- Email: [email protected]
Laryngeal mask airway in patients with tracheal stents who are undergoing non-airway related interventions: report of three cases
Case Reports Laryngeal Mask Airway in Patients with Tracheal Stents Who Are Undergoing NonAirway Related Interventions: Report of Three Cases Wei-Te Hung, MD, MPH,* Shin-Ming Liao, MD,† Jang-Ming Su, MD, MS‡ Department of Anesthesiology, Chung Shan Medical University Hospital, Taichung, Taiwan
The tracheal stent is an alternative nonsurgical management tool for patients with tracheal stenosis caused by disease or iatrogenic trauma. Some patients with tracheal stent may need to be anesthetized to allow invasive techniques or surgery to be performed. In these patients, general anesthesia by endotracheal intubation may dislodge the stent distally or cause lethal complications such as bleeding. We describe three patients with a tracheal stent in place, who were anesthetized using a Laryngeal Mask Airway for surgery, with smooth results. © 2004 by Elsevier Inc. Keywords: Laryngeal Mask Airway; tracheal stent.
Introduction
*Chairman, Department of Anesthesiology, School of Medicine, Chung Shan Medical University, Taichung, Taiwan †Resident, Chung Shan Medical University Hospital, Taichung, Taiwan ‡Head, Division of Chest Surgery, Department of Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan Address correspondence to Dr. Wei-Te Hung at the 21 Thornridge Lane, Centereach, NY 11720, USA. E-mail: hung@biostat. Columbia.edu Received for publication November 25, 2002; revised manuscript accepted for publication July 14, 2003. Journal of Clinical Anesthesia 16:214 –216, 2004 © 2004 Elsevier Inc. All rights reserved. 360 Park Avenue, South, New York, NY 10010
Surgical resection and anastomosis are the standard approaches to the treatment of symptomatic tracheal stenosis. When considering the length of the tracheal stenosis or the underlying diseases of the upper airway, the tracheal stent is a good alternative method to keeping the airway patent. Among tracheal stents, the silicone Dumon stent (Novatech, Grasse, France) is the most widely used. Although techniques for the placement of a stent in the trachea of such patients have been reported,1–5 few papers have discussed administration of general anesthesia to a patient with a Dumon stent in place. Endotracheal intubation for general anesthesia in such patients may cause dislodgement of the Dumon stent or lethal complications during operation. We used different kinds of Laryngeal Mask Airways (LMA) to anesthetize three patients who underwent surgical procedures without complications.
Case Reports Case 1 A 61-year-old, ASA physical status III male was admitted with the chief complaints of left flank colic pain and hematuria. He had a diagnosis of esophageal squamous cell 0952-8180/04/$–see front matter doi:10.1016/j.jclinane.2003.07.010
LMA in patients with tracheal stents: Hung et al.
carcinoma with mid third tracheal invasion one year prior to admission. A Dumon stent (TD, 16mm/L, 40mm) was placed for maintenance of airway patency 1 month later because of respiratory signs of stenosis. He was sent to the operating room (OR) for double-J procedure because of left ureteral stone with hydronephrosis. Although regional anesthesia was considered as the first choice of anesthesia to perform the procedure, his coagulation data, prothrombin time, and partial thromboplastin time were longer than 1.5 times of the normal range because of his co-existing liver cirrhosis. Preoperative fiberoptic bronchoscopic examination showed no neogrowth or displacement of stent, and his pulmonary function test revealed mild obstructive lung disorder. Anesthesia was induced with intravenous (IV) propofol 1.5 mg/kg and fentanyl 1 g/kg, and a LMA (classic type, #4) was inserted for airway management after another five minutes of inhalation of 5% sevoflurane. Anesthesia was maintained with sevoflurane with spontaneous breathing. The double-J procedure was performed on the patient smoothly by the urologist. The LMA was removed at the end of the procedure without any complication.
Case 2 A 75-year-old, ASA physical status III male was diagnosed with hydrocephalus by computed tomographic (CT) scan and scheduled for ventricle-peritoneal shunt. He had a history of intracranial hemorrhage of the left temporal area, and tracheostomy had been performed because of respiratory failure 2 years prior to this admission. He had developed shallow breathing and dyspnea after removal of the tracheostomy tube 6 months later. A tracheal stent (TD, 16mm/L, 40 mm) had then been placed under the impression of tracheal stenosis after fiberoptic bronchoscopy. His preoperative fiberoptic bronchoscopic examination showed a patent airway. Induction of anesthesia was performed with propofol 1 mg/kg, fentanyl 0.5 g/kg, and atracurium 0.5 mg/kg, followed by insertion of flexible LMA (#4). Anesthesia was maintained with sevoflurane, and controlled ventilation was performed during the procedure. The flexible LMA was removed smoothly after the procedure.
Case 3 A 55-year-old, ASA physical status III male came to the OR for placement of a feeding jejunostomy. Esophageal squamous cell carcinoma had been diagnosed 4 months prior to this admission. One month later, a Dumon stent (TD, 14 mm/L, 40 mm) was placed in the trachea because of tumor invasion that caused respiratory symptoms (shallow of breathing, dyspnea, hoarseness, stridor, and hematosputum). An endoscopic specialist found neogrowth of tumor from both sides of the stent margin during routine fiberoptic bronchoscopy. Anesthesia was induced with 1 mg/kg propofol, 2 g/kg fentanyl, followed by intubation with a number 4 Proseal LMA. Anesthesia was maintained with desflurane and controlled
ventilation was performed during the procedure. The Proseal LMA was removed smoothly without any complications.
Discussion The tracheal stent is a good alternative method to treat tracheal stenosis when surgical treatment is not appropriate. Various anesthetic methods, such as small-diameter endotracheal tube, jet ventilation, and LMA, that could be used in patients with tracheal stents who are undergoing non-airway-related interventions. Noppen et al.4 reported that reintubation of the trachea of the patient following placement of a tracheal stent should always be done with a small-diameter tube, and endoscopic examination should always be performed after extubation. Displacement of the Dumon stent or tumor contact bleeding is a concern when reintubation of the patient is needed. Theoretically, the patient’s airway will remain patent after placement of a tracheal stent. The LMA can provide a patent airway without harming the trachea or the stent, and it provides an alternative anesthetic method if regional anesthesia is contraindicated. In Case 3, we hesitated to place a tube in the trachea because of tumor neogrowth from both ends of the stent, as seen on fiberoptic bronchoscopy. For upper abdominal surgery, a classical LMA with controlled ventilation may cause airway leakage during surgery. We used a Proseal LMA to provide better seal capability and good ventilation effect. Bailey et al.6 reviewed flexible LMAs and suggested that they might be useful for surgery of the head, neck, and shoulder. For those patients, the classical LMA shaft might interfere with the surgical field. In Case 2, we used a flexible LMA to provide anesthesia and an airway to prevent tube torsion during manipulation of the head position during surgery. Use of the LMA has been widely reported. Many specialized modifications of the LMA have been proposed.7,8 Pulmonary aspiration is the most serious potential complication of the LMA, although minor complications such as trauma, oral ulcer, and nerve paralysis have been reported.9 Tanigawa et al.5 reported that the LMA is a safe and useful adjunct for placement of stents when treating patients with upper tracheal stenosis. The patient’s airway will remain patent after placement of a tracheal stent. For cases involving tracheal stents, and to reduce tracheal trauma, the LMA provides good anesthetic maintenance and good airway patency to the patient undergoing operation or invasive procedures for nonmajor cardiac or chest surgery.
References 1. Dumon JF: A dedicated tracheobronchial stent. Chest 1990;97: 328 –32. 2. Magee MJ, Klain M, Ferson PF, et al: Nasotracheal jet ventilation for rigid endoscopy. Ann Thorac Surg 1994;57:1031–2. 3. Ducic Y, Khalafi RS: Use of endoscopically placed expandable nitinol tracheal stents in the treatment of tracheal stenosis. Laryngoscope 1999;109:1130 –3. 4. Noppen M, Meysman M, Claes I, et al: Screw-thread vs Dumon endoprosthesis in the management of tracheal stenosis. Chest 1999;115:532–5. 5. Tanigawa N, Sawada S, Okuda Y, et al: Expandable metallic stent J. Clin. Anesth., vol. 16, May 2004
215
Case Reports placement in upper tracheal stenosis: value of laryngeal masks. AJR Am J Roentgenol 2001;177:1423–6. 6. Bailey P, Brimacombe JR, Keller C: The flexible LMA: literature considerations and practical guide. Int Anesthesiol Clin 1998;36: 111–22. 7. Alexander CA: A modified Intavent laryngeal mask for ENT and
216
J. Clin. Anesth., vol. 16, May 2004
dental anesthesia. Anaesthesia 1990;45:892–3. 8. Brain AI, Verghese C, Strube PJ: The LMA ⬘Proseal’—a laryngeal mask with an oesophageal vent. Br J Anaesth 2000;84:650 –4. 9. Berry A: Problems and complications. In: Brimacombe J, Brain A, (eds): The Laryngeal Mask Airway (LMA): A practical guide. London, UK: W. B. Saunders Co., Ltd, 1996:117–33.
The tracheal stent is an alternative nonsurgical management tool for patients with tracheal stenosis caused by disease or iatrogenic trauma. Some patients with tracheal stent may need to be anesthetized to allow invasive techniques or surgery to be performed. In these patients, general anesthesia by endotracheal intubation may dislodge the stent distally or cause lethal complications such as bleeding. We describe three patients with a tracheal stent in place, who were anesthetized using a Laryngeal Mask Airway for surgery, with smooth results. © 2004 by Elsevier Inc. Keywords: Laryngeal Mask Airway; tracheal stent.
Introduction
*Chairman, Department of Anesthesiology, School of Medicine, Chung Shan Medical University, Taichung, Taiwan †Resident, Chung Shan Medical University Hospital, Taichung, Taiwan ‡Head, Division of Chest Surgery, Department of Surgery, Chung Shan Medical University Hospital, Taichung, Taiwan Address correspondence to Dr. Wei-Te Hung at the 21 Thornridge Lane, Centereach, NY 11720, USA. E-mail: hung@biostat. Columbia.edu Received for publication November 25, 2002; revised manuscript accepted for publication July 14, 2003. Journal of Clinical Anesthesia 16:214 –216, 2004 © 2004 Elsevier Inc. All rights reserved. 360 Park Avenue, South, New York, NY 10010
Surgical resection and anastomosis are the standard approaches to the treatment of symptomatic tracheal stenosis. When considering the length of the tracheal stenosis or the underlying diseases of the upper airway, the tracheal stent is a good alternative method to keeping the airway patent. Among tracheal stents, the silicone Dumon stent (Novatech, Grasse, France) is the most widely used. Although techniques for the placement of a stent in the trachea of such patients have been reported,1–5 few papers have discussed administration of general anesthesia to a patient with a Dumon stent in place. Endotracheal intubation for general anesthesia in such patients may cause dislodgement of the Dumon stent or lethal complications during operation. We used different kinds of Laryngeal Mask Airways (LMA) to anesthetize three patients who underwent surgical procedures without complications.
Case Reports Case 1 A 61-year-old, ASA physical status III male was admitted with the chief complaints of left flank colic pain and hematuria. He had a diagnosis of esophageal squamous cell 0952-8180/04/$–see front matter doi:10.1016/j.jclinane.2003.07.010
LMA in patients with tracheal stents: Hung et al.
carcinoma with mid third tracheal invasion one year prior to admission. A Dumon stent (TD, 16mm/L, 40mm) was placed for maintenance of airway patency 1 month later because of respiratory signs of stenosis. He was sent to the operating room (OR) for double-J procedure because of left ureteral stone with hydronephrosis. Although regional anesthesia was considered as the first choice of anesthesia to perform the procedure, his coagulation data, prothrombin time, and partial thromboplastin time were longer than 1.5 times of the normal range because of his co-existing liver cirrhosis. Preoperative fiberoptic bronchoscopic examination showed no neogrowth or displacement of stent, and his pulmonary function test revealed mild obstructive lung disorder. Anesthesia was induced with intravenous (IV) propofol 1.5 mg/kg and fentanyl 1 g/kg, and a LMA (classic type, #4) was inserted for airway management after another five minutes of inhalation of 5% sevoflurane. Anesthesia was maintained with sevoflurane with spontaneous breathing. The double-J procedure was performed on the patient smoothly by the urologist. The LMA was removed at the end of the procedure without any complication.
Case 2 A 75-year-old, ASA physical status III male was diagnosed with hydrocephalus by computed tomographic (CT) scan and scheduled for ventricle-peritoneal shunt. He had a history of intracranial hemorrhage of the left temporal area, and tracheostomy had been performed because of respiratory failure 2 years prior to this admission. He had developed shallow breathing and dyspnea after removal of the tracheostomy tube 6 months later. A tracheal stent (TD, 16mm/L, 40 mm) had then been placed under the impression of tracheal stenosis after fiberoptic bronchoscopy. His preoperative fiberoptic bronchoscopic examination showed a patent airway. Induction of anesthesia was performed with propofol 1 mg/kg, fentanyl 0.5 g/kg, and atracurium 0.5 mg/kg, followed by insertion of flexible LMA (#4). Anesthesia was maintained with sevoflurane, and controlled ventilation was performed during the procedure. The flexible LMA was removed smoothly after the procedure.
Case 3 A 55-year-old, ASA physical status III male came to the OR for placement of a feeding jejunostomy. Esophageal squamous cell carcinoma had been diagnosed 4 months prior to this admission. One month later, a Dumon stent (TD, 14 mm/L, 40 mm) was placed in the trachea because of tumor invasion that caused respiratory symptoms (shallow of breathing, dyspnea, hoarseness, stridor, and hematosputum). An endoscopic specialist found neogrowth of tumor from both sides of the stent margin during routine fiberoptic bronchoscopy. Anesthesia was induced with 1 mg/kg propofol, 2 g/kg fentanyl, followed by intubation with a number 4 Proseal LMA. Anesthesia was maintained with desflurane and controlled
ventilation was performed during the procedure. The Proseal LMA was removed smoothly without any complications.
Discussion The tracheal stent is a good alternative method to treat tracheal stenosis when surgical treatment is not appropriate. Various anesthetic methods, such as small-diameter endotracheal tube, jet ventilation, and LMA, that could be used in patients with tracheal stents who are undergoing non-airway-related interventions. Noppen et al.4 reported that reintubation of the trachea of the patient following placement of a tracheal stent should always be done with a small-diameter tube, and endoscopic examination should always be performed after extubation. Displacement of the Dumon stent or tumor contact bleeding is a concern when reintubation of the patient is needed. Theoretically, the patient’s airway will remain patent after placement of a tracheal stent. The LMA can provide a patent airway without harming the trachea or the stent, and it provides an alternative anesthetic method if regional anesthesia is contraindicated. In Case 3, we hesitated to place a tube in the trachea because of tumor neogrowth from both ends of the stent, as seen on fiberoptic bronchoscopy. For upper abdominal surgery, a classical LMA with controlled ventilation may cause airway leakage during surgery. We used a Proseal LMA to provide better seal capability and good ventilation effect. Bailey et al.6 reviewed flexible LMAs and suggested that they might be useful for surgery of the head, neck, and shoulder. For those patients, the classical LMA shaft might interfere with the surgical field. In Case 2, we used a flexible LMA to provide anesthesia and an airway to prevent tube torsion during manipulation of the head position during surgery. Use of the LMA has been widely reported. Many specialized modifications of the LMA have been proposed.7,8 Pulmonary aspiration is the most serious potential complication of the LMA, although minor complications such as trauma, oral ulcer, and nerve paralysis have been reported.9 Tanigawa et al.5 reported that the LMA is a safe and useful adjunct for placement of stents when treating patients with upper tracheal stenosis. The patient’s airway will remain patent after placement of a tracheal stent. For cases involving tracheal stents, and to reduce tracheal trauma, the LMA provides good anesthetic maintenance and good airway patency to the patient undergoing operation or invasive procedures for nonmajor cardiac or chest surgery.
References 1. Dumon JF: A dedicated tracheobronchial stent. Chest 1990;97: 328 –32. 2. Magee MJ, Klain M, Ferson PF, et al: Nasotracheal jet ventilation for rigid endoscopy. Ann Thorac Surg 1994;57:1031–2. 3. Ducic Y, Khalafi RS: Use of endoscopically placed expandable nitinol tracheal stents in the treatment of tracheal stenosis. Laryngoscope 1999;109:1130 –3. 4. Noppen M, Meysman M, Claes I, et al: Screw-thread vs Dumon endoprosthesis in the management of tracheal stenosis. Chest 1999;115:532–5. 5. Tanigawa N, Sawada S, Okuda Y, et al: Expandable metallic stent J. Clin. Anesth., vol. 16, May 2004
215
Case Reports placement in upper tracheal stenosis: value of laryngeal masks. AJR Am J Roentgenol 2001;177:1423–6. 6. Bailey P, Brimacombe JR, Keller C: The flexible LMA: literature considerations and practical guide. Int Anesthesiol Clin 1998;36: 111–22. 7. Alexander CA: A modified Intavent laryngeal mask for ENT and
216
J. Clin. Anesth., vol. 16, May 2004
dental anesthesia. Anaesthesia 1990;45:892–3. 8. Brain AI, Verghese C, Strube PJ: The LMA ⬘Proseal’—a laryngeal mask with an oesophageal vent. Br J Anaesth 2000;84:650 –4. 9. Berry A: Problems and complications. In: Brimacombe J, Brain A, (eds): The Laryngeal Mask Airway (LMA): A practical guide. London, UK: W. B. Saunders Co., Ltd, 1996:117–33.