The anesthetic management of patients with tracheal stenosis presents a number of significant challenges, including the potential for airway obstruction, difficulty in ventilation, and an increased risk of perioperative complications. Tracheal stenosis, defined as a narrowing of the tracheal lumen, can result from a variety of different etiologies, including prolonged intubation, trauma, infections, and inflammatory diseases. Effectively and safely administering anesthesia for patients with tracheal stenosis requires careful preoperative evaluation, diligent planning, and knowledge of specialized techniques (1).

A comprehensive preoperative evaluation is necessary and should include a detailed assessment of the patient’s medical history, presenting symptoms, and physical examination findings. Imaging studies, such as computed tomography (CT) scans or magnetic resonance imaging (MRI), are essential for determining the location, extent, and severity of the condition. Furthermore, pulmonary function tests and bronchoscopy can provide valuable information regarding the degree of airway obstruction and the dynamic nature of tracheal stenosis, which can then be used to guide the administration of anesthesia (2). The anesthetic management strategy must be tailored to the patient, taking into account the severity of their condition and the surgical procedure planned. Prior to surgery, it is vital to optimize the patient’s respiratory status, including the treatment of any concurrent respiratory infections or bronchospasm. Anxiolytics may be used with caution to minimize respiratory depression while ensuring patient comfort.

Induction of anesthesia in patients with tracheal stenosis requires careful consideration. Inhalational induction may be preferable in some cases to maintain spontaneous ventilation and allow continuous assessment of airway patency. However, intravenous induction agents such as propofol or etomidate can be used with careful titration and preparation for rapid airway intervention if necessary (3). The choice of induction technique should be based on the patient’s airway anatomy and the experience of the anesthesiologist. Airway management is the most critical aspect of anesthesia in patients with tracheal stenosis. Awake fiberoptic intubation is often the preferred technique because it allows direct visualization of the stenotic segment and minimizes the risk of complete airway obstruction. Topical anesthesia and minimal sedation facilitate patient cooperation and comfort during the procedure. In cases where fiberoptic intubation is not feasible, video laryngoscopy or rigid bronchoscopy can be used as alternative approaches (4).

During maintenance of anesthesia, ensuring adequate ventilation and oxygenation is paramount. The use of smaller endotracheal tubes may be necessary to navigate the narrowed tracheal lumen, but this may increase airway resistance and work of breathing. Pressure-controlled ventilation with careful monitoring of peak inspiratory pressures and tidal volumes can help optimize gas exchange while avoiding barotrauma. In addition, intraoperative bronchoscopy can be used periodically to assess the airway and remove secretions or debris that may exacerbate the stenosis (5).

Extubation of patients with tracheal stenosis should ideally be performed in a controlled environment, such as the operating room or intensive care unit, where immediate reintubation or surgical intervention can be readily performed if necessary. Postoperative monitoring in an intensive care setting may be warranted to promptly identify and manage any respiratory complications.

In conclusion, anesthesia management of patients with tracheal stenosis requires a multidisciplinary approach, careful planning, and the use of specialized airway management techniques. Preoperative optimization, careful induction, vigilant intraoperative monitoring, and cautious extubation are essential components of a successful anesthetic strategy in these high-risk patients. Adherence to these principles can significantly reduce perioperative morbidity and mortality in patients with tracheal stenosis.

References

1. Daumerie G, Su S, Ochroch EA. Anesthesia for the patient with tracheal stenosis. Anesthesiol Clin. 2010;28(1):157-174. doi:10.1016/j.anclin.2010.01.010
2. Isono S, Kitamura Y, Asai T, Cook TM. Case scenario: perioperative airway management of a patient with tracheal stenosis. Anesthesiology. 2010;112(4):970-978. doi:10.1097/ALN.0b013e3181d4051a
3. Zhu JH, Lei M, Chen EG, Qiao Q, Zhong TD. Ventilation strategy and anesthesia management in patients with severe tracheal stenosis undergoing urgent tracheal stenting. Acta Anaesthesiol Scand. 2018;62(5):600-607. doi:10.1111/aas.13062
4. Zhou YF, Zhu SJ, Zhu SM, An XX. Anesthetic management of emergent critical tracheal stenosis. J Zhejiang Univ Sci B. 2007;8(7):522-525. doi:10.1631/jzus.2007.B0522
5. Wright CD, Li S, Geller AD, et al. Postintubation Tracheal Stenosis: Management and Results 1993 to 2017. Ann Thorac Surg. 2019;108(5):1471-1477. doi:10.1016/j.athoracsur.2019.05.050