Abstract. Introduction. Case presentation

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1 Ying-Jen Chang et al. Awake Laryngeal Mask Airway Intubation for Tracheal Stent Insertion in a Patient with Massive Tumor Invasion to trachea: a Case Report Ying-Jen Chang 1, Chia-Ming Chen 1, Kuo-Mao Lan 1, Ming-Chung Ling 2, Chi-Lun Tsai 3, Jen-Yin Chen 1, Yu-Hsuan Yen 1 Abstract Increasing numbers of patients are being treated with tracheal stenting as a palliative option to extend life-span. However, anesthesiologists may experience challenges ensuring adequate ventilation in the stenotic segment. Here we report a case of tumor spreading from neck to trachea scheduled for tracheal stenting. We chose LMA for airway management instead of an endotracheal tube due to an endotracheal tube may interfere with the expansion of the tracheal stent. The patient received awake intubation with a LMA after lidocaine inhalation and spray. Lidocaine produces a powerful anesthetic effect on the trachea. No muscle relaxant was administered. Spontaneous ventilation may improve the dynamics in intrathoracic lesions. A strategy for anesthesia and emergency rescue planning should be established prior to the procedure. The strategies of managing are discussed in this article. Key Words: Airway collapse, tracheal stenosis, tracheal stent, awake intubation, awake laryngeal mask, nebulized lidocaine, lidocaine spray Introduction Airway stents are employed in procedure to alleviate large airway obstruction, which can occur in patient with various disorders, including malignancy in the mediastinum and intrinsic neoplasia in the trachea. 1 Following advance in airway stent quality, 2 increasing numbers of patients are being treated with this option to relieve symptoms and to extend life-span. 3 General anesthesia is frequently required to ensure that surgeons have a clear operative view. However, anesthesiologists may experience challenges such as ensuring adequate ventilation in the stenotic segment, adjusting anesthetic depth, providing a relatively dry surgical field to facilitate the operation, and monitoring for acute complications. In this article, we report a case of stenting at Chi Mei Hospital in Tainan, Taiwan. Case presentation A 66-year-old male patient, weight 57 kg and height 170 cm, developed a progressively worsening dry cough and hoarseness over 2 months. Chest X-rays showed a mass le- Correspondence: Dr. Yu-Hsuan Yen Department of Anesthesiology, Chi Mei Medical Center; No. 901, Zhonghua Rd, Yongkang District, Tainan City710, Taiwan 1 Phone: ext ; takoyan117@gmail.com Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan, Taiwan 2 Department of Intensive Care Medicine, Chi Mei Medical Center, Tainan, Taiwan 3 38

2 Awake LMA for tracheal stent sion approximately 6.0 cm in size located in the right upper zone of lung that caused the tracheal to deviate to the left. The chest CT revealed a confluent tumor at least 9.8 cm large, spreading from the right lower neck area to the supraclavicular region, subclavicular region and mediastinum, with an irregular, lobulated shape. Tracheal compression was noted, accounting for significant stenosis with tumor invasion. (Figs. 1, 2) Furthermore, vessels were encased in the tumor. Ultrasound guided biopsy was performed, and the biopsy report suggested that the patient had metastatic squamous cell carcinoma that originated in the lungs. An otolaryngologist performed laryngoscopy, which revealed right vocal palsy. Chest surgeon was consulted and the patient was scheduled for a palliative tracheal stenting surgery. On examination, the patient could lie supine without experiencing respiratory distress. The Mallampati score of the patient was class II, indicating that the oral airway was normal. The initial vital signs were stable, and the SpO 2 was 100%. After standard noninvasive monitoring was applied, intravenous access was gained. The patient received a 2% lidocaine 1 ml inhalation and 10% lidocaine spray for 5 times in the oral pharynx. After preparation, we performed laryngeal mask airway insertion with the patient s full understanding and co-operation. After laryngeal mask airway insertion, we used propofol and fentanyl as a totally intravenous technique for induction and maintenance of anesthetic depth. No muscle relaxant was administered so the patient could maintain spontaneous ventilation throughout the operation with pressure support mode of mechanical ventilation. A bolus of propofol was administered to increase the anesthetic depth. A flexible bronchoscope and the introducer of the tracheal stent were then inserted into the laryngeal mask airway. Flexible bronchoscopy was used to visualize the glottic opening, stenotic area, and protruding tissue from posterior wall of trachea (Fig. 3). The self-expanding metallic stent was inserted into the tracheal stricture by using the introducer. After the introducer and the bronchoscope were removed, the stent in the airway was expanded to the maximal diameter under fluoroscopic guidance (Fig. 4). The laryngeal mask airway was then removed smoothly after stent expansion. The patient maintained spontaneous ventilation under lowdose propofol infusion, and the level of saturation of pulse oximeter was kept in a safe margin. Fig. 1. Chest CT showed a mass lesion cause tracheal compression. Fig. 2. Chest CT showed the trachea was deviated to right side. 39

3 Ying-Jen Chang et al. Fig. 3. Bronchoscopy showed airway narrowing and protruding tissue from posterior wall of the trachea. Fig. 4. Bronchoscopy showed the airway was patent after the stenting procedure. Discussion Stent placement can be performed using flexible fiberscopy and topical anesthesia in a conscious patient or in a patient under general anesthesia with or without muscle paralysis. However, misplaced stents pose a high risk of acute airway obstruction. For example, airway perforation, tracheal dissection by iatrogenic false lumen, or a misplacement of covered stent leading to bronchial occlusion. 4 Whatever the anesthetic method is chosen, we should prepare an emergency plan for rescue. We should have intermittent oxygen jets standing by for partial collapse and be prepared for possible complications during jet ventilation, such as pneumothorax. 5 If the capnography shows an abnormal waveform, surgeons should halt the operation to reexamine for problems. Extracorporeal membrane oxygenation (ECMO) should be available for use in the event of airway total collapse. 4,6 Some previous study suggested veno-venous extracorporeal membrane oxygenation (VV ECMO) established just after anesthetic induction in high risk patient. 6 We prefer a laryngeal mask instead of an endotracheal tube because this technique provides adequate ventilation and an unobstructed surgical view and is especially useful if the stenotic area lies above the carina. An endotracheal tube may interfere with the expansion of the tracheal stent. Maintaining spontaneous ventilation and the basic muscle tone of the large airway is critical. Airway collapse is frequently caused by loss of muscle tone. 7 However, spontaneous ventilation has advantages and disadvantages. Some studies have indicated that airway collapse can occur because of negative pressure in the large airways. 8,9 In some case reports, episodes of desaturation have been noted during spontaneous ventilation. 8,10,11 Moreover, voluntary movement or the cough reflex during operation will increase the risk of surgical complications. Complete paralysis can prevent this risk. Miller defined classic patterns of upper airway obstruction according to location: an extrathoracic lesion, a lesion above the thoracic inlet; and an intrathoracic lesion, a lesion below the thoracic inlet. 12 The degree of upper airway obstruction, quantified using flow-volume loops, was recorded in conditions of muscle relaxation and spontaneous ventilation when conscious. 8 During 40

4 Awake LMA for tracheal stent expiration, compression caused by increasing pleural pressures leads to a decrease in the size of the airway lumen at the site of intrathoracic obstruction and a producing a flattening of the flow-volume loop expiratory limb. A collapsible extrathoracic airway narrows during inspiration and dilates during expiration because the transluminal pressure decreases during inspiration and increases during expiration. Airflow is predominantly limited in the extrathoracic airway during inspirations and in the intrathoracic airway during expiration. During spontaneous inspiration in extrathoracic lesion, negative intratracheal pressure causes indrawing of the mobile tracheal segments, further narrowing the lumen and limiting inspiratory airflow. Positive-pressure ventilation, therefore, has a favorable impact on extrathoracic stenosis. 8,13 In summary, spontaneous ventilation may impair the ventilatory dynamics in extrathoracic airway lesions, but may improve the dynamics in intrathoracic lesions. Because our patient had intrathoracic airway obstruction caused by external compression of the tumor, we used spontaneous ventilation throughout the operation, including the course of LMA insertion. Nebulized 2% lidocaine 1mL was administrated through a facial mask and 10% lidocaine was sprayed 5 times into the oral cavity and oral pharyngeal space before the LMA was inserted. Administering nebulized 2%-4% lidocaine for min can produces a highly effective anesthetic effect on the trachea. When applied to mucosal membranes, 2% lidocaine produces superficial anesthesia for min, and the peak anesthetic effect occurs within 2-5 min. 14 According to this information, lidocaine can provide an effective anesthetic effect before the onset of volatile anesthetics. The peak plasma lidocaine level was far below the accepted toxic threshold of 5 mg/l after the nebulization of 6 mg/kg lidocaine, 15 indicating that lidocaine can be administrated safely through inhalation. Many case reports have described the insertion of an LMA into healthy conscious volunteers 16 or the patients with difficult airway. 17 All volunteers were co-operative during the procedure, and only a few patients reported discomfort. 16 According to the patient in our study, the discomfort was tolerable. In conclusion, to provide optimal ventilation, a crisis management strategy, which was built according to the degree and level of tracheal obstruction, should be established before a tracheal stenting surgery. References 1. Saito Y, Imamura H. Airway stenting. Surg Today 2005;35: Conacher ID. Anaesthesia and tracheobronchial stenting for central airway obstruction in adults. Br J Anaesth 2003;90: Miwa K, et al. Temporary stenting for malignant tracheal stenosis due to esophageal cancer: a case report. Jpn J Clin Oncol 2002;32: Jones C, A.J. Crerar-Gilbert, B.P. Madden. Anaesthesia for endobronchial intervention and tracheobronchial stents. Current Anaesthesia & Critical Care 2009;20: Brodsky JB. Bronchoscopic procedures for central airway obstruction. Journal of Cardiothoracic and Vascular Anesthesia 2003;17: Hong SH, et al. Anesthetic management for the insertion of a self-expandable metallic tracheal stent under venovenous extracorporeal membrane oxygenation. Korean J Anesthesiol 2012;63: Piao M, et al. Successful management of trachea stenosis with massive substernal goiter via thacheobronchial stent. J Cardiothorac Surg 2013;8: Nouraei SA, et al. Physiological comparison of spontaneous and positive-pressure ventilation in laryngotracheal stenosis. Br J Anaesth 2008;101: Murgu SD, H.G. Colt. Tracheobronchomalacia and excessive dynamic airway collapse. Respirology 2006;11: Ho, A.M., et al. Total airway obstruction during local anesthesia in a non-sedated patient with a compromised airway. Can J Anaesth 2004;51: Gardner J.C., R.L. Royster. Airway collapse with an anterior mediastinal mass despite spontaneous ventilation in an adult. Anesth Analg 2011;113: Miller RD, R.E. Hyatt. Obstructing lesions of the larynx and trachea: clinical and physiologic characteristics. Mayo Clin Proc 1969;44:

5 Ying-Jen Chang et al. 13. Isono S, et al. Case scenario: perioperative airway management of a patient with tracheal stenosis. Anesthesiology 2010;112: Pani N, S. Kumar Rath. Regional & topical anaesthesia of upper airways. Indian J Anaesth 2009;53: Parkes SB, C.S. Butler, R. Muller. Plasma lignocaine concentration following nebulization for awake intubation. Anaesth Intensive Care 1997;25: Lee MC, et al. Awake insertion of the laryngeal mask airway using topical lidocaine and intravenous remifentanil. Anaesthesia 2006;61: Lopez AM, et al. Awake intubation using the LMA-C Trach in patients with difficult airways. Anaesthesia 2009;64:

6 清醒喉罩插管及氣管支架置放 病例報告 - 為氣管受腫瘤侵犯之患者進行清醒喉罩插管及氣管支架置放 張穎真 1, 陳家銘 1, 籃國懋 1, 林明忠 2, 蔡季倫 3, 陳貞吟 1 1, 顏郁軒 摘要 現今放置氣管支架的手術逐漸增多, 越來越多緩和醫療的重症病患被胸腔外科醫師安排放置氣管支架來延長生命, 但這樣的手術與麻醉其實具有極高的困難度和風險, 尤其手術過程中麻醉醫師必須確保在氣管狹窄的部分能維持足夠的通氣量 本文提供一位頭頸部及氣管受腫瘤侵犯患者放置氣管支架的病例報告 本案特色為選擇局部麻醉噴劑使用後清醒置入喉罩, 保持病患自主呼吸之下進行全身麻醉 喉罩不進入氣管, 相較於傳統氣管內管較不會阻礙氣管支架撐開 清醒的置入喉罩和全程的自主呼吸, 同樣皆利用保持肌肉張力之原理以避免氣管狹窄處塌陷 由於麻醉中氣管塌陷的可能性高, 執行支架置放的團隊必須具有塌陷發生後 無法通氣時緊急應變的急救能力 本文將討論術前評估準備與相關緊急應變措施 關鍵詞 : 呼吸道塌陷, 氣管狹窄, 氣管支架, 清醒插管, 清醒喉罩, 局部麻醉劑 Lidocaine 霧化裝置, 局部麻醉劑 Lidocaine 噴劑 通訊作者 : 顏郁軒醫師 台南市永康區中華路 901 號 ; 奇美醫療財團法人奇美醫院麻醉部電話 : 轉 53341; takoyan117@gmail.com 2 奇美醫療財團法人柳營奇美醫院麻醉科 3 奇美醫療財團法人奇美醫院加護醫學部 43