Options for Airway Management During Complex Resection and Reconstruction

Transcription

1 Options for Airway Management During Complex Resection and Reconstruction Brian E. Louie MD, FACS, FRCSC, MHA, MPH Director, Thoracic Research and Education Co-Director, Minimally Invasive Thoracic Surgery Program Co-chair, Digestive Health Institute, Swedish Health Services Division of Thoracic Surgery Swedish Cancer Institute and Medical Center Seattle, Washington AATS Focus on Thoracic Surgery Mastering Innovation Las Vegas, NV October 28 th, 2017

2 Disclosures Educational Grants Olympus Corporation of America Boston Scientific Medtronic/Covidien Restricted Research Grants Torax Medical Incorporated Intuitive Surgical

3 Diseases requiring complex airway management

4 The patient Can be debilitated, dehydrated, malnourished Recent or concurrent pneumonia Contralateral involvement Stridor

5 The Environment Communication with anaesthesia paramount Long duration of surgery Prone to ventilatory insufficiency Requires adequate gas exchange Operative field is small and visualization is key Certain options require additional health care members

6 Surgical approaches

7 Airway technique and phases of resection Dissection Phase Resection Phase Closure Phase Endotracheal intubation (96%) Cardiopulmonary bypass (2%) Tracheostomy (2%) Crossfield intubation (80%) Transtracheal intubation (12%) Transtracheal jet ventilation (8%) Crossfield jet ventilation (0.1%) Cardiopulmonary bypass (0.1%) Endotracheal intubation (96%) Tracheostomy (4%) Schieren et al. J Cardiothoracic and Vascular Anesthesia (2017)

8 Airway Management Intubation/Dissection In most situations can be accomplished with ETT May require rigid bronchoscopy and dilation to allow a 6 or 6.5 Fr ETT TEF should have NG tube in place on suction Rarely is a double lumen used/required Tracheostomy may have been placed previously

9 Cross field Intubation Safe and applicable Sterile circuit, cuffed armored ETT (6Fr) Positive pressure ventilation Aspiration protection May obstruct view/access Available in all centers

10 Cross field Intubation When apneic access required - pre oxygenate/ventilate to provide 5 min w/o tube in field Prone to dislodgement or movement can reduce by suturing to pleura Accidental distal damage

11 Transtracheal Intubation Less common Usually for cervical approaches May not be feasible with stenotic area Similar issues to cross field Periods of apnea Place a suture into end of ETT to pull down and allow for easy repositioning

12 Transtracheal Jet Intubation ETT with 2 suction catheters (12/14Fr) and 1 Fogarty catheter (14 Fr) (L) vent: 100% O2, RR=150/min, driving pressure 35 psi, inspiratory time 50% (R) vent: RR=140, 5 psi, 50% Catheters move, spraying of blood/fluid Perera et al. Can J Anaesthesia (1993)

13 Transtracheal Jet Intubation Settings: 100% FiO2, RR 2hz, driving pressure 15 psi, inspiratory time 25% Improved visualization Lessens aspiration risk Air trapping and barotrauma risks Recommend to have sterile ETT/circuit ready Chin et al. J Korean Med Sci (2010)

14 Cardiopulmonary Bypass Limited to case reports from highly selected centers Indications: Difficulty with ventilation secondary to left lung edema Carinal resection right atrial and ascending aortic access Recommend: early use of CPB if this occurs De Perrott et al. Annals of Thoracic Surgery 2015

15 Airway Management Closure Most commonly, ETT used Rarely, a tracheostomy Favor, therapeutic bronchoscopy to clear any residual secretions, inspect anastomosis

16 Influx of new approaches to airway management Number of Studies Conventional New Approaches Regional anesthesia with spontaneous ventilation LMA ECMO Extracorporeal decarboxylation/apneic oxygenation Schieren et al. J Cardiothoracic and Vascular Anesthesia (2017)

17 Spontaneous ventilation Facilitated by new local and regional anesthetic options Cervical epidural, bilateral cervical plexus block or catheters Usually subglottic or proximal lesions, but reports of lower tracheal and carinal resections Can be combined with LMA Mostly case reports

18 Concerns with spontaneous ventilation Management of hypoxia requires HF O2 and can be a fire risk Hypercapnia Unable to air leak test Secretion management difficult to suction Cough suppression No overwhelming benefit over intubated surgery Okuda and Nakanishi. Journal of Thoracic Disease (2016)

19 Extracorporeal membrane oxygenation Options V-V or V-A Limited to case reports Redwan et al. ICVTS (2015)

20 Conclusions Outside of select centers are uncommon cases in most practices Simplicity favors, trans-tracheal intubation or cross field intubation Requires collaboration with experienced anesthesiologist Newer techniques require a highly functional team of MDs, nursing, perfusionists, etc particularly for ECMO, CPB

21 Options for Airway Management During Complex Resection and Reconstruction Brian E. Louie MD, FACS, FRCSC, MHA, MPH Director, Thoracic Research and Education Co-Director, Minimally Invasive Thoracic Surgery Program Co-chair, Digestive Health Institute, Swedish Health Services Division of Thoracic Surgery Swedish Cancer Institute and Medical Center Seattle, Washington AATS Focus on Thoracic Surgery Mastering Innovation Las Vegas, NV October 28 th, 2014