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Author Topic: Help for Serious tracheal stenosis management  (Read 7670 times)

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Stefano_Soriano

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Help for Serious tracheal stenosis management
« on: November 04, 2005, 04:54:55 PM »
Hello. 
My name is Stefano  and i writes from Italy. 
First of all sorry for my english.
I would want to introduce a problem. 
In my unit of intensive therapy, a patient of 42 years with massive stenosis of the trachea has been admitted 8 days ago. 

She had been admitted in urgency in operating room of thoracic surgery for removal of the stenosis due to tracheal intraluminal tumor.

This nodule is found at the level of first segment of intrathoracic  trachea. 

During the removal laser surgery,  the patient accused serious respiratory insufficiency and readly was intubate and assisted with mechanical ventilation. 

Then she was transferred in unit of intensive therapy for mechanical ventilation and stabilization. 

The thoracic surgeon has practiced after 5 days a surgical tracheostomy with a long tube whose extremity ends under the stenosis, but he has not removed the tumor that obstructs nearly the 100% of tracheal lumen.


He has also programmed for the next days a new surgery with the laser.


How do  you suggest  to carry out the respiratory and anaesthesiological management, considerating the fact that the surgeon would operate with the great possible space in trachea. 

I would have to be equipped for extracorporeal circulation? 


Whichever council is welcome.

Thanks

Stefano Soriano
Italy

Sorry for my bad english :-)
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hemanayakulu

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Re: Help for Serious tracheal stenosis management
« Reply #1 on: November 26, 2007, 04:53:35 PM »
Sir,
  I can suggest you two methods.
1) You can ask surgeon to do tracheostomy under local anaesthesia prefereblyTUMISSED. Then, you can intubate orally and this tube can be negotiated by surgeon in to lower end when he is ready.

2) You can use MLE Tube  which is very lengthy and smaller in diameter.

                                                Hemanayakulu
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yogenbhatt1

  • Yogen Bhatt, Mumbai, India
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Re: Help for Serious tracheal stenosis management
« Reply #2 on: November 27, 2007, 11:36:40 AM »
Hi, Good case you have as a brain teaser.
Not used to this kind of cases, yet it is always easy to advise someone.
You think a tracheal stenting can help?  It certainly will open up the lumen to over 60 % size, providing the nodule is soft and can get compressed. The tube that you can use now will be much bigger than an MLS tube.
Not sure if it can work, but gives ideas.
Regards and best wishes. Do let us know how you succeeded in managing and also post pictures of the nodule.
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jafo1964

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Re: Help for Serious tracheal stenosis management
« Reply #3 on: November 28, 2007, 11:31:47 PM »
With fem-fem bypass pumonary blood flow is still maintained and without ventilation may produce shunt and V/Q mismatch
Jet ventilation may be an alternative
Place 2 catheters distal to obstruction in each bronchi and use 2 separate Sanders injector to jet ventilate.
Patient may be anaesthetized(TIVA with Propofol-Ketamine infusion) and paralyzed and without ETT

Alternatively 1 catheter may be placed distal to the stenosis but above carina and use single jet ventilator to ventilate both lungs

Surgeon has to be fast and good suction equipment should be available to prevent soiling of unprotected lungs by blood from tumour. With laser surgry bleeding may be less

PROBLEMS

barotrauma
CO2 retention limiting duration of surgery
Venturi effect pulling in blood and debris into lungs. I think this may not happen as the pressure build up occurs below the operating site and hence it may push blood and debris out . I am not sure though, just postulating

Use steroids.
Have all size ETT
at first evidence of problem re-insert tracheostomy tube.
Bronchospasm may occur - smoke and debris into lung
Risk of airway fire accident

after removal put biggest possiblity ETT in and retain, because we can anticipate edema in operated tissue of trachea.

We have experience in managing FB trachea in unintubated airways in paralysed patients. so I think it must be possible although i have never done a case like this before.

HFOV may be alternative . Never seen one

regs


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