Journal of Clinical Anesthesia (2016) 32, 134136

Case Report

Anesthesia airway management in a patient with

upper tracheal tumor,
Chen Wendi 1 , Jiang Zongming MD ,1 , Chen Zhonghua MD
Department of Anesthesia, Shaoxing People's Hospital (Shaoxing Hospital of Zhejiang University), Shaoxing 312000, PR China

Received 21 December 2014; revised 17 February 2016; accepted 18 February 2016

Keywords:
Abstract The main challenge for surgical resection of tumors located at the upper trachea is contemplate for-
Tracheal tumor;
mulated plan for providing maximal surgical access to the trachea while ensuring patent airway and ade-
anesthesia;
quate oxygenation at the same time. In this report, we describe a patient who presented with an upper
ventilation
tracheal tumor located 3 cm from the vocal cord and severe tracheal constriction, occluding tracheal lumen
by 90%. Initial ventilation was established by implantation with a supreme laryngeal mask airway. An emer-
gent tracheotomy and distal tracheal intubation were used to combat bleeding and subsequent airway ob-
struction. Eventually, tracheal tumor resection plus tracheal reconstruction via median sternotomy was
successfully conducted under general anesthesia. The whole process is uneventful.
2016 Elsevier Inc. All rights reserved.

1. Introduction vital importance to contemplate possible problems and formu-

Tracheal tumors can lead to severe tracheal constriction
followed by progressive airway obstruction, which can be
life-threatening when effective ventilation cannot be estab-
lished after induction of general anesthesia. Most importantly,
airway is shared by both surgeon and anesthesiologists during
surgery. Viable strategies for airway management during tra-
cheal tumor surgery vary depending on the tumor's nature,
growth pattern, and location, as well as the degree of airway
obstruction and surgical approach [13]. Therefore, it is of
There was no grant support for the research, and the authors declare no
competing interests.
late airway management options based on individual specic
condition and tumor's nature for ensuring successful anesthet-
ic management and uneventful outcomes.
2. Case report
The informed consent was obtained from the patient. A 70-
year old man weighing 65 kg presented at our department due
to coughing and stridor with paroxysmal dyspnea, which sev-
ered after exertional activity. The patient was diagnosed as
having upper tracheal cancer. A cauliower-shaped mass
was found in the main trachea under bronchoscopy, which

The manuscript has not been published previously or submitted
elsewhere.
Corresponding author at: Department of Anesthesia, Shaoxing People's
Hospital (Shaoxing Hospital of Zhejiang University), No 568,North Zhongx-
ing Road, Shaoxing 312000, PR China. Tel.: +86 135 15852725, +86 575
88229212 (mobile); fax: +86 575 88228888.
E-mail address: jiangzhejiang120@163.com (J. Zongming).
1
Contribute equally to the article.
caused airway stenosis, and the beroptic bronchoscope
(FOB) failed to pass through the narrowest point during preop-
erative routine examination. The tumor bleeds easily when
probed. Enhanced chest compute tomography plus 3-
dimensional tracheal reconstruction revealed that the tumor
size was about 1.6 cm with broad base, and the tumor was sit-
uated in the upper segment of the trachea. The lower edge of

http://dx.doi.org/10.1016/j.jclinane.2016.02.023
0952-8180/ 2016 Elsevier Inc. All rights reserved.
Anesthesia for upper tracheal tumor
the tumor was about 5.5 cm proximal to the carina and the up-
per edge was about 3 cm from vocal cord, obstructing the tra-
cheal lumen by 90%. The gap at the narrowest intraluminal
point was about 0.4 cm. Arterial blood gas tests only showed
abnormal PaO2 (7.847 kPa) on room air after the patient en-
tered the theater. The patient was grade II based on the Amer-
ican Society of Anesthesiologists physical status grading and
grade A according to American Heart Association system.
The patient received tracheal tumor resection plus tracheal re-
construction via median sternotomy under general anesthesia.
After the patient entered the operating room, a peripheral
large pore venous access was obtained. The standard noninva-
sive monitoring was initiated through anesthesia monitor. In-
vasive arterial pressure was monitored by left radial artery
catheterization. Oxygen ow of 6 L/min was given via mask
and deep breath for 2 minutes, then the patient was anesthe-
tized and paralyzed with intravenous injection of midazolam
1.5 mg, fentanyl 0.2 mg, etomidate 12 mg, and succinylcho-
line chloride 100 mg. After administering manual positive
pressure ventilation for 2 minutes, a laryngeal mask airway
(LMA) Supreme 4.0 (LMA North America, Inc, San Diego,
CA) was smoothly inserted. After conrming LMA position
and airway patent, mechanical ventilation was initiated by an-
esthesia machine. Median sternotomy was performed to ex-
pose the trachea under supine position. An FOB that is
4 mm in outer diameter was inserted through the LMA to
the site of the tumor with a view to positioning exact tumor
site. However, the tumor bled and blurred the vision of the
FOB when it approached the tumor site. The FOB was then
immediately pulled out. Airway pressure was sharply in-
creased to 40 cm H2O. After suctioning secretions containing
blood and sputum, airway pressure without a doubt declined,
but pulse oxygen saturation dropped to 85%. Immediate tra-
cheotomy was performed to remove the secretions, and an
inner-diameter ID 6.5-mm endotracheal tube (ETT) was suc-
cessfully intubated to connect the patient to the anesthesia ma-
chine. The airway pressure then dropped to 14 cm H2O.
After resection the tumor and length of 2.5-cm segmental
trachea, orotracheal intubation with an ETT (ID 7.0 mm)
was inserted under direct vision, the ETT tip passed beyond
distal end of the trachea for mechanical ventilation, and trache-
al anastomotic stump was sutured under head exion position.
After completion of anastomosis, the ETT was withdrawn un-
til the ETT cuff above the glottis, the tip of the ETT was sent to
the vocal cord, and the cuff was stocked in the glottis by hand
using manual controlled moderate pressure (b 25 cm H2O). A
little bit of water was dripping onto the surface of the anasto-
mosis to test sealing integrity. In this case, no air leakage
was found, the air in the cuff was released, and the ETT ad-
vanced deeper into the trachea beyond anastomotic site. Tube
cuff was inated moderately for mechanical ventilation. Be-
fore the end of the surgery, the chin was xed to the chest wall
using silk thread to maintain head exion and ameliorate anas-
tomosis tension. The surgery lasted for 135 minutes. After re-
moving the ETT, providing oxygen, and recovery for
45 minutes, the patient showed stable vital signs and was
135
returned to the ward. The patient was discharged 4 weeks after
surgery showing good rehabilitation. No postoperative injury
to the glottis was observed.
3. Discussion
Surgical resection of lesions and airway reconstruction are
the preferred options for dealing with primary tracheal tumors
[4].Therapeutic bronchoscopy, laser vaporization (Nd:YAG or
CO2), photodynamic therapy, cryotherapy, endobronchial
brachytherapy, or stenting implantation is used to palliate
unresectable tumors [5], and liberal use of these techniques
should be avoided because the merits and shortcomings of ev-
ery technique must be weighed cautiously [6]. Although, for
some patients, the nal outcome is often dismal, relief of air-
way obstruction can produce signicant improvement in qual-
ity and length of life. Comprehensive perioperative airway
management protocols are essential and critical for successful
therapy and uneventful outcomes in these patients.
In the present case, several perioperative airway manage-
ment options are concepted for combating anticipated and un-
expected conditions. Cardiopulmonary bypass instruments are
available and high-frequency jet ventilation machine is pre-
pared for emergent airway situation. Because the length of
the cuff plus tube bevel tip is about 5 cm, the tumor margin
was only about 3 cm from the vocal cords, the tumor had brit-
tle texture and bled easily when probed, the tumor mass was
large, tracheal stenosis was severe, and the lumen of the nar-
rowest gap was only 0.4 cm. If conventional endotracheal in-
tubation technique were instituted, the ETT tip would contact
tumor body and cause tumor deformation, which carried the
risk of bleeding and complete airway obstruction, resulting
in life-threatening and catastrophic condition. So this protocol
was abandoned. Distal tracheotomy under local anesthesia and
a sterile ETT intubation by surgeon might be a way of securing
a patent airway but with patient discomfort. Eventually, LMA
Supreme 4.0 was smoothly inserted after anesthesia induction,
and then median sternotomy was conducted by the surgeon,
lower tracheotomy was done, and a small-sized ID 6.5-mm
ETT was intubated through lower tracheotomy incision for
mechanical ventilation. Finally, tumor resection and tracheal
reconstruction were successfully performed.
The LMA Supreme 4.0 is a newly introduced single-use
supraglottic device, with curved shaft consisting of a double
lumen. The bending design ts the human larynx anatomical
structure and makes insertion faster and easier [7]. The modi-
ed cover bag and epiglottic ns make it easier to advance into
the exact location, and appropriate sealing can provide a con-
duit for spontaneous breathing or mechanical ventilation.
The patient underwent mechanical ventilation after implanta-
tion with an LMA Supreme 4.0. The breathing indices were
good. Using the head-tilted back position [8], the surgical pro-
cedures performed on the neck did not inuence the ventila-
tion of the LMA. The merit of using LMA Supreme 4.0 in
136
this case is providing efcacious ventilation and adequate ox-
ygenation, while without interventions to the lower respiratory
tract, which would cause catastrophic situations.
In this case, the use of FOB to locate the tumor through
a laryngeal mask caused intraoperative bleeding and sub-
sequent airway obstruction. Because of the trachea being
already exposed, tracheotomy and distal tracheal intuba-
tion were performed. Therefore, this case implicated that
ventilation with an ETT should not be routinely adopted.
In this case, there are some problems in the examination
of anastomotic leaks: because the length of the cuff plus
tip is about 5 cm, when the tip of tube was retreated to the tra-
cheal anastomosis, the cuff almost prolapsed out of the glottis
and could not maintain effective airway pressure. Therefore,
the ETT tip was timely withdrawn under direct vision to t in-
to the tracheal anastomosis and glottis location. The tip of the
ETT was sent to the glottis, and the cuff was streaked at the
glottis.
In summary, airway management in patients with upper tra-
cheal resection requires careful concepting of a safe, reliable,
practical, and feasible airway management program. Good
communication, coordination, and cooperation between the
surgeons and anesthesiologists are mandatory throughout the
operation for a successful outcome. The LMA Supreme 4.0
provided a safe and efcacious solution for ventilation and cre-
ated the conditions for surgical exposure of the trachea as well
as improving the safety of anesthesia. The strategy used in this
report can be an option for management of patients with tra-
C. Wendi et al.
cheal tumors located at the upper trachea that cannot be intu-
bated via conventional technique.
Acknowledgments
We thank the thoracic surgical team of our hospital in deal-
ing with the case. We are thankful to the patient for his agree-
ment to publish the manuscript.
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