General Considerations

General Considerations. Surgery of the trachea and mainstem bronchi involves significant anesthetic risks, including interruption of airway continuity and the potential for total obstruction of an already stenotic airway.

1. The surgical approach depends on the location and extent of the lesion. Lesions of the cervical trachea are approached through a transverse neck incision. Lower lesions necessitate an upper sternal split. Lesions of the distal trachea and carina may require a median sternotomy or a right thoracotomy.
2. Extubation at the conclusion of the surgical procedure is the goal of the anesthetic because it will put less strain on the fresh tracheal anastomosis.
   1. Induction
3. The anesthetic technique must include a plan for preserving airway patency throughout induction and intubation and emergency plans and equipment for dealing with any sudden loss of airway control, ranging from rigid bronchoscopy to CPB based on the clinical assessment and experience of the team.
4. If the airway is critically stenotic, spontaneous ventilation should be maintained throughout the induction because it may not be possible to ventilate the lungs by mask ventilation if apnea occurs. A volatile agent in oxygen is the preferred anesthetic, and no muscle relaxants are used. Sevoflurane, with its lack of airway irritability, is suitable for inhalational induction. A deep plane of anesthesia must be achieved before instrumentation, and this may require 15 to 20 minutes in a patient with small tidal volumes and a large functional residual capacity. Hemodynamic support with phenylephrine may be required for an elderly or debilitated patient to tolerate the necessary high concentration of volatile agent.
5. Patients with preexisting mature tracheostomies may be induced with intravenous agents followed by cannulation of the tracheostomy with a cuffed, flexible, armored endotracheal tube. The surgical field around the tube is prepared, and the tube is removed and replaced with a sterile one by the surgeon.