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خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : -8 مورد

Key procedural details for airway management and induction of GA in patients with potentially unstable tracheal pathology

Key procedural details for airway management and induction of GA in patients with potentially unstable tracheal pathology
Inhalation induction of GA Awake tracheal intubation before induction of GA
Rationale: When spontaneous negative pressure ventilation is necessary to maintain optimal respiratory mechanics Rationale: When tracheal pathology may result in difficulty securing the airway after induction of GA
Key procedural details:
  • Minimize or avoid administration of preinduction sedative agents to ensure preservation of respiratory drive.
  • Elevate the head of bed to 25 to 30 degrees to optimize FRC.
  • Preoxygenate with 100% oxygen.
  • Initiate inhalation anesthesia with a low concentration of sevoflurane, then slowly increase concentration.
  • Allow for extra time to achieve inhalation induction (several minutes).
  • Once an anesthetized breathing pattern is established, apply a low level of positive pressure near the end of each spontaneous inhaled breath.
  • If this partial PPV is effective, proceed to full control of ventilation.
  • If the patient has critical tracheal stenosis, inhaled heliox can be used during inhalation induction to decrease resistance to airway flow.
 Key procedural details:
  • Maintain communication to reassure the patient.
  • Optimize topical local anesthesia and use only low doses of carefully titrated sedative agents.
  • Ensure that a JV is immediately available in case PPV initiated after tracheal intubation does not provide adequate ventilation and oxygenation.
  • Withhold administration of any NMBA until the ability to provide adequate PPV has been demonstrated and anesthetic agents have been administered.

This table summarizes key procedural details for techniques to induce anesthesia in patients with potentially unstable tracheal pathology such as critical tracheal stenosis, unstable tracheal mass, or combined tracheomalacia and stenosis. Such patients may be stable while awake and breathing spontaneously, but have the potential to destabilize when GA is induced and PPV is initiated. Techniques used to reduce risk for adverse airway events include inhalation induction of GA while maintaining spontaneous negative pressure ventilation and optimal respiratory mechanics until the airway can be secured, or performance of awake tracheal intubation before induction of GA. Rarely, other techniques such as planned preinduction tracheostomy or ECMO are employed.

By contrast, patients who may undergo routine IV induction of GA and initiation of PPV (with use of NMBAs if desired) include those with:
  • A minor tracheal lesion (eg, small tumor with no obstruction of the tracheal lumen)
  • Documented recent uneventful IV induction of GA with PPV (if there are no interval changes in physical status)
  • Isolated tracheomalacia since initiation of PPV typically improves airway dynamics if no other tracheal pathology is present

Choice of induction technique should be individualized based on the precise nature of the tracheal pathology and expertise of the surgical and anesthesia teams. In all patients with tracheal lesions, the surgeon should be present during induction of GA to urgently insert a small diameter rigid bronchoscope if necessary.

This table is intended for use in conjunction with other UpToDate content addressing anesthesia for tracheal resection and reconstruction, repair of tracheoesophageal fistula, or other major tracheal surgical procedures.
ECMO: extracorporeal membrane oxygenation; FRC: functional residual capacity; GA: general anesthesia; IV: intravenous; JV: jet ventilator; NMBA: neuromuscular blocking agent; PPV: positive pressure ventilation.
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