Challenging airway management in a patient having subglottic tumor with slit tracheal passage

Tracheal resection and reconstruction (TRR) is the treatment of choice for most patients with tracheal stenosis or tracheal tumors. Anesthesia for TRR offers distinct challenges, especially for the less experienced practitioner. This article explores the preoperative assessment, strategies for induction and emergence from anesthesia, the essential coordination between the surgical and anesthesia teams during airway excision and anastomosis, and postoperative care. The most common complications are reviewed. Targeted readership is practitioners with less extensive experience in managing airway surgery cases. As such, the article focuses first on the most common proximal tracheal resection. Final sections discuss specific considerations for more complicated cases.

Tracheal resection anastomosis is one of the most challenging surgeries. Notable advances in this field have made possible a variety of surgical, anesthetic, and airway management options. There are reports of newer approaches ranging from use of supraglottic airway devices, regional anesthesia, and extracorporeal support. Endotracheal intubation with cross-field ventilation and jet ventilation are the standard techniques for airway management followed. These call for multidisciplinary preoperative planning and close communication during surgery and recovery. This review highlights the anesthetic challenges faced during tracheal resection and anastomosis with specific considerations to preoperative workup, classification of tracheal stenosis, airway management, ventilation strategies, and extubation. The newer advances proposed have been reviewed.

Upper airway obstruction due to a subglottic tumor can be easily misdiagnosed as bronchial asthma. We report on a 50-year-old woman who was ultimately diagnosed with subglottic tumor, but who presented with near-fatal asthma. According to her medical history she had been treated with high doses of prednisolone and bronchodilators for the past year for difficult asthma. The patient presented to the Emergency Department (ED) in severe respiratory distress. The chest X-ray study revealed bilateral hyperinflation. The flow-volume curve suggested a fixed airway obstruction. After performing a laryngoscopic examination, a subglottic mass was discovered and an urgent tracheotomy was performed. After the operation, all symptoms and respiratory distress disappeared. This case report emphasizes the fact that not all wheezes are attributable to asthma. Upper airway obstructions can lead to asthma-like symptoms in which establishment of the correct diagnosis may be challenging.