU) for postoperative observation and management. Other aspects of extubation and
recovery are similar to those after other types of major tracheal surgery, as discussed above
and in a separate topic. (See 'Extubation and recovery' above and "Anesthesia for tracheal
surgery: General considerations", section on 'Emergence and extubation'.)

SUMMARY AND RECOMMENDATIONS
● General considerations for anesthetic management of tracheal surgery including

preoperative assessment and planning; anesthetic techniques; options for oxygenation and
ventilation; induction, maintenance, and emergence from general anesthesia; and
management of pain and other issues in the immediate postoperative period are discussed
in a separate topic. (See "Anesthesia for tracheal surgery: General considerations".)
● Specific anesthetic considerations and techniques are procedure-dependent, as described

above:
• Tracheostomy (see 'Tracheostomy' above)
• Bronchoscopic evaluation (see 'Flexible bronchoscopy' above and 'Rigid bronchoscopy'

above and "Anesthesia for adult bronchoscopy")
• Insertion of an endotracheal stent (see 'Insertion of an endotracheal stent' above)
• Open repair or stent occlusion of a tracheoesophageal fistula (TEF) (see 'Open repair or
stent occlusion of a tracheoesophageal fistula' above)
• Tracheal resection and reconstruction (see 'Tracheal resection and reconstruction'

above)
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REFERENCES
1. Apfelbaum JL, Caplan RA, Barker SJ, et al. Practice advisory for the prevention and
management of operating room fires: an updated report by the American Society of
Anesthesiologists Task Force on Operating Room Fires. Anesthesiology 2013; 118:271.
2. Modalsli L, Liknes K, Flaatten H. Outcomes after percutaneous dilatation tracheostomy:

Patients view 6 years after the procedure. Acta Anaesthesiol Scand 2020; 64:798.
3. Klotz R, Probst P, Deininger M, et al. Percutaneous versus surgical strategy for

tracheostomy: a systematic review and meta-analysis of perioperative and postoperative
complications. Langenbecks Arch Surg 2018; 403:137.

4. Ronen O, Gurevich A, Ivry S, et al. Percutaneous Dilatational Tracheostomy Using Tube

Exchanger. Anesth Analg 2019; 129:e45.
5. Pathak V, Welsby I, Mahmood K, et al. Ventilation and anesthetic approaches for rigid
bronchoscopy. Ann Am Thorac Soc 2014; 11:628.
6. Diaz Milian R, Foley E, Bauer M, et al. Expiratory Central Airway Collapse in Adults:
Corrective Treatment (Part 2). J Cardiothorac Vasc Anesth 2019; 33:2555.
7. Zhu JH, Lei M, Chen EG, et al. Ventilation strategy and anesthesia management in patients
with severe tracheal stenosis undergoing urgent tracheal stenting. Acta Anaesthesiol
Scand 2018; 62:600.
8. Madden BP, Loke TK, Sheth AC. Do expandable metallic airway stents have a role in the
management of patients with benign tracheobronchial disease? Ann Thorac Surg 2006;
82:274.
9. Okamoto S, Somiya N, M Saito A, et al. A Prospective, Randomized Trial Comparing

Respiratory Status During Anesthesia for Airway Stenting: Spontaneous Respiration Versus
Controlled Ventilation With Muscle Relaxants. Anesth Analg 2020; 131:893.
10. Patel A, El-Boghdadly K. Apnoeic oxygenation and ventilation: go with the flow.
Anaesthesia 2020; 75:1002.
11. Schreiber JU, Lysakowski C, Fuchs-Buder T, Tramèr MR. Prevention of succinylcholine-

induced fasciculation and myalgia: a meta-analysis of randomized trials. Anesthesiology
2005; 103:877.
12. Miller RD, Way WL. Inhibition of succinylcholine-induced increased intragastric pressure by
nondepolarizing muscle relaxants and lidocaine. Anesthesiology 1971; 34:185.
13. Kucuk C, Arda K, Ata N, et al. Tracheomegaly and tracheosephagial fistula following
mechanical ventilation: A case report and review of the literature. Respir Med Case Rep
2016; 17:86.
14. Sethi P, Bhatia PK, Biyani G, et al. Acquired Tracheo-oesophageal Fistula: A Challenging
Complication of Tracheostomy. J Coll Physicians Surg Pak 2015; 25 Suppl 2:S76.
15. Smeltz AM, Bhatia M, Arora H, et al. Anesthesia for Resection and Reconstruction of the
Trachea and Carina. J Cardiothorac Vasc Anesth 2020; 34:1902.

16. Schieren M, Böhmer A, Dusse F, et al. New Approaches to Airway Management in Tracheal
Resections-A Systematic Review and Meta-analysis. J Cardiothorac Vasc Anesth 2017;
31:1351.
17. Schweiger T, de Faria Soares Rodrigues I, Roesner I, et al. Laryngeal Mask as the Primary
Airway Device During Laryngotracheal Surgery: Data From 108 Patients. Ann Thorac Surg
2020; 110:251.
18. Schieren M, Egyed E, Hartmann B, et al. Airway Management by Laryngeal Mask Airways
for Cervical Tracheal Resection and Reconstruction: A Single-Center Retrospective Analysis.
Anesth Analg 2018; 126:1257.
Topic 129133 Version 2.0

GRAPHICS
Rigid bronchoscopy
Efer-Dumon rigid bronchoscope with external port for ventilation, free moving
telescope with attached C-mount for video, and external side port for suction catheter
and laser fiber.
Courtesy of Henri G Colt, MD.
Graphic 53603 Version 2.0

Rigid bronchoscopy equipment
From left to right:

(A) Rigid biopsy forceps.
(B) Rigid optical telescope for visualization.
(C) Rigid bronchoscope.
(D) Rigid tracheoscope with attachment for anesthesia port and side working channel.
Note that the rigid tracheoscope is shorter for tracheal intervention compared with the
longer rigid bronchoscope, which can be placed in or beyond the main stem bronchi.

Wire-reinforced endotracheal tube
Wire-reinforced endotracheal tubes such as this one have an integrated spiral-wound

reinforcing wire designed to reduce the risk of kinking, especially if the patient's head is
flexed or extended.
Shiley™ Oral/Nasal Endotracheal Tube © 2018 Medtronic. All rights reserved. Used with the
permission of Medtronic. Available at: http://www.medtronic.com/covidien/en-
us/products/intubation/shiley-oral-nasal-endotracheal-tube-reinforced.html (Accessed on March 6,
2018).

Advantages and disadvantages of different airway stents
Silicone Metal (uncovered) Hybrid
Bronchoscopy Rigid Flexible Variable
Migration +++* +¶ ++
Tumor/granulation tissue + (proximal and distal ends) +++ + (proximal and distal ends)
growth
Airway perforation – + ±
Resists extrinsic – +++ ++

compression
Suitability for indefinite use +++ – ±
Suitability for temporary +++ – ±

use
Mucus plugging ++ + +
Stent fracture ± + +
Expense + ++ +++
Clinicians should be familiar with the advantages and disadvantages of each individual stent from each manufacturer. All stents
require expertise for placement and removal.
* This feature makes silicone stents suitable for repositioning and removal.
¶ This feature makes metal stents difficult to remove.

Tracheoesophageal fistula
Bronchoscopic view of a large tracheoesophageal fistula. The tracheal carina can be

seen in the distance (arrow). The fistula can be seen in the posterolateral position
(thick arrows) with a nasogastric tube in place (arrowhead).

Causes of acquired tracheoesophageal fistula
Malignancy
Common: Esophageal cancer, lung cancer
Less common: Laryngeal cancer, thyroid cancer, lymphoma, thymic cancer
Prolonged endotracheal intubation or tracheostomy
Endoscopic intervention (eg, endobronchial laser or cryotherapy)
Infectious diseases
Tuberculosis
Actinomycosis
Bacterial abscess
Inflammatory diseases (eg, rheumatoid arthritis)
Trauma (eg, penetrating trauma to the neck or chest)
Caustic ingestion
Esophageal stent
Surgery
Thoracic laryngectomy, esophagectomy
Cardiac
Mediastinal
Radiotherapy
Chemotherapy (eg, bevacizumab)

Airway silicone stent in a patient with tracheoesophageal fistula
Flexible bronchoscopic view of a patient with tracheoesophageal fistula (arrow)

covered by silicone stent.

Fully covered esophageal stent in a patient with

tracheoesophageal fistula

Contributor Disclosures
Vicki E Modest, MD Nothing to disclose Peter D Slinger, MD, FRCPC Nothing to disclose Carin A
Hagberg, MD, FASA Grant/Research/Clinical Trial Support: Ambu [Airway management (Ambu aScope 3,
Ambu AuraFlex, Ambu AuraGain, Ambu Aura-I, Ambu AuraOnce, Ambu AuraStraight, Ambu Aura40, King
Vision Video Laryngoscope, King Vision Video Laryngoscope aBlade System, King LT, King LT-D, King LTS,
King LTS-D)]; Karl Storz Endoscopy [Airway management (Bonfils Retromolar Intubation Endoscope,
Brambrink Intubation Endoscope, Berci-Kaplan DCI Video Laryngoscope, C-MAC Video Laryngoscope, C-
MAC Pocket Monitor)]; Vyaire Medical [Airway Management, respiratory diagnostics, ventilation and
operative care consumables (Vital Signs Head Positioner, VSD Laryngoscope systems Greenlight and Vital
View, Vital Signs humidification and filtration, oral airways, endotracheal tube, stylets and Laryngeal Mask
Airways, Vyaire Anaesthesia breathing circuits, face masks [SuperNova], nasal cannulas, Medisorb CO2
absorbent, enFlow fluid warming system and temperature probes and cables)]. Nancy A Nussmeier, MD,
FAHA Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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Anesthesia for tracheal surgery: Specific procedures

General considerations for anesthetic management of tracheal surgery (eg, preoperative

● (See "Anesthesia for head and neck surgery".)

https://www.uptodate.com/contents/anesthesia-for-tracheal-surgery-specific-procedures/print?search=anesthesia in tumor&source=search_result&sel… 1/29

A tracheostomy is performed to bypass pathology that compromises upper airway patency, or

General considerations — Important aspects of anesthetic management during a

● Appropriate control of oxygen and ignition source, particularly during open

• If correct positioning of the tracheostomy tube is uncertain, flexible bronchoscopy is

Patient-specific considerations — Open tracheostomy is typically performed for one of the

Anesthetic management involves continuing or adjusting baseline intravenous (IV) sedative-

Although administration of a neuromuscular blocking agent (NMBA) is common and typically

Anticipated airway compromise above the vocal cords — Selection of local or general

https://www.uptodate.com/contents/anesthesia-for-tracheal-surgery-specific-procedures/print?search=anesthesia in tumor&source=search_result&sel… 4/29

Emergency tracheostomy for critical airway occlusion — Emergency surgical entry

Percutaneous "mini" tracheostomy — A percutaneous tracheostomy is typically performed in

BRONCHOSCOPIC EVALUATION BEFORE TRACHEAL SURGERY

Flexible bronchoscopy — Before beginning some elective tracheal surgical procedures, such as

https://www.uptodate.com/contents/anesthesia-for-tracheal-surgery-specific-procedures/print?search=anesthesia in tumor&source=search_result&sel… 5/29

If a general anesthetic technique is selected, support of ventilation will be necessary. The

Either an inhalation anesthetic technique or total intravenous anesthesia (TIVA) may be

Rigid bronchoscopy — Rigid bronchoscopy may be employed in selected patients to

● Standard positive pressure ventilation (PPV) – PPV is accomplished by attaching the

● Intermittent ventilation with an ETT – If necessary to ensure adequacy of ventilation, the

We usually select a TIVA technique to maintain general anesthesia, including administration of a

INSERTION OF AN ENDOTRACHEAL STENT

https://www.uptodate.com/contents/anesthesia-for-tracheal-surgery-specific-procedures/print?search=anesthesia in tumor&source=search_result&sel… 7/29

An endotracheal stent provides tracheal support to improve or maintain airway patency in

● Local anesthesia – In selected cases it is possible to place a stent via a flexible

https://www.uptodate.com/contents/anesthesia-for-tracheal-surgery-specific-procedures/print?search=anesthesia in tumor&source=search_result&sel… 8/29

(See "Anesthesia for tracheal surgery: General considerations", section on 'Endotracheal

Before extubation, possible administration of dexamethasone 8 to 10 mg to reduce airway

OPEN REPAIR OR STENT OCCLUSION OF A TRACHEOESOPHAGEAL FISTULA

Preoperative assessment and planning — General anesthesia is necessary for open repair

● Confirm optimal medical condition, particularly whether treatment of pulmonary infection

● Confirm administration of usual medications on the morning of surgery, particularly proton

● If a right thoracotomy is planned, insertion of a thoracic epidural (TEA) or paravertebral

considerations", section on 'Operating room setup'):

• Preinduction stomach evacuation via an esophagoscope after numbing the

https://www.uptodate.com/contents/anesthesia-for-tracheal-surgery-specific-procedures/print?search=anesthesia in tumor&source=search_result&s… 11/29

• Awake intubation of a spontaneously breathing patient after topical anesthesia and/or

• Induction of general anesthesia with efficient endotracheal intubation and avoidance

- Rapid sequence induction and intubation (RSII). If succinylcholine is used, we

- Inhalation induction to avoid PPV by maintaining negative pressure spontaneous

https://www.uptodate.com/contents/anesthesia-for-tracheal-surgery-specific-procedures/print?search=anesthesia in tumor&source=search_result&s… 12/29

Maintenance and intraoperative airway management — After general anesthesia has been

Extubation and recovery

https://www.uptodate.com/contents/anesthesia-for-tracheal-surgery-specific-procedures/print?search=anesthesia in tumor&source=search_result&s… 14/29

TRACHEAL RESECTION AND RECONSTRUCTION

Tracheal pathology requiring tracheal resection and reconstruction may be malignant or

● Upper or midtracheal lesions such as postintubation injuries are typically approached

Preoperative assessment and preparation — Preoperative preparations are generally similar

● An intra-arterial catheter is inserted in all patients undergoing tracheal resection and

Induction and initial airway management — Anesthetic induction requires careful planning

https://www.uptodate.com/contents/anesthesia-for-tracheal-surgery-specific-procedures/print?search=anesthesia in tumor&source=search_result&s… 15/29

An endoscopic airway evaluation with flexible or rigid bronchoscopy, or both, is typically

Maintenance and intraoperative airway management — We typically select a total

https://www.uptodate.com/contents/anesthesia-for-tracheal-surgery-specific-procedures/print?search=anesthesia in tumor&source=search_result&s… 17/29

SUMMARY AND RECOMMENDATIONS

● General considerations for anesthetic management of tracheal surgery including

● Specific anesthetic considerations and techniques are procedure-dependent, as described

• Tracheostomy (see 'Tracheostomy' above)