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Anesthesia airway management for tracheal resection and reconstruction: a single-center case series 背景：气道切除及重建的麻醉气道管理具有挑战性。这些病例介绍了四种气道管理的方法，讨论了他们的优势及不足。 方法：2013-2019年间，13名患者接受了其中一种气道管理方案：插管；插管及高频喷射通气；不插管及VV-ECMO。通过我们的数据库比较术中变量及术后相关结果。 结果：8名患者接受VV-ECMO，2名患者接受插管，2名患者接受高频喷射通气，1名患者喉罩通气。4名患者最低脉氧＜90%。3名患者自主呼吸完全恢复时手术室内拔管。多数患者进入ICU治疗。2名患者死亡，分别由于吻合口渗漏及急性呼吸窘迫症。此外，一名患者出现严重的伤口渗出。 结论：我们临床经验表明，单一的气道管理策略并不合适。应该根据术前共病，梗阻性质、手术经验、患者情况选择合适的气道管理策略。 Discussion Anesthesia airway management plays a significant role in ensuring the safety of patients undergoing trachealresection and reconstruction. There is no consensus on the optimal airway strategy for tracheal surgeries, and our experience with the 13 patients described in this study suggests that no single strategy is appropriate. Instead, the strategy should be chosen based on the state and preference of the patient the experience of the surgeons, the surgical methods, and the equipment of anesthesia. 麻醉气道管理在术中扮演保障患者安全的关键角色。目前没有气道手术的最佳气道策略，并且我们的经验注重综合判断。应根据患者情况、手术经验、手术方式及麻醉设备综合考虑。 The important factor for airway management is clinical evaluation. In our study, most patients presented exertional dyspnea and stridor at rest. Exertion dyspnea appears when the tracheal diameter is narrowed by more than 50% or to a final value of 8 mm (18,19). When the internal diameter falls below 5–6 mm, patients present with stridor at rest (20).To formulate the most appropriate anesthesia plan, we carefully assessed preoperative symptoms and used high resolution, three-dimensional computed tomography (CT) and fiber-optic bronchoscopy to assess the nature, growth pattern, and location of the obstructive mass, the degree of airway obstruction, and the distance from the vocal cords and carina (21). We also determined in which position the patient was most comfortable and the patient’s airway is least likely to be obstructed after induction of anesthesia (22). We communicated with surgeons about the patients’ pulmonary function, length of tracheal resection, and any areas of tracheomalacia or tracheal inflammation (3). 术前评估很重要。我们的患者大多表现为劳力性呼吸困难及静息喘鸣。当气管直径减少小超过50%或内径小于8 mm时，会出现劳力性呼吸困难。当内径小于5-6mm时，患者出现静息喘鸣。为了制定最佳麻醉策略，我们仔细评估了术前症状，并使用高分辨率三维CT和纤支镜来评估肿块位置、生长方式、梗阻程度以及距声带和隆突的距离。我们选择了诱导后能够防止气道梗阻及具备舒适性的体位。我们了解患者肺功能情况、手术时间及是否存在气管软化及气道炎症。In our study, the levels of airway obstruction and the tracheal diameters of the 2 patients with intubation (patients 1 and 2) were 70% (6 mm) and 55% (8 mm).As demonstrated in a previous case report (7), the anesthesia plan for endotracheal intubation is suitable for patients with soft or mild tracheal stenosis. In our cases, the level of tracheal stenosis was below 75% with the unobstructed tracheal diameter beyond 5 mm, which could ensure sufficient space to intubate with the endotracheal tube. Moreover, the mass was not prone to bleeding or detachment. Otherwise, endotracheal intubation may result in tumor fragmentation or bleeding, which may aggravate tracheal stenosis. However, even a small-caliber endotracheal tube placed in the distal tracheal lesion can reduce visibility of the surgical field during anastomosis.在我们的研究中，2名患者气道梗阻程度和气道内径分别为70%(6mm)及55%(8mm)。既往病例报道，气管插管适用于轻度狭窄的患者。我们的病例中气管狭窄程度＜75%，气管内径＞5 mm，才能选择插管。此外，考虑到肿块不易出血及脱离，插管不会引起肿块碎片及出血加重梗阻。然而，即使在远端病变放置小口径气管导管，也会影响手术视野 The 2 patients with the HFJV catheter showed an obvious buildup of carbon dioxide during anastomosis. Patient 3 presented the lowest SpO2 level of 74% and a peak end-tidal carbon dioxide level of 111 mmHg during surgery. This patient showed postoperative complications with anastomotic leakage, which might have been due to the length of tracheal resection (3.0 cm), wind-induced contusion by the HFJV, and high stretching tension at the anastomotic site. The patient ultimately died after the family refused further surgery-related treatment and left the hospital against medical advice. We conclude that HFJV may worsen intra- and postoperative outcomes, although the poor outcomes of our patient might have been due to the more difficult surgery because of the tumor location. Nevertheless, HFJV may allow for greater visibility of the surgical field than distal tracheal intubation (3), and can support ventilation in rescue situations (22). Further work should examine the advantages of HFJV in different types of patients 2名HFJV患者术中出现明显CO2蓄积。患者3术中的最低为SpO274%，呼末CO2为111 mmHg。该患者术后出现吻合口瘘，可能是由于气管切除（3.0 cm）、HFJV气流伤、吻合口高张力。患者家属拒绝接受进一步治疗离院，该患者最终死亡。我们的结论是，HFJV增加手术不良事件发生率。尽管HFJV提供了良好的手术视野及紧急维持通气，肿瘤位置增大的手术难度仍导致了患者的不良预后。进一步实践应该研究HFJV在不同类型患者中的优势A previous case report summarized the indications for non-intubated spontaneous respiration anesthesia as follows: (I) no contraindications for anesthesia or surgery; (II) no severe cardiopulmonary diseases; and (III) low airway secretions (4). In the present case series, the patient with non-intubation (patient 5) was 28 years old, had a BMI of 18 kg/m2, and did not have severe cardiopulmonary diseases. Tracheal stenosis was due to endotracheal intubation injury 3 months before. The tracheal scarring stenosis was followed by a chronic inflammatory reaction, granulation tissue formation, and subsequent fibrous scar formation owing to prolonged mechanical ventilation in the ICU. The level of airway obstruction was more than 90%, and the narrowest tracheal diameter of the patient was 3 mm (Figure 3). Although the patient presented transient hypoxia and hypercapnia during the operation, she was extubated 5 minutes after the operation in the operating room. She did not require transfer to the ICU after surgery, and no complications were recorded. Her rapid recovery from the anesthesia was attributed to the accuracy of anesthetic depth monitoring and the absence of muscle relaxants (14). In this case, the greatest advantage of non-intubation was good visibility of the surgical field during reconstruction. Consistent with our experience, a single center retrospective analysis showed that supraglottic airway devices for cervical tracheal resection and reconstruction were appropriate for patients diagnosed with scar tissue in the stenotic area and with anticipated difficult transstenotic tube placement (22). Based on that study and our own experience, we suggest that non-intubation may be a feasible, relatively safe airway management method for patients with (I) BMI <25 kg/m2, (II) less risk of airway secretion and bleeding, and (III) tracheal scarring stenosis who (IV) do not have severe cardiopulmonary dysfunction and (V) for whom transstenotic tube intubation is expected to be difficult既往病例总结了非插管自主呼吸麻醉的适应症：(I)无麻醉或手术禁忌症；（II）无严重心肺疾病；（III）气道分泌物少。在本病例系列中，非插管患者（患者5）年龄28岁，BMI为18 kg/m2，没有严重的心肺疾病。3个月前因气管插管损伤导致气管狭窄。气管瘢痕性狭窄后出现慢性炎症反应，肉芽组织形成，随后由于ICU长时间机械通气导致瘢痕形成。气道阻塞程度大于90%，患者气管直径为3mm（图3）。患者术中出现短暂缺氧和高碳酸血症，但术后5分钟在手术室拔管。术后无需ICU监护，无并发症。麻醉深度的准确监测及无肌松麻醉促进患者快速苏醒。在这种情况下，非插管的最大优势是良好的手术视野。与我们的经验一致，一项单中心回顾性分析显示，气管切除和重建的声门上气道装置适用于诊断为瘢痕狭窄和狭窄段导管难以通过的患者。基于这项研究和我们自己的经验，我们建议非插管麻醉可能是一个可行且安全的气道管理方法：(I) BMI <25 kg/m2，（II）气道分泌物少及出血风险低（III）瘢痕狭窄（II）没有严重的心肺功能障碍(V)预计经狭窄段插管困难 Previous studies have suggested that ECMO can provide sufficient ventilation and oxygenation during surgery, and is especially suitable for critical patients with severe airway obstruction or when extensive resection of the infiltrating tumor is needed (14,21,23). In our study, SpO2 was maintained above 90% in 6 out of 8 patients who received ECMO. In the other 2 patients, it dropped to 87% for approximately 10 min. Similar to patients with a laryngeal mask, those on ECMO do not require airway既往研究证明，ECMO能够维持通气及氧合，尤其适用于严重气道梗阻及需要广泛切除浸润肿瘤的危重患者。我们的研究中，8例接受ECMO治疗的患者中有6例的SpO2维持在90%以上。其他2例患者中，下降至87%持续约10min。与喉罩患者类似，使用ECMO的患者不需要导管，提供气道后部重建的良好手术视野。然而接受ECMO患者住院时间更长，费用更高。既往研究表明ECMO并发症更多，包括高昂的住院费用，肝素导致出血，插管相关感染，血栓栓塞，下肢缺血。我们的患者中，1例ECMO患者凝血功能障碍伤口渗血，该患者接受2u血浆和2u红悬输血，术后第3天恢复。另一名ECMO患者（患者10）死于急性肺损伤。患者的呼吸衰竭很可能由已存在的晚期肺部感染Our study presents several limitations. The first is the small number of patients analyzed, which could limit our conclusions regarding the benefits and limitations of the 4 airway management strategies. Secondly, as a retrospective study, post-discharge data, such as fiberoptic bronchoscopy images, clinical symptom and quality of life improvements, and long-term survival, were not collected我们的研究仍有限制。首先是样本量小，总结的优缺点不够全面。其次，回顾性研究未能收集纤支镜图像，临床症状，生活质量改善和长期生存率。Despite these limitations, our case series offers additional experiences to guide airway management planning for tracheal resection and reconstruction surgery. Tracheal resection and reconstruction require multidisciplinary collaboration involving surgical, anesthesia, interventional, and ICU teams. Airway strategies should be tailored to preoperative comorbidities, unique features of the obstructive mass, surgical experience, and patient consent.尽管有这些局限性，我们的病例仍然提供了经验来指导气管切除和重建的气道管理计划。气管切除和重建需要多学科的合作，包括外科、麻醉、介入和ICU团队。气道策略应根据术前共病、梗阻性质、手术经验和患者知情个体化制定。原文链接： http://dx./10.21037/apm-21-431
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