Anesthesia for tracheal resection and reconstruction

INTRODUCTION — Elective or emergency tracheal surgical procedures are performed to remove pathology, improve tracheal patency, or repair loss of tracheal integrity. Anesthetic challenges include managing abnormal airway anatomy, use of specialized endotracheal tubes and other airway devices to meet evolving intraoperative conditions, and need for changes in the mode of ventilation (eg, jet ventilation [JV], intermittent ventilation) during periods when the trachea is open or obstructed.

This topic will discuss anesthetic management of adult patients undergoing open or robotic tracheal resection and reconstruction. Anesthetic management of other tracheal procedures is discussed separately. (See "Anesthesia for tracheostomy" and "Anesthesia for endotracheal stenting or repair of tracheoesophageal fistula".)

PREANESTHETIC ASSESSMENT

Preanesthetic consultation — Tracheal lesions may cause airway obstruction [1,2]. The degree of airway patency may be dynamic and influenced by factors such as patient position, airway and thoracic muscle tone, mode of ventilation (spontaneous or controlled), or phase of respiration.

A major goal of the preanesthetic evaluation is to determine whether the tracheal lesion could cause airway obstruction during induction of anesthesia, or subsequently during surgical manipulation and/or resection. Details regarding evaluation of central airway obstruction are available in a separate topic. (See "Clinical presentation, diagnostic evaluation, and management of malignant central airway obstruction in adults".)

History and physical examination

●Patient history – Ask the patient what positions, breathing techniques, or other maneuvers improve or worsen breathing.

●Physical examination and functional status

•Observe breathing at rest and, if possible, during mild exertion. In patients with tracheal stenosis, determine whether increased work of breathing and dyspnea on exertion are present. These symptoms reflect a reduction in luminal diameter that is ≥50 percent [3,4].

•Observe the breathing pattern relative to posture. Patients naturally choose their resting position to optimize tracheal patency. Look at their chosen position on the stretcher and then see if the patient can assume a supine posture without increased breathing difficulty. Ideally, the induction position should be the patient's preferred posture.

•Perform a bedside version of the forced volume exhaled in the first second (FEV₁), also known as a "birthday candle" test, to obtain a qualitative sense of dynamic respiratory function. Ask the patient to blow forcibly on your hand and look for airflow obstruction during forced exhalation, which results in high positive intrathoracic pressure.

•Auscultate for respiratory phase-specific noises that suggest location and degree of airway pathology. Inspiratory stridor is associated with at least a 50 percent reduction in diameter at the glottis or periglottis. Expiratory or biphasic stridor is associated with pathology located below the vocal cords. Such findings suggest critically narrowed central airways with risk of acute airway obstruction during induction of general anesthesia due to tracheal wall collapse, secretions, or airway swelling.

Review of imaging and other studies

•Radiographs and scans – Imaging studies must be reviewed but may be falsely reassuring and often provide an incomplete picture. The patient's history and recent bronchoscopy results carry more weight. (See "Clinical presentation, diagnostic evaluation, and management of malignant central airway obstruction in adults", section on 'Imaging'.)

•Flow-volume loops – If available, flow-volume loops can provide supplemental information regarding tracheal obstruction (figure 1 and figure 2 and figure 3) [5,6]. Details are discussed in a separate topic. (See "Clinical presentation, diagnostic evaluation, and management of malignant central airway obstruction in adults", section on 'Pulmonary function tests'.)

Considerations for patients with a previous tracheostomy

●Preoperative assessment – Important patient-related and procedure-related factors in patients with a previous tracheostomy are noted during the preoperative assessment (table 1) [2,7,8]. Plans for airway management are reviewed before beginning the procedure. (See "Airway management for anesthesia for the patient with a tracheostomy", section on 'Creating a plan for airway management'.)

●Intraoperative strategies – If the tracheostomy device in place needs to be changed for the procedure, device selection and techniques depend on several factors including stomal maturity, ventilation goals during the procedure, intraoperative positioning, and need for aspiration protection. The final device to be placed at the end of the tracheal surgical procedure should also be available and in the operating room. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Tube types'.)

•Mature stoma with a device that is not a stent – All types of tracheostomy devices are used in mature stomas, including cuffed devices. Confirm the date of stomal creation.

If the patient has a history of frequent and uneventful decannulations, then the stomal device can be changed out for an appropriately sized armored endotracheal tube (ETT) (see 'Endotracheal tubes and supraglottic airways' below). Whether tube exchange occurs before or after induction depends on condition of the tracheostomy and the clinical situation, as discussed in a separate topic. (See "Airway management for anesthesia for the patient with a tracheostomy", section on 'Awake versus asleep tube change'.)

If there is no history of decannulation, then we use a Seldinger technique from the device in place to an armored ETT. A tube exchanger is placed through the device and into the trachea, and is held in place while the device is slid out. Then a lubricated armored ETT is gently advanced over the tube exchanger into position.

Always confirm proper ETT positioning with flexible bronchoscopy. (See 'Flexible bronchoscopy' below.)

•Mature stoma with a stent device (eg, T-tube or Y-tube) – If a stent is present, never manipulate or pull out the device. The surgical team managing the current tracheal procedure will remove the stent if this is necessary to perform the procedure, and will replace it with a cuffed armored ETT. In some cases, a supraglottic airway (SGA) may be used in a patient with a stent device in place while further tracheal surgery is performed. (See 'Endotracheal tubes and supraglottic airways' below.)

Flexible bronchoscopy is used to verify proper placement of the replacement ETT. The tip of this ETT should traverse the area where the stent was located, with final positioning beyond that tracheal region. (See 'Flexible bronchoscopy' below.)

•Immature stoma – It takes 7 to 10 days for a stoma to mature. Accidental decannulation of an immature tracheostomy can be disastrous with loss of the airway. Management is described in the algorithm (algorithm 1).

If a planned change of the tracheostomy device is necessary to perform a tracheal procedure that cannot be delayed in a patient with an immature stoma, strategies to minimize risk include:

-Ensure that backup plans have been communicated prior to starting the exchange. (See "Airway management for anesthesia for the patient with a tracheostomy", section on 'Creating a plan for airway management' and 'Preinduction communication' below and 'Key points for the surgical briefing' below.)

-The surgeon should be present for the exchange. (See "Airway management for anesthesia for the patient with a tracheostomy", section on 'Is assistance from a surgeon necessary?'.)

-If the airway is lost, the best strategy is usually to establish orotracheal intubation if possible (algorithm 1) [7].

-If orotracheal intubation fails, then a Seldinger technique is used to change out the tracheal device through the immature stoma, as explained above for mature stomas.

-Prior to ventilation, always confirm ETT positioning with flexible bronchoscopy. (See 'Flexible bronchoscopy' below.)

Re-evaluation on the day of surgery — Re-evaluation of the patient on the day of surgery is necessary since some tracheal lesions can rapidly progress to effect patency. Optimal condition of pulmonary status must be confirmed before elective surgery. If change(s) in status are noted, consult the surgical team regarding potential impact of new findings on planned surgical and anesthetic management. (See 'Preinduction communication' below.)

If the patient is having a tracheal resection that results in a shortened trachea, they are reminded of the need to awaken calmly. They are told to expect a possible retention "chin-stitch" running from their chin to upper chest that holds their head and neck in flexion during the postoperative period (to offload tracheal tension). This position will be maintained for a few days after surgery.

PREPARATION OF ANESTHETIC EQUIPMENT — Specialized equipment should be immediately available in the operating room [1,9-13].

Endotracheal tubes and supraglottic airways

●Endotracheal tubes – Endotracheal tubes (ETTs) in a variety of sizes (diameter and length), material (metal or plastic), and construction (armored, laser-resistant, tube tip shape, single versus double-lumen) may be necessary [10,11]. Some ETTs are manufactured with variations in cuff volume, configuration, and location of the cuff endpoint relative to the tip of the ETT. Specific considerations include:

•If laser use in or near the airway is planned, a laser-resistant ETT is used [14]. (See "Fire safety in the operating room", section on 'Special precautions during airway surgery'.)

•If jet ventilation (JV) is planned, a laser-resistant plastic catheter is used. Instead of a straight JV catheter, we prefer a catheter with a "cage" that helps to stabilize the catheter within the trachea (picture 1). (See "Anesthesia for adult bronchoscopy", section on 'Jet ventilation'.)

•If a highly flexible crush-resistant tube will be necessary to prevent kinking (eg, when the tube may be sharply bent after insertion into a tracheostomy stoma), we select a wire-reinforced, "armored" ETT (picture 2).

•For procedures on the distal portion of the trachea or the carina, intubation of a mainstem bronchus may be necessary. Options include [15]:

-A double-lumen ETT (DLT) with only the endobronchial cuff inflated after it has been advanced into the mainstem bronchus on the side of the lung that will be ventilated. In addition, an optional bronchial blocker can be passed into the bronchial lumen of the nonventilated lung to isolate it. (See "Lung isolation techniques".)

-If a DLT is too bulky, then an extra-long ETT may be advanced into the mainstem bronchus of the lung that will be ventilated. However, some long ETTs are floppy with a tendency to dislodge from an endobronchial position (picture 3).

Other ways to create a long endobronchial ETT with a small diameter and improved stability include:

-Cutting the tracheal channel and its cuff off from a DLT, and using only the endobronchial side of the DLT with its preserved cuff (picture 3). However, this requires preparation time that includes careful and thorough sanding/smoothing of the cut edges, and it is difficult to cut off the tracheal lumen. Careful maintenance of the integrity of the ETT cuff and pilot balloon is essential during use of such an improvised long ETT alternative. Reconfirm integrity just prior to use.

-Combining two regular ETTs. The larger of the two is used distally, with a preserved cuff and pilot balloon. The smaller ETT is used as an extension within the larger one. The two ETTs are joined together after wiping the connecting surfaces with alcohol to improve bonding (picture 3).

Also, management of the contralateral/unintubated mainstem bronchus is necessary after planned mainstem bronchial intubation. For example, a bronchial blocker may be passed into the bronchial lumen of the contralateral lung to isolate it if this lung will not be ventilated. An alternative strategy is JV of the contralateral lung via a jet ventilator catheter.

●Tracheal tubes – Any device to be replaced in a patient with a previous tracheostomy after completion of the procedure should be available and in the operating room. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Tube types'.)

●Supraglottic airways – Some centers employ a supraglottic airway (SGA) as the primary airway device for selected patients undergoing laryngotracheal surgery [1,10,12]. An advantage of this technique is the absence of airway tubing in the surgical field, thereby allowing continuous visualization of the posterior trachea during anastomosis [1,16]. Also, avoiding airway catheters or tubes near a friable tracheal lesion may prevent tracheal injury. (See "Supraglottic devices (including laryngeal mask airways) for airway management for anesthesia in adults".)

Other airway management equipment

●Check availability and functionality of flexible and rigid bronchoscopes in a range of calibers (ie, both adult and pediatric sizes), as well as ancillary equipment (eg, light sources, endoscopic tower). Also, dedicated suction for the bronchoscope and a second setup with a Yankauer suction tip should be available at the head of the bed. (See 'Bronchoscopy and tracheal surgery' below.)

●Ensure availability of other equipment for managing a difficult airway such as airway exchange catheters or bougies, facemasks, laryngoscopes of appropriate sizes and various types (direct, indirect, flexible), oral and nasal airways, and equipment for emergency invasive airway access. (See "Management of the difficult airway for general anesthesia in adults", section on 'Equipment preparation'.)

●Lung isolation devices for one lung ventilation should be available. (See "Lung isolation techniques", section on 'Types of lung isolation devices'.)

●Prepare a jet ventilator setup with subjective confirmation of delivered JV pressures if JV is planned [9].

MONITORING AND INTRAVASCULAR ACCESS

●Venous access – We prefer two reliable peripheral or other intravenous (IV) catheters since the arms will be tucked and inaccessible.

●Intra-arterial catheter – We insert an intra-arterial catheter immediately before or after induction in all patients undergoing tracheal resection and reconstruction. This is useful for:

•Continuous monitoring of arterial blood pressure, so that hemodynamic instability due to high airway pressures, hemorrhage, or compression of the heart or major vessels will be immediately detected.

•Intermittent sampling of arterial blood gases to detect hypoxemia and hypercarbia, particularly during nonstandard modes of ventilation.

●Neuromonitoring – We typically use processed or unprocessed electroencephalography (EEG) to avoid high EEG indices that may indicate possible awareness during total intravenous anesthesia (TIVA) techniques. Such neuromonitoring is particularly important if the IV catheter cannot be seen after positioning the surgical drapes, or if administration of a neuromuscular blocking agent (NMBA) is planned. These considerations are discussed in detail separately. (See "Accidental awareness during general anesthesia", section on 'Brain monitoring' and "Accidental awareness during general anesthesia", section on 'Total intravenous anesthesia' and "Accidental awareness during general anesthesia", section on 'Neuromuscular blockade'.)

INTRAOPERATIVE COMMUNICATION

Preinduction communication — Preoperative communication and joint planning with the surgery team are necessary to avoid or immediately manage loss of airway patency or inability to ventilate and oxygenate the patient during induction, emergence, or critical portions of the procedure due to [2,9]:

●Airway obstruction during tracheal manipulation or compression

●Loss of airway continuity or patency during planned resection of a portion of the trachea or due to unplanned tracheal injury

●Procedures that temporarily obstruct the airway (eg, tracheal dilation or stent placement)

●High risk for airway fire

Key points for the surgical briefing — The preoperative briefing is typically performed with the aid of a checklist, addressing the following specific points (see "Patient safety in the operating room", section on 'Timeouts, briefing, and debriefing') [9]:

●Challenges in airway and ventilation management

•Specific protocols for management of a difficult airway, including possible use of jet ventilation (JV) [9].

•Potential for intraoperative modifications of the surgical plan and goals, including dynamic airway management strategies with sequential changes of airway devices and alternative modes of ventilation [13].

•Rescue plans if inability to ventilate occurs during induction or emergence from anesthesia, or due to intraoperative surgical interventions or complications [13].

•Potential adverse or beneficial changes in tracheal anatomy that may occur during changes in modes of ventilation or due to surgical interventions. Examples include:

-Changes in tracheal diameter – Positive intrathoracic pressure causes inward projection of the membranous back wall of the trachea, while negative pressure causes an outward bowing of the back wall. If tracheomalacia is present, high positive intrathoracic pressure (eg, during forced exhalation or coughing) is avoided as this may cause complete tracheal obstruction. Reopening can be achieved with either spontaneous inhalations or applied positive pressure ventilation.

-Changes in tracheal length – Strained inspiratory efforts result in added tracheal tension and should be avoided after a tracheal repair with a fragile suture line. Head or neck extension also places cephalad pull on the trachea and can alter the length by a few centimeters, while flexion reduces tension on the trachea and pushes the extrathoracic trachea down into the mediastinum. This mobility may be used to facilitate optimal surgical exposure of the trachea or to reduce tension on suture lines with retention "chin" stitches running from their chin to upper chest to hold the head and neck in flexion.

In some cases, up to 50 percent of tracheal length is surgically resected. Laryngeal or hilar release may be performed to add 2 to 3 cm of additional tracheal length and mobility, reducing tension on anastomotic sites [17].

●Airway fire prevention strategies – Tracheal procedures have the highest airway fire risk score. (See "Fire safety in the operating room", section on 'Risk-based approach to fire prevention'.)

The preoperative surgical briefing should include plans for fire risk mitigation (algorithm 2) (see "Fire safety in the operating room", section on 'Special precautions during airway surgery'):

•Use a gas analyzer to ensure the oxygen concentrations (fraction of inspired oxygen [FiO₂] and fraction of expired oxygen [FeO₂]) are <30 percent if an electrosurgery unit (ESU) is to be used in or near an open airway. Only medical air rather than nitrous oxide (N₂O) can be used to dilute oxygen concentration to <30 percent. Similar to oxygen, N₂O supports combustion. (See "Fire safety in the operating room", section on 'Limit oxygen administration and avoid nitrous oxide'.)

•Special precautions that are necessary to minimize fire risk once the trachea is exposed include reducing the FiO₂ and waiting for the FeO₂ to be <30 percent if use of an ESU is planned. If an FiO₂ >30 percent is needed, then all ESU devices must be handed off the surgical field immediately before transection of the trachea. (See "Fire safety in the operating room", section on 'Special precautions during airway surgery'.)

The preoperative surgical briefing should also discuss immediate management of suspected airway fire (algorithm 3) [14]. (See "Fire safety in the operating room", section on 'Fire in the airway'.)

Intraoperative timeouts — These include:

●Standard timeout just before incision and additional intraoperative timeouts before surgical interventions that may interfere with ability to provide ventilation – (See "Patient safety in the operating room", section on 'Timeouts and briefing in the operating room'.)

●Timeout before use of an ESU to avoid risk of airway fire – (See "Fire safety in the operating room", section on 'Special precautions during airway surgery'.)

●Pre-emergence timeout to discuss potential problems after extubation that may put the surgical repair at risk or interfere with airway patency. (See 'Emergence and extubation' below.)

BRONCHOSCOPY AND TRACHEAL SURGERY — Flexible or rigid bronchoscopy may be necessary before, during, and/or after tracheal reconstructions.

Flexible bronchoscopy

●Before beginning the procedure – Flexible bronchoscopic inspection of the glottis and trachea is often performed before surgery begins to define current anatomy and pathology, confirm that the planned surgical procedure is appropriate, and rule out the presence of a new acute process that could be improved with therapy [1,11]. Typically, a flexible bronchoscope is inserted transorally in an awake patient using local anesthetic topicalization of the vocal cords and trachea with optional or no sedation, particularly if it is necessary to have an awake and cooperative patient while the surgeon observes the dynamic nature of the tracheal lesion. (See "Anesthesia for adult bronchoscopy", section on 'Topical airway anesthesia with sedation'.)

In other cases, a flexible bronchoscope is inserted after induction of general anesthesia through an endotracheal tube (ETT) or a supraglottic airway (SGA). During the examination, intravenous (IV) rather than inhalation anesthetic agents are used since frequent suctioning of the trachea causes interruptions in delivery of inhalation anesthetic agents. (See "Anesthesia for adult bronchoscopy", section on 'General anesthesia'.)

●After completion of the procedure – The surgeon often repeats flexible bronchoscopy to evaluate the tracheal repair or to clear tracheal secretions. (See 'Emergence and extubation' below.)

Rigid bronchoscopy — Rigid bronchoscopy may be used to evaluate the airway, with visualization of the trachea and/or mainstem bronchi (picture 4 and picture 5). This is performed in patients after induction.

●Before beginning the procedure – Rigid bronchoscopy may be necessary to dilate the trachea in some patients with critical airway stenosis. The surgeon may insert a small diameter rigid bronchoscope immediately after anesthetic induction to establish a reliable airway and to gently dilate the stenotic area. This may be followed by serial dilations via sequential reintubations with bronchoscopes of increasing diameter to facilitate a traumatic passage of a 5.5 or 6.0 mm cuffed ETT though the dilated area.

●During the procedure – Rigid bronchoscopes provide wide clear view and allow passage and manipulation of a variety of interventional tools/devices. Considerations are:

•Ventilation methods – Ventilation methods through a rigid bronchoscope include:

-Positive pressure ventilation (PPV), accomplished by attaching the anesthesia circuit to the side port of the rigid bronchoscope (picture 6). (See "Anesthesia for adult bronchoscopy", section on 'Positive pressure ventilation'.)

-Jet ventilation (JV) via a purpose-built port that has a Luer-Lock connector for the jet ventilator tubing (picture 5 and picture 7). (See "Anesthesia for adult bronchoscopy", section on 'Jet ventilation'.)

In patients with tracheal narrowing, conditions for ventilation may vary as dilation is accomplished. For example, a small-caliber rigid bronchoscope may be passed through a tracheostomy stoma, with ventilation via the side-port of the bronchoscope. The tight fit of the rigid bronchoscope against the narrowed segment of the trachea allows PPV. However, leakage of gases around the bronchoscope occurs as the stenotic tracheal segment becomes progressively dilated, or when the bronchoscope is not fully engaged with the stricture. High flows of oxygen may be administered to compensate for the leaked airway gases. Chest rising is observed and continuous pulse oximetry is monitored to ensure adequate gas delivery and oxygenation [18]. Notably, capnography is not a useful monitor during administration of high gas flows, and measurements of end-tidal anesthetic agents will not be inaccurate.

If necessary to ensure adequate ventilation, the bronchoscope may be intermittently removed and replaced by an ETT. In such cases, we prefer a flexible kink-resistant ETT (eg, a wire-reinforced "armored" ETT) (picture 2).

•Anesthetic techniques and agents – Deep general anesthesia and neuromuscular relaxation is necessary during rigid bronchoscopy because of noxious airway stimulation and extreme discomfort and to avoid injury to the trachea due to movement. We usually select a total IV anesthetic (TIVA) technique to maintain general anesthesia, and we administer a neuromuscular blocking agent (NMBA) to induce complete muscle relaxation. We avoid administration of inhaled anesthetic agents since leakage of gases around and through the bronchoscope will contaminate the operating room. Furthermore, if JV is employed, TIVA is the only anesthetic choice since inhalation anesthetics cannot be administered via a JV system. (See "Anesthesia for adult bronchoscopy", section on 'Total intravenous anesthesia'.)

●After completion of the procedure – In rare cases, rigid bronchoscopy may be necessary to urgently treat airway obstruction after the procedure has been completed. (See 'Emergence and extubation' below.)

OPEN TRACHEAL RESECTION AND RECONSTRUCTION

Procedural considerations — General anesthesia is necessary for open tracheal resection and reconstruction, regardless of the surgical approach [1]:

●Upper or midtracheal lesions such as post-intubation injuries are typically approached through a cervical transverse collar incision.

●Lower tracheal or carinal lesions, as well as hilar or carinal releases are typically approached via either a sternotomy in the supine position or a right thoracotomy in the left lateral decubitus position, using one lung ventilation after collapse of the right lung. (See "One lung ventilation: General principles" and "Lung isolation techniques".)

●If a right thoracotomy is planned, postoperative pain management is typically achieved with either thoracic epidural analgesia (TEA) or paravertebral block (PVB). The epidural or paravertebral catheter is placed before induction of anesthesia to provide intraoperative as well as postoperative analgesia. Alternative analgesic techniques are offered if neither TEA nor PVB is appropriate, or if attempted catheter placement is unsuccessful. These are discussed separately. (See "Anesthesia for open pulmonary resection", section on 'Post-thoracotomy pain management'.)

Induction and initial airway management

Planning for airway management — As the ventilation mode shifts from spontaneous negative pressure breathing to applied positive pressure ventilation (PPV) during induction of anesthesia, the presence of a tracheal or extrinsic mass may result in airway collapse and inability to achieve adequate mask ventilation. Administration of a neuromuscular blocking agent (NMBA) may not improve or may worsen the clinician's ability to ventilate the patient.

Therefore, selection of an induction technique and development of contingency plans are based on the potential for compromised ventilation (see 'Preanesthetic assessment' above) [1]. Decisions include:

●Selecting an endotracheal tube (ETT) versus a supraglottic airway (SGA) device for part or all of the case

●Timing for tracheal intubation (preinduction [awake] versus postinduction [asleep]), and whether dilation of the trachea will be necessary before ETT placement, as well as method of dilation

●Planning for sedation before induction

●Selecting an intravenous (IV) versus an inhalation induction technique

●Timing of administration of an NMBA

●Timing for initiation of PPV and initial positive pressure settings

Specific strategies — The entire surgical, anesthesia, and nursing teams should be assembled at the time of induction to help execute plans discussed in the preoperative briefing. (See 'Key points for the surgical briefing' above.)

●Selection of an airway device – Usually, we insert a cuffed ETT to reliably secure the airway. However, in some patients with a friable mid- to proximally-located subglottic stenosis, an SGA may be initially used as the primary airway until cross-table or jet ventilation (JV) is established [1,10,12,19]. (See 'Airway management' below.)

Potential advantages of an SGA include:

•Cross-table ventilation may not be necessary if the transected trachea can be traversed by a small jet ventilator catheter passed through the SGA (picture 8).

•The lack of need to traverse the tracheal pathology with an ETT reduces risks for mechanical trauma, swelling, bleeding, or tumor fragmentation with resultant airway occlusion if the tracheal lesion is friable.

•An SGA may serve as a rescue airway if the trachea cannot be intubated after anesthetic induction agents are administered [13,19]. However, airway rescue using an SGA is unlikely if the trachea cannot be intubated. The SGA may be no more effective than ventilation with an airway mask.

Potential disadvantages of using an SGA include:

•Managing an unsecured airway throughout the case.

•After completion of the tracheal repair, an anastomotic leak test (a brief applied positive pressure breath at ≥20 cm H₂O) cannot be performed via an SGA [1].

●Induction strategies – Based on re-evaluation of the patient's anatomy and pathology on the day of the surgery, specific induction strategies include (see 'Re-evaluation on the day of surgery' above) [1]:

•Patients without risks for airway compromise – If there are no identified risks for airway collapse or compromise during induction due to tracheal or anterior mediastinal pathology, or if a very recent uneventful routine induction has been documented with no interval changes in physical status, then an IV anesthetic induction technique may be selected. For this, we typically use propofol 2 mg/kg and fentanyl 150 to 250 mcg, plus an NMBA. In some cases, the NMBA is withheld until the ability to provide adequate PPV has been demonstrated. (See "Induction of general anesthesia: Overview" and "General anesthesia: Intravenous induction agents".)

An IV induction is also reasonable in a patient with tracheomalacia since instituting post-induction PPV by mask is likely to improve tracheal patency.

•Patients who requiring continued spontaneous (negative pressure) ventilation – In some patients, maintaining adequate airway patency during induction depends on maintaining respiratory mechanics similar to the awake state by maintaining spontaneous negative pressure breathing. Examples include critical tracheal stenosis, unstable tracheal mass, or dynamic tracheal pathology such as combined stenosis and malacia. In such cases, we select an inhalation induction technique by mask using sevoflurane (see "Induction of general anesthesia: Overview", section on 'Inhalation anesthetic induction') [1,10,20]. An inhalation induction technique should be considered only after consultation with the surgeon to ensure adequate preparation for urgent intervention (eg, rigid bronchoscopy) if this becomes necessary due to airway compromise [21].

Specific techniques for inhalation induction in this setting include:

-Minimize or avoid preinduction sedation to preserve respiratory drive.

-Adjust the head of the bed to a 30 degree inclination (to optimize functional residual capacity and improve respiratory mechanics), or allow the awake patient to choose their own best position for spontaneous ventilation. (See 'Preanesthetic consultation' above.)

-Preoxygenate with 100 percent oxygen [22]. (See "Management of the difficult airway for general anesthesia in adults", section on 'Patient preparation'.)

-In selected patients with critical tracheal stenosis, inhaled heliox is used during the inhalation induction, if available. Compared with pure oxygen, heliox is a mixture of oxygen and helium that has lower gas density with less resistance to airway flow. (See "Physiology and clinical use of heliox".)

-Initiate inhalation anesthesia with a low concentration of sevoflurane and then slowly increase the concentration. Unlike children, adults may hold their breath if a high concentration of sevoflurane is administered; this may result in loss of airway control.

-Allow for a longer time than usual to achieve inhalation induction (several minutes) in a patient with tracheal stenosis. During this time, there is increased risk of breath-holding, coughing, or vomiting because of a protracted stage 2 of anesthesia (table 2). Ensure that room noise and distractions are minimized while the inhalation anesthetic level is slowly deepened.

-Once an anesthetized breathing pattern is established (rapid, regular, decreased tidal volumes (figure 4)), apply a low level of positive pressure near the end of each spontaneous inhaled breath to test the airway for patency, then gradually apply positive pressure at an increasingly earlier point during inhalation.

-If this partial PPV is effective, proceed to full control of ventilation. Then, the anesthetic induction can be completed by administering IV induction agents and, if desired, an NMBA.

•Patients requiring awake intubation – If securing the airway and initiating PPV after induction of general anesthesia is likely to be difficult due to tracheal or other airway pathology, then we perform an awake tracheal intubation technique to maintain awake respiratory mechanics with compensated functional physiology.

Specific techniques for awake intubation in this setting include:

-Maintain communication to reassure the patient. Optimize topical local anesthesia and use only low doses of carefully titrated sedative agents. (See "Anesthesia for adult bronchoscopy", section on 'Topical anesthesia'.)

-Ensure that the surgeon is present during attempts to tracheally intubate since urgent insertion of an immediately available small diameter rigid bronchoscope may become necessary. Subsequently, PPV via a rigid bronchoscope usually provides adequate ventilation. However, the anesthesia clinician must be prepared to initiate JV before or immediately after insertion of the rigid bronchoscope. (See "Anesthesia for adult bronchoscopy", section on 'Jet ventilation'.)

-Withhold administration of an NMBA until the ability to provide adequate PPV has been demonstrated and anesthetic agents have been administered.

•Patients requiring preinduction tracheostomy – Tracheostomy before induction may be selected in certain patients to avoid possible need for postoperative emergency cricothyroidotomy. An example is planned proximal tracheal repair near the cricoid, which may result in postoperative glottic or vocal cord swelling.

However, a tracheostomy can only provide airway patency if the airway obstruction is superior to or covered by the new tracheostomy tube. If the obstruction is distal to the tip of the tube, a wire-reinforced ETT with a small diameter, as well as a jet ventilator catheter, should be immediately available for insertion and ventilation via the newly created tracheostomy stoma.

•Rare extracorporeal membrane oxygenation (ECMO) – Very rarely, ECMO may be planned to maintain gas exchange of oxygen and carbon dioxide [1,9-11,13,23-27]. Examples include patients at high risk for inadequate gas exchange due to unusual location or size of the tracheal lesion, or those who are likely to lose airway patency for a prolonged period during the surgical procedure. Advantages of using ECMO include a surgical field free of airway devices with a clear view of the posterior trachea during anastomosis [1]. Increased risk of surgical bleeding due to the need for systemic anticoagulation is a disadvantage.

Advance planning is necessary to ensure availability of equipment and perfusionist personnel to manage ECMO. (See "Anesthesia for patients with an anterior mediastinal mass", section on 'Planned cardiopulmonary bypass' and "Extracorporeal life support in adults in the intensive care unit: Overview".)

Post-induction considerations — Important aspects of postinduction management include:

●If an ETT is in place:

•Confirm that the ETT cuff pressure is adequate for airway protection before surgical incision.

•Suction secretions pooled in the oropharynx before surgical drapes cover the patient’s head.

•If appropriate, place an orogastric tube to suction gastrointestinal contents.

●Protect the patient's eyes with an eye cover product before surgical drapes cover the head. (See "Postoperative visual loss after anesthesia for nonocular surgery", section on 'Corneal abrasion'.)

●Ensure that the head and neck are neutral and that the occiput is resting on gel since the duration of these cases may be several hours.

●Be prepared for flexible or rigid bronchoscopy immediately after induction. (See 'Flexible bronchoscopy' above and 'Rigid bronchoscopy' above.)

Maintenance and subsequent airway management

Selection of anesthetic agents

●Intravenous versus inhalation anesthetic technique – We usually select a total intravenous anesthesia (TIVA) technique with propofol and remifentanil. This is appropriate if the procedure will involve unreliable delivery and inaccurate end-tidal measurements of inhaled anesthetic gases (eg, during JV, intermittent ventilation, or when frequent suctioning of the airway is necessary). Also, a TIVA technique avoids pollution of the atmosphere when a significant leak of inhaled anesthetic gas is expected, such as when the airway is opened by a tracheal incision [1,11,28].

Since intermittent manipulation of the airway during surgery is highly stimulating, the IV anesthetic agents must be frequently adjusted to rapidly change anesthetic depth. For these reasons, we typically select propofol and remifentanil infusions. (See "Maintenance of general anesthesia: Overview", section on 'Total intravenous anesthesia'.)

In some cases when the airway and ventilation system will remain closed, then a simple and less expensive volatile inhalation anesthetic-based technique is a good alternative choice. (See "Maintenance of general anesthesia: Overview", section on 'Inhalation anesthetic agents and techniques'.)

●Administration of opioid agents – Although remifentanil is usually selected as the opioid component for a TIVA technique, we avoid intraoperative administration of long-acting opioids. Although manipulation of the trachea during the procedure is stimulating, postoperative pain is mild after a cervical incision. Even after other surgical approaches, we minimize opioid dosing to avoid potential for postoperative emergency airway management in an over-sedated patient. (See 'Postoperative pain management' below.)

●Administration of an NMBA – We usually add the nondepolarizing NMBA rocuronium to avoid patient movement during critical periods of the procedure [1,11]. We select rocuronium regardless of the anticipated duration of the procedure. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Rocuronium'.)

At the end of all cases, we administer reversal agents to eliminate neuromuscular blockade. If the procedure terminates abruptly resulting in a need for rapid reversal of a relatively large dose of rocuronium, then we administer sugammadex (in doses up to 16 mg/kg) (see "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Sugammadex') [29,30]. In countries without ready access to rocuronium and/or sugammadex, another reversible nondepolarizing NMBA may be selected. However, extreme care is necessary to ensure full reversal at the end of the procedures, and to maintain reversal in the postoperative period. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Reversal of neuromuscular block'.)

Although several hours are usually needed to perform most tracheal repairs, another option is use of an infusion of succinylcholine for cases expected to last <20 minutes. For longer cases, succinylcholine is not a suitable alternative due to the likelihood of inducing a phase 2 blockade. (See "Clinical use of neuromuscular blocking agents in anesthesia", section on 'Pharmacology of succinylcholine'.)

We use precautions to avoid awareness during general anesthesia if an NMBA is administered. These precautions are discussed separately. (See "Accidental awareness during general anesthesia", section on 'Neuromuscular blockade' and "Accidental awareness during general anesthesia", section on 'Prevention'.)

Airway management — As noted above, either a cuffed ETT or an SGA may be selected as the initial primary airway until cross-table or JV can be established [1,10,12,19]. (See 'Induction and initial airway management' above.)

Subsequent ventilation strategies include:

●Cross-field ventilation

•If an oral ETT is in place and standard cross-field ventilation is planned after transection of the trachea, the oral ETT is retracted so that the tip is just proximal to the transected portion of the trachea. Then the surgeon directly intubates the main conducting airway distal to the resected tracheal area with a sterile wire-reinforced ETT. This new ETT is connected to a sterile breathing circuit on the surgical field.

•If JV is planned after transection of the trachea, a jet ventilator catheter can be inserted by the surgeon into the distal trachea, then connected to sterile JV tubing on the surgical field.

The limbs of the sterile breathing circuit or the jet ventilator tubing are then passed over the surgical drapes to be connected to nonsterile extension tubing leading to the anesthesia machine or jet ventilator, and cross-field ventilation is initiated [10].

●Other options that avoid cross-field ventilation

•A small-diameter flexible jet ventilator catheter may be advanced into a retracted ETT or SGA, then into the distal trachea to be adjusted within the surgical field as necessary (picture 8).

•The jet ventilator tubing can be passed from the surgical field retrograde up into the oropharynx and through the lumen of an SGA. Then the anesthesia provider can grasp the tubing and connect it to the jet ventilator while the surgeon places the tip of the tubing into the proximal trachea [19]. (See 'Management of ventilation and oxygenation' below.)

Management of ventilation and oxygenation — Cross-field ventilation may be necessary for a prolonged period during tracheal reconstruction. Strategies to manage this include:

●Intermittent ventilation

•Technique – Intermittent hand-delivered breaths are timed to occur when the surgeon reinserts the ETT back into the distal tracheal stump, with cessation of ventilation when the ETT is removed from the trachea. Duration of apnea is limited by an individual patient’s ventilatory needs.

•Advantages – This technique provides an intermittently unobstructed surgical field when needed by the surgeon.

•Disadvantages

-Carbon dioxide accumulation – Theoretically, during extended periods of apnea [31], hypercapnia and acidosis may develop leading to increased heart rate, blood pressure, pulmonary vascular resistance with right ventricular dysfunction, and risk for cardiac arrhythmias. However, if intermittent ventilation is delivered at appropriately frequent intervals, these adverse effects rarely occur. (See "Permissive hypercapnia during mechanical ventilation in adults", section on 'Adverse effects'.)

-Inadequate oxygenation – During periods of intermittent ventilation, we administer 100 percent oxygen before each apneic episode to prolong the duration of time before clinically significant desaturation will occur, and we monitor oxygenation with pulse oximetry [22]. However, the specific duration of apnea that can be tolerated varies according to patient- and procedure-related factors (figure 5) [32].

●Jet ventilation – JV is an alternative technique that delivers low-volume, relatively high-pressure boluses of gas via a metal or plastic catheter attached to a jet ventilator. (See 'Airway management' above.)

In some cases, JV is used as a supplemental ventilation technique to augment standard PPV or intermittent ventilation. Examples include use of JV to provide independent oxygenation of targeted lobes or distal airway segments if tracheal reconstruction involves the distal trachea or carina.

We use the only electronic JV system that is commercially available in the United States (the Monsoon III Jet Ventilator (picture 9)). This ventilator humidifies the administered gas and measures airway pressures within the jet ventilator catheter. Despite these precautions, not all patients tolerate JV, particularly those with poor lung function.

•Jet ventilator settings – We usually initiate JV using 100 percent oxygen, a low frequency respiratory rate (RR) of 15 breaths/minute, and a low driving pressure of 15 pounds/square inch (PSI). That driving pressure is likely to be a safe starting point for most small adults.

Almost immediately after initiating JV, driving pressure is adjusted upward to a mid-to-high pressure of 20 PSI until visible rising of the chest is clearly observed. The RR may be increased, but must always allow for full chest recoil and exhalation before the beginning of the next breath. Although each delivered breath may be right on the tail end of exhalation, sequential breaths should never overlap. In the presence of chronic obstructive pulmonary disease, reaching full end-expiration may be challenging. In those cases, the RR is kept low, but the duration of each breath is slightly increased.

Subsequently, the fraction of inspired oxygen (FiO₂) is adjusted as necessary to maintain adequate oxygenation. However, if ignition sources are to be used near an open airway during JV, an oxygen analyzer must be used to ensure that both the FiO₂ and the fraction of expired oxygen content (FeO₂) are <0.3. (See "Fire safety in the operating room", section on 'Special precautions during airway surgery'.)

In some cases, it is necessary to give some PPV breaths via an ETT or SGA as a strategy to maintain adequate oxygenation.

•Advantages

-Surgical exposure is facilitated by having only the small JV catheter in the surgical field.

-The small tidal volumes delivered via JV create only minimal chest excursions and a quieter surgical field than standard PPV.

•Disadvantages – Disadvantages and possible complications include (see "High-frequency ventilation in adults", section on 'Harms'):

-Potential for ineffective ventilation.

-Hypothermia or desiccation of airway tissue due to administration of cold dry gas during use of a jet ventilator model that does not humidify the gas.

-Inability to perform an anastomotic leak test by using a brief Valsalva maneuver after completion of tracheal reconstruction. (See 'Airway management' above.)

-Potential for catastrophic injury such as barotrauma or pneumothorax. The Monsoon III Jet Ventilator has built-in precautions (picture 9), in that pressures exceeding the chosen limit cause an automatic suspension of ventilation that can only resume when the pressure issue is resolved.

●Re-establishing positive pressure ventilation – After the procedure is complete, the oral ETT is carefully readvanced through the new tracheal anastomosis. Circumferential tracheal sutures are then tightened with the goal of achieving adequate controlled PPV without leakage of gas. An anastomotic leak test is typically performed (ie, a brief Valsalva maneuver at ≥20 cm H₂O) [1].

ROBOTIC TRACHEAL RESECTION AND RECONSTRUCTION — Some centers perform selected tracheal resection and reconstruction procedures using robotic techniques. General anesthesia is necessary. If the trachea will be opened, a total intravenous anesthesia (TIVA) technique is selected, similar to open tracheal procedures. (See 'Selection of anesthetic agents' above.)

Considerations that differ for management of the airway, oxygenation, and ventilation during robotic versus open tracheal procedures are discussed below.

Procedural considerations — Robotic tracheal procedures are performed in the left lateral decubitus position, using one lung ventilation (OLV) after collapse of the right lung (see "One lung ventilation: General principles" and "Lung isolation techniques"). To further optimize exposure, the right thoracic cavity is compressed by insufflation of approximately 6 to 10 mmHg of carbon dioxide (CO₂).

Airway management — Airway management strategies include oral intubation, or rigid bronchoscopy may be used after anesthetic induction to dilate a critical airway stenotic lesion before intubation (see 'Rigid bronchoscopy' above). Ideally, a small double-lumen endotracheal tube (DLT) is advanced through the tracheal lesion to achieve lung isolation for one lung ventilation. If the tracheal diameter will not allow use of a DLT even after dilation, then a single lumen tube may be placed through the stoma, with plans to use a bronchial blocker for lung isolation. In some cases, it may be necessary to insert a long single lumen endotracheal tube (ETT) into the left main bronchus to achieve lung isolation. (See 'Endotracheal tubes and supraglottic airways' above.)

Management of oxygenation — Due to the additional lung compression created by CO₂ insufflation to a pressure of 5 to 10 mmHg, maintaining adequate oxygenation during OLV is particularly challenging for these procedures compared with other types of video-assisted thoracoscopic surgery (VATS). (See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection", section on 'Ventilation'.)

General strategies to improve oxygenation during OLV are discussed in a separate topic (see "One lung ventilation: General principles", section on 'Management of hypoxemia'). Additional strategies to optimally compensate for compression of the collapsed lung and achieve adequate oxygenation in this setting include:

●Limiting the CO₂ insufflation pressure to limit lung compression.

●If a DLT is in place, applying continuous positive airway pressure (CPAP) starting at 5 to 10 cm H₂O to the nonventilated lung. Expect to need a higher CPAP pressure counter the insufflation pressure.

●If a single-lumen ETT is in place, oxygenation strategies include

•Placing a bronchial blocker into the right mainstem bronchus to allow insufflation of small amounts of oxygen (O₂). This can be accomplished by injecting a 50 mL bolus of 100 percent O₂ into the collapsed lung. For this, some improvisation is needed:

Attach a 50 mL Luer lock syringe to a 3-way stopcock. Cut the tubing off a face mask or nasal canula and then press-fit the cut end of that tubing onto the stub in the male port of the stopcock. Attach this tubing to the auxiliary O₂ supply on the anesthesia machine to fill the syringe with 100 percent O₂ . Initially, keep the stopcock closed while it is attached to the Luer lock on the bronchial blocker, then open the stopcock so that O₂ can be injected into the collapsed lung, then close it again.

Boluses larger than 50 mL may be more effective, but may also inflate the collapsed lung. The goal is to avoid visible inflation of the collapsed lung, while inducing a modest increase in the O₂ concentration in this lung.

Typically, the 50 mL bolus results in an increase in peripheral arterial oxygen saturation (SpO₂) of 3 to 5 percent. The SpO₂ gradually decreases over the next 10 minutes. Once the patient's SpO₂ has declined to the pre-bolus level, the Luer lock connector on the bronchial blocker is opened to allow the lung to empty. Then, the process described above to administer a 50 mL bolus of O₂ is repeated.

•An alternative method is to connect a CPAP circuit to a bronchial blocker. Improvise the connection by attaching a 6.5 mm internal diameter ETT tube connector to the empty barrel of a 3 mL syringe. The CPAP connects to the ETT connector.

Management of ventilation — Similar to open tracheal resection and reconstruction, at a critical point in the surgery, ventilation through the oral ETT stops, and cross-field ventilation is initiated (see 'Airway management' above). For robotic surgery, an ETT may be passed through a small incision in the closed chest, and the oral ETT is retracted to be just above the lesion. Then ventilation is resumed after robotic re-intubation of the distal trachea. This process requires careful communication between the surgical and anesthesia teams to ensure proper timing of repositioning of the oral ETT to avoid unintended oral extubation.

Later in the surgery, cross-field ventilation is stopped, the transthoracic ETT is removed from the chest, and the oral ETT is readvanced through the partially closed tracheal anastomosis so that positive pressure ventilation (PPV) can be resumed.

As with laparoscopic abdominal surgical procedures, the addition of exogenous CO₂ can result in hypercarbia. Management is similar to laparoscopic abdominal surgical procedures. We increase the respiratory rate (RR) rather than increasing tidal volume to increase minute ventilation and compensate for CO₂ absorption. Mild hypercapnia (ie, end-tidal CO₂ [ETCO₂] of approximately 40 mmHg) is acceptable. (See "Anesthesia for laparoscopic and abdominal robotic surgery in adults", section on 'Mechanical ventilation'.)

Of note, jet ventilation (JV) is not appropriate for use in the closed and pressurized chest since the delivered gas (with no reliable egress point) will cause increases in intrathoracic pressure that will eventually interfere with ventilation and circulation.

EMERGENCE AND EXTUBATION

●Closure of the surgical wound – Closure of an open surgical wound is accomplished with the patient's head flexed and supported on blankets to reduce tension on the fresh tracheal suture lines. Typically, the surgeon places retention "chin" stitches running from chin to upper chest to hold the head and neck in flexion during the postoperative period (to minimize tracheal tension), as explained to the patient immediately before surgery. (See 'Re-evaluation on the day of surgery' above.)

●Emergence and extubation – We conduct a final pre-emergence timeout to discuss plans for airway and ventilation support during the immediate postoperative period (see 'Intraoperative timeouts' above). This plan may include using continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) with established pressure limits, criteria for endotracheal reintubation (and whether the anesthesiologist or the surgeon will accomplish this), and whether performance of a tracheostomy might be necessary.

Prior to emergence, the surgeon may elect to use a flexible bronchoscope to evaluate the repair and to clear secretions from the bronchi and trachea. The bronchoscope may be inserted via either a retracted endotracheal tube (ETT) or a supraglottic airway (SGA). In this setting, advantages for an SGA rather than an ETT include less risk of coughing and mechanical stress on the freshly sutured airway [1,19]. (See "Anesthesia for open pulmonary resection", section on 'Final bronchoscopy before emergence' and "Supraglottic devices (including laryngeal mask airways) for airway management for anesthesia in adults".)

Most patients are allowed to emerge from general anesthesia with the ETT or SGA in place and are extubated while still in the operating room in a supine position [1,11].

●Post-extubation management – Supplemental oxygen is administered before and after extubation. Secretions pooled in the oropharynx are suctioned before deflation of the cuff to withdraw the ETT. Close observation of airway patency is necessary during and immediately after emergence and extubation. Communication with the patient is essential, including ongoing evaluation and reassurance.

For patients with a potentially tenuous airway, the surgeon should remain immediately available. Development of airway obstruction is more likely in patients with intraoperative airway bleeding or excessive secretions since even a small clot or mucous plug may compromise a narrowed airway. Equipment such as flexible and rigid bronchoscopes are kept immediately available in the operating room. Prompt intervention is necessary to treat symptoms or signs of respiratory distress such as:

•Airway obstruction due to accumulation of secretions or clot, or if a recently placed stent drifts into malposition in a patient with a dynamic tracheal lesion. In such cases, either rigid or flexible bronchoscopy may be necessary to treat the obstruction.

•In rare cases, reintubation in the operating room (OR) or in the immediate postoperative period may be necessary. Typically, a small ETT is selected and placed over a fiberoptic bronchoscope [1].

•If symptoms similar to laryngospasm become apparent, the possibility of vocal cord edema or recurrent laryngeal nerve dysfunction should be ruled out. Phonation is checked and the vocal cords are inspected with diagnostic laryngoscopy or flexible bronchoscopy. If the cords are in continuous apposition at the midline, bilateral recurrent laryngeal nerve injury is suspected. Attempt to gently mask ventilate, while preparations are made for emergency tracheostomy. We consider reintubation only if the view of the cords is clear with likely ease of passage of a small ETT. However, reintubation attempts are usually avoided since they are often traumatic and unsuccessful. (See "Overview of the management of postoperative pulmonary complications".)

POSTOPERATIVE MANAGEMENT

Transfer to intensive care unit — Patients are transported to the intensive care unit (ICU) for close postoperative observation of the airway and for pain management [1]. During transport, continuous monitoring and immediately available airway equipment are necessary. (See "Transport of surgical patients", section on 'Monitoring' and "Transport of surgical patients", section on 'Airway equipment and supplemental oxygen'.)

In addition to standard handoff procedures upon arrival in the ICU (table 3) (see "Handoffs of surgical patients", section on 'Operating room to intensive care unit'), the following specific points are addressed:

●Limits for positive pressure if the patient requires airway support such as bilateral positive airway pressure (BiPAP)

●Safety considerations for pulmonary toilet (eg, length-limited blind tracheal suctioning, criteria for performing fiberoptic bronchoscopy to clean the airway)

●Criteria for reintubation or tracheostomy

Postoperative pain management — Postoperative pain management is procedure-dependent. Long-acting opioid agents are avoided in all cases since airway patency may be tenuous after tracheal surgery.

●Small transverse cervical incision – Postoperative pain is usually minimal. Typical options include a multimodal nonopioid systemic analgesic regimen with acetaminophen and/or a nonsteroidal anti-inflammatory agent (NSAID) [1]. Intravenous (IV) acetaminophen may be used unless this agent was administered in the preoperative period. For complaints of persistent pain in the immediate postoperative period, IV ketorolac (eg, 15 to 30 mg) may be administered together with small doses of IV fentanyl (eg, 25 to 50 mcg).

●Right thoracotomy – If a right thoracotomy was necessary, management of postoperative pain is similar to that for patients undergoing any thoracotomy. Typically, a thoracic epidural or a paravertebral block catheter is placed before induction of anesthesia. (See "Anesthesia for open pulmonary resection", section on 'Post-thoracotomy pain management'.)

●Sternotomy – If a sternotomy was necessary, management of postoperative pain is similar to that for cardiac surgical patients after sternotomy. (See "Postoperative care after cardiac surgery", section on 'Analgesia'.)

●Robotic ports – For pain after robotic thoracic surgery, robotically placed rib blocks can be helpful but are short-lived (approximately four hours). Non-opioid multimodal pain control may suffice after the blocks wear off, but judicial and monitored use of opioids is necessary in some patients.

SUMMARY AND RECOMMENDATIONS

●Preanesthesia assessment

•Preanesthetic consultation – Determine whether the tracheal lesion could cause airway obstruction during induction of anesthesia, or during surgical manipulation or resection. Airway patency may be dynamic, influenced by factors such as patient position, phase of respiration, or mode of ventilation (spontaneous negative pressure or controlled positive pressure). (See 'Preanesthetic consultation' above.)

•Reevaluation on the day of surgery – Check for changes in status. Inform the surgical team of any issues of concern. Inform the patient that they may awaken with retention "chin" stitches running from chin to upper chest to hold the head and neck in flexion and a calm awakening is essential. (See 'Re-evaluation on the day of surgery' above.)

●Preparation of anesthetic equipment

•Endotracheal tubes (ETTs) and supraglottic airway (SGA) devices – (See 'Endotracheal tubes and supraglottic airways' above.)

-Specialized ETTs in a variety of sizes (diameter and length) and construction (armored, laser-resistant, tube tip shape, single versus double-lumen [DLT]) may be necessary during induction of anesthesia and subsequent surgical interventions. (See 'Endotracheal tubes and supraglottic airways' above.)

-Some centers employ an SGA as the primary airway device to avoid having an airway tube in the surgical field.

•Other airway equipment – Bronchoscopy equipment, jet ventilator equipment, lung isolation devices, equipment for managing a difficult airway, and extension tubing for the ventilator for cross-field ventilation are necessary. (See 'Other airway management equipment' above.)

●Monitoring and intravascular access – We insert two reliable intravenous (IV) catheters since the arms will be tucked and inaccessible. We insert an intra-arterial catheter for continuous monitoring of blood pressure and intermittent sampling of blood gases. We use processed or unprocessed electroencephalography (EEG) to monitor for possible awareness. (See 'Monitoring and intravascular access' above.)

●Intraoperative communication – Communication with the surgery team before induction, before incision, and at critical periods during the procedure is necessary to prevent airway fire, manage oxygenation and ventilation, and avoid or immediately manage loss of airway continuity or patency with inability to ventilate during induction, emergence, or surgical interventions such as tracheal transection. (See 'Intraoperative communication' above.)

●Bronchoscopy – Flexible and/or rigid bronchoscopy is often used before, during, and after tracheal procedures. (See 'Bronchoscopy and tracheal surgery' above.)

●Open tracheal resection and reconstruction

•Procedural considerations – Upper to midtracheal lesions are typically approached through a cervical transverse collar incision. Lower tracheal or carinal lesions are typically approached via either a sternotomy in the supine position, or a right thoracotomy in the left lateral decubitus position with collapse of the right lung and one lung ventilation. Regardless of the surgical approach, general anesthesia is necessary. (See 'Procedural considerations' above.)

•Induction and initial airway management – Selection of an induction technique and development of contingency plans are based on potential for compromised ventilation. Decisions include timing of tracheal intubation (preinduction [awake] versus postinduction [asleep]), whether to use an IV versus an inhalation induction technique, when to administer a neuromuscular blocking agent (NMBA), and timing for initiation of positive pressure ventilation (PPV). (See 'Induction and initial airway management' above.)

•Maintenance

-Selection of anesthetic agents – We employ a total intravenous anesthesia (TIVA) technique with propofol and remifentanil to maintain adequate anesthetic depth, and with rocuronium to avoid patient movement during critical periods of the procedure. (See 'Selection of anesthetic agents' above.)

-Airway management – Either a cuffed ETT or an SGA may be used as the primary airway until cross-table or jet ventilation (JV) is established. A wire-reinforced ETT (picture 2) or a jet ventilator catheter is inserted by the surgeon into the main conducting airway distal stump of the transected trachea, and ventilation is resumed at that point of entry.

-Management of ventilation – This ETT or jet ventilator catheter is directly connected to a sterile breathing circuit (or jet ventilator tubing) on the surgical field, then is passed over the surgical drapes to achieve cross-field ventilation. After partial reconstruction of the trachea, the oral ETT is readvanced through the new anastomosis and ventilation through that ETT is resumed for the duration of the surgery. (See 'Airway management' above.)

-Management of oxygenation – To minimize fire risk after tracheal exposure and opening, the fraction of expired oxygen (FeO₂) is reduced to <30 percent if an ignition source such as an electrosurgery unit (ESU) will be used. Immediately before transection of the trachea, if the FeO₂ must be >30 percent, all ESU devices are handed off the surgical field.

●Robotic tracheal resection and reconstruction

•Procedural considerations – General anesthesia is TIVA. The left lateral decubitus position is employed, with right lung collapse and optimal exposure achieved by insufflation of approximately 6 to 10 mmHg of carbon dioxide (CO₂) into the chest. (See 'Procedural considerations' above.)

•Airway management – Strategies include oral intubation, or use of rigid bronchoscopy to dilate critical airway stenosis (before intubation but after anesthetic induction). Ideally, a DLT is advanced through the tracheal lesion to achieve lung isolation. If the tracheal diameter will not allow passage of a DLT, then a long single lumen ETT is inserted into the left main bronchus to achieve lung isolation. (See 'Airway management' above.)

•Oxygenation strategies – Maintaining adequate oxygenation is challenging due to compression of the right lung. Management strategies are discussed above. (See 'Management of oxygenation' above.)

•Ventilation techniques – At a critical point in the surgery, the oral ETT is retracted, and cross-field ventilation is established by passing another ETT through the closed chest via a small thoracic incision, with robotic re-intubation of the distal trachea. Later, the transthoracic ETT is removed, and the oral ETT is readvanced through the partially closed anastomosis to resume ventilation through that tube. (See 'Management of ventilation' above.)

●Extubation and recovery – The surgeon often repeats flexible bronchoscopy to inspect and clean the trachea, either via the retracted ETT or through an SGA inserted shortly before emergence. Most patients emerge from general anesthesia with the ETT or SGA in place, and are extubated in the operating room. (See 'Emergence and extubation' above.)

●Postoperative care – Patients are transported to the intensive care unit for postoperative airway and pain management. (See 'Postoperative management' above.)