Learning from Experience – Intra Operative, Chapters 19 and 20

INTRA-OPERATIVE

Chapter 19

Intra Luminal Bronchial Tumour: Challenge to Anaesthetist and Surgeon

Dr. Vasanthi Vidyasagaran*

Department of Anaesthesiology, Kauvery Hospital, Chennai, Tamilnadu, India

A 20-year-old, well-built man presented with history of difficulty in breathing and sudden bouts of coughing on lying down. Clinical evaluation did not correlate to a respiratory tract infection or exercise-induced cardiac pathology. His oxygen saturations were 92-95% on air, hemodynamically stable. Chest auscultation revealed rales on both sides. Post-nebulisation with steroids and bronchodilators, symptoms were slightly better. He had no stridor preoperatively. He required to be slightly sat up 30 to 45 degrees to breathe without having obstructive symptoms. He had no other comorbidities.

All his blood investigations were within normal limits. A chest x-ray revealed a shadow in the tracheal region. CT scan of the chest revealed an intraluminal tumour occupying nearly 50% of the lumen of the trachea at the T1-T2 level. Preoperatively surgeon performed flexible bronchoscopy to assess the tumour, and decided to perform surgical resection of tumour with tracheal reconstruction.

After ensuring that a cardiopulmonary bypass standby was available, this patient was induced with Propofol 150 mg and Suxamethonium 100 mg. The first attempt at intubation using a Mackintosh laryngoscope with a 7.0 mm cuffed flexo-metallic tube failed. The tube entered the glottic opening quite easily, but there was obstruction beyond that. Hence tube was quickly removed and patient was mask ventilated. Fortunately, ventilation was possible and there was no bleeding or drop in oxygen saturation.

At second attempt, with further muscle relaxation and IV Propofol, a 6.5 mm ETT was used over the fibre optic bronchoscope. The mass was seen arising from the left tracheal wall and an air shadow was seen towards the right side. Keeping this picture in mind the tube was maneuvered slightly towards the right side. Trachea was intubated and ventilation was resumed without any further resistance. Tube was secured. Anaesthesia was maintained with nitrous oxide, oxygen and sevoflurane.100 mic fentanyl and a total of 50 mg atracurium was used.

The surgery was allowed to proceed. The surgeons approached the trachea through an incision in the neck. As soon as the trachea was incised the 6.5 tube was withdrawn and a second sterile size 7 cuffed ETT was inserted into the distal segment to continue ventilation.

The tumour was excised along with 2 tracheal rings. At the end of the procedure as the surgeons began anastomosing the proximal and distal tracheal segments, the size 7 tracheal tube was removed and a smaller size 5.5 tube was used to re-intubate the patient. Under vision the cuff of the tube was placed distal to the anastomotic site and inflated to resume ventilation.

During both the tube exchanges the patient remained apnoeic for a period of 45/s min. He was oxygenated with 100% oxygen for 3 min prior to the exchange. Thus, no desaturation was observed and he remained haemodynamically stable throughout the procedure. Dexamethasone 8 mg was administered to reduce risk of airway oedema.

At the end of surgery, patient recovered well and was reversed with Neostigmine 2.5 mg and Glycopyrrolate 0.5 mg. He was awake and responding to commands. It was planned to extubate on table maintaining neck flexion, and ensuring no significant airway oedema, with the knowledge that good quality post-surgical care was available and experts in airway management were present.

Discussion

Airway management in patients with tracheal lesions of this kind is always tricky and has to be dealt with cautiously. Appropriate planning and execution of case management with backup plan is vital in such challenging situations. Competency of the entire team involved and good communication between the team members helps successful management of the patient.

Position of the tracheal mass, pedunculated or not, the size and extension into the tracheal lumen as well as the mediastinal extension and external compression of the airway must be considered. Thorough preoperative investigation including lung function tests and MRI become essential to plan management. When the lesion occupies 50% or more of the lumen, securing the airway may be impossible, and cardiopulmonary bypass may be kept on standby.

Calculated risk – removing or debulking the tumour preoperatively using a rigid bronchoscope to maintain airway may be necessary. Serious complications such as bleeding, aspiration, hypoxia, and inability to secure and maintain airway may occur even then and a Bypass back up must always be ready.

When surgery is planned through the cervical incision and tumour is situated in the upper trachea and/or larynx, single lumen tube is usually used and passed beyond the lesion to secure airway. When a thoracic access is planned, for tumours in lower part of trachea and/or the carina involving one or both bronchi, it becomes more challenging. Double lumen tubes will be required. If a double lumen tube placement is difficult, a single lumen tube may be passed into one (more patent) bronchus under fibre optic guidance. Cardiopulmonary bypass may be required when airway patency is questionable or even during the procedure when the tumour is being handled. Post-operative elective ventilation is desirable in surgery involving the carina.

Difficulties in airway management are anticipated at multiple steps in tracheal surgeries:

Securing airway, awake or asleep intubation

Manipulation of the endo tracheal tube through trachea; tracheostomy not an option in this case as the tumour was lower down

Ventilation

Intraoperative airway management – ‘Shared airway’, bleeding from lesion

Extubation and postoperative care

Tracheal reconstruction may give way during manipulation of the ETT.

Any violent coughing in the post-operative period may even cause rupture.

If the patient requires post-operative ventilator support care must be taken to prevent barotrauma.

Special considerations during emergence and extubation include maintenance of neck flexion, assessing and managing tracheal bleeding and obstruction (not to overuse suction catheters and cause damage), laryngeal oedema and vocal cord dysfunction. Extubation initiated too early or too late, or injudicious use of postoperative pain medications may result in loss of airway patency, which may require reintubation or emergency tracheostomy. Phonation must be tested in the immediate postoperative period.

References

[1] Furimsky M, Aronson S, Ovassapian A. Perioperative management of a patient presenting for resection of a tracheal mass. J Cardiothorac Anesth. 1998;12:701-4.

[2] English J, Norris A, Bedforth N. Anaesthesia for airway surgery. Contin Educ Anaesth Crit Care Pain. 2006;6(1): 28-31.

[3] McRae K. Anesthesia for airway surgery. Anesthesiol Clin North America. 2001;19:497-541.

[4] Saroa R, Gombar S, Palta S. Low tracheal tumor and airway management: An anesthetic challenge. Saudi J Anaesth. 2015;9(4):480-3.

[5] Macfie A. Anaesthesia for tracheal and airway surgery. Anaesthesia and Intensive care medicine. 2008;9(12):534-7.

“Nobody in the world is indispensable but no one is replaceable either”

Chapter 20

Intraoperative Bronchospasm in a Cardiac Patient: Magnesium to the Rescue

A 76-year-old man was posted for plating of a proximal humerus fracture. He had a history of coronary artery disease for which he was on treatment with antiplatelet agent, Dipyridamole and a vasodilator, ISDN for nearly five years. He was a smoker till three days ago, before his fall.

Blood investigations were within normal limits. ECG showed changes of an old anterior wall MI. There was mild left ventricular dysfunction and moderate diastolic dysfunction., EF was 40%. in the ECHO report. He was taken up under general anaesthesia, with informed consent after explaining the risks of anaesthesia and surgery in a patient with history of MI, and smoking.

He was induced with 200 mg Thiopentone,100 mic Fentanyl, and intubated with 8.0 mm cuffed ETT using Atracurium 30 mg. For maintenance, a 50% mixture of Oxygen and Nitrous Oxide, with Isoflurane 1% was used. Few minutes into the procedure, there was a tightening of the reservoir bag. Circuit problems and endobronchial intubation were excluded. Auscultation revealed bilateral rhonchi all over the chest.

The saturation dropped to 95%. IV Deriphylline and Hydrocortisone were given slowly but, the spasm did not improve. Isoflurane was increased to provide bronchodilation. Following this, chest auscultation revealed reduction in the intensity of spasm, but ventilation was still difficult.

With the background of cardiac illness, further doses of Deriphylline and/or Salbutamol were avoided to prevent sympathetic stimulation. A physician opinion was obtained, and it was decided to administer Magnesium as bronchodilator. Magnesium Sulphate 2 g IV was given over 30 min, which dramatically reversed the spasm, and the surgery was completed. Patient recovered well, was shifted to HDU over night. Nebulised Budesonide was given postoperatively.

Discussion

This was an unanticipated case of bronchospasm in an elderly patient with known cardiac illness. The line of management of bronchospasm in patients with specific problems such as cardiac ischemia may not be conventional bronchodilators. The usual treatment of back to back Salbutamol/Deriphylline may trigger tachyarrhythmia and cardiac ischemia in such patients. Hence if the bronchospasm is too severe, not responding to first dose of beta receptor agonist and steroid, second line of drugs may be considered.

Magnesium sulphate appears to be a wonder drug in anaesthesia and intensive care. Evidence over the last two decades suggests its positive role in therapeutic and preventive acute medicine. Magnesium has diverse clinical applications. It is a physiological antagonist of calcium. By virtue of antagonizing calcium, it helps with reversal of calcium induced bronchospasm, vasospasm, hypertension, pregnancy induced hypertension, and neuromuscular spasm.

Dose of 2 g intravenously is the best route of administration for relief of bronchospasm. Further doses may be administered based on response and hemodynamic stability of the patient. The drug may also be safely used in children. One has to be wary about the effect of magnesium on neuromuscular block and use monitors to reverse the effect of non-depolarizing block. Although magnesium has been recommended for bronchospasm, this was the first and only case witnessed by me.

There is a lot of scope for research using naturally occurring substances like magnesium, and melatonin for use in general anaesthesia, and it deserves much more attention than what is being done as of date. It may be worthwhile to encourage more youngsters to take up to research specially in anaesthesia as there has been very little contribution from our country in this subject.

References

[1] Powell CV. The role of magnesium sulfate in acute asthma: does route of administration make a difference? Curr Opin Pulm Med. 2014;20(1):103-8.

[2] Abreu González J1, et al. Effect of intravenous magnesium sulfate on chronic obstructive pulmonary disease exacerbations requiring hospitalization: a randomized placebo-controlled trial. Arch Bronconeumol. 2006;42(8):384-7.

[3] Watson, et al. Magnesium and the anaesthetist BJA CEPD reviews. 1(1): 2001.

[4] James FM, et al. Magnesium: an emerging drug in anaesthesia. Br J Anaesth. 2009;103(4):465-467.

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Learning from Experience – Intra Operative, Chapters 19 and 20

INTRA-OPERATIVE

Chapter 19

Intra Luminal Bronchial Tumour: Challenge to Anaesthetist and Surgeon

Discussion

References

Chapter 20

Intraoperative Bronchospasm in a Cardiac Patient: Magnesium to the Rescue

Discussion

References

Journals