RevBrasAnestesiol.2017;67(1):92---94
REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologia www.sba.com.brCLINICAL
INFORMATION
Maintenance
of
balance
between
airway
pressure
and
intracranial
pressure
in
a
patient
with
tracheal
stenosis
undergoing
craniotomy:
a
case
report
C
¸i˘
gdem
Yıldırım
Güc
¸lü
∗,
Bas
¸ak
Ceyda
Mec
¸o,
Meltem
Karamustafa,
Yüksel
Kec
¸ik
AnkaraUniversitySchoolofMedicine,DepartmentofAnesthesiologyandICU,Ankara,Turkey
Received1June2014;accepted2October2014 Availableonline25October2014
KEYWORDS
Craniotomy; Trachealstenosis; Intracranialpressure
Abstract
Backgroundandobjectives: Tracheal stenosis isa rare but alife-threatening condition and anesthesiaofapatient withtrachealstenosisischallengingfor anesthesiologists. Maintain-ingstablehemodynamicsandventilationparametersareimportantissuesinneuroanesthesia. AnyincreaseinairwaypeakpressureandETCO2willresultinincreaseinintracranialpressure
whichmustbeavoidedduringcraniotomies.Trachealstenosiscouldbeareasonforincreased airwaypressure.
Casereport: Wedescribedapatientundergoingcraniotomywithtrachealstenosis.
Conclusion:Detailedpreparationforintubation,tostabilizeairwaydynamicsandtomakethe rightdecisionforthesurgerywereimportantpoints.Tomaintainofagoodbalancebetween cerebraldynamicsandairwaydynamicswerethepearlsofthiscase.
©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
PALAVRAS-CHAVE
Craniotomia; Estenosetraqueal; Pressãointracraniana
Manutenc¸ãodoequilíbrioentreapressãodasviasaéreaseapressãointracraniana empacientecomestenosetraquealsubmetidoàcraniotomia:relatodecaso
Resumo
Justificativaeobjetivos: Estenosetraquealéumadoenc¸arara,masderisco,eaanestesiaem pacientecomestenosetraquealéumdesafioparaosanestesiologistas.Manterosparâmetros hemodinâmicosestáveiseaventilac¸ãosãoquestõesimportantesemneuroanestesia.Qualquer aumento dapressãode picodas viasaéreas e daETCO2 resultaráem aumento dapressão
intracraniana,oquedeveserevitadodurantecraniotomias.Aestenosetraquealpodeseruma razãoparaoaumentodapressãodasviasaéreas.
∗Correspondingauthor.
E-mail:[email protected](C¸.Y.Güc¸lü).
http://dx.doi.org/10.1016/j.bjane.2014.07.006
Trachealstenosisandcraniotomy 93
Relatodecaso: Descrevemosocasodeum paciente submetidoàcraniotomiacomestenose traqueal.
Conclusão:A preparac¸ãodetalhadaparaaintubac¸ão,estabilizar adinâmica dasviasaéreas etomaradecisãocertaparaacirurgiaforampontosimportantes.Manterumbomequilíbrio entreadinâmicacerebraleadinâmicadasviasaéreasfoiapéroladestecaso.
©2014SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigo OpenAccess sobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Tracheal stenosis is a rare but life-threatening condition. It may be caused by congenital problems, postintubation injury, trauma, intratracheal tumors, or compression by extratrachealtumors.1Anesthesiainpatientswithtracheal
stenosis is challenging for anesthesiologists. In addition, anestheticmanagementofpatientsundergoingcraniotomy requiresspecialattentiontomaintainstablecerebral hemo-dynamics.Aftertakingconsentfrompatientforpublication we herein describe a patient with tracheal stenosis who underwent craniotomy for treatment of a supratentorial mass.
Case
description
A58-year-oldwomanwasadmittedtoourhospitalforvision problemscausedbyanintracranialmass.Shehadtracheal stenosis due to prolonged intubation in 1999 and under-wenttrachealstentingin2000.Shesubsequentlydeveloped respiratorydistress,andthestentwasremovedin2005at herrequest.Sincethattime,shehasexperienceddyspnea, orthopnea, and limited effort capacity. After taking the patient’s consent the preoperative evaluation performed, herphysicalevaluationrevealedroughbreathsounds,and arterial blood gas analysisindicated mildly impaired oxy-genation (pO2, 58; SpO2, 91%; pCO2, 41.9; FiO2, 0.21). Spirometry in the sitting position gave unreliable results because the patient was uncooperative. Thoracic com-puted tomography revealed tracheal stenosis that began 2cmdistaltothevocalcordsandcontinued2cmintothe trachea.Uponarrivalintheoperatingroom,routine moni-toringwasbegun.Wewerepreparedfordifficultintubation (different size of laryngoscopes, laryngeal mask airways, bronchoscopy, tracheostomy set). Anesthesia wasinduced withPentothal,safemaskventilationwasestablished,and rocuronium was administered. Laryngoscopy allowed for visualization of the stenosis just under the vocal cords, and theCormack---Lehane scorewas I.In the first intuba-tionattempt,ano.7tubewasunabletopassthestenosis. Hence, we tried no.6and 5.5tubes. We avoidedusing a smallertubebecausetheincreasedairwaypressurewould compromisethecerebralpressure.Wedecidedtoevaluate theventilationparameterswiththeuseofano.5.5tube. Althoughthetubecouldnotbeadvancedpastthestenosis, thepatient’sventilationcouldbeadequatelymanaged.The
tidalvolumewas400mL,frequencywas14/min,peak pres-surewas27mmHg,andETCO2was35mmHg.Wefollowed the peakpressure and ETCO2 values. Because peak pres-sureoftheairwayandETCO2remainedstable,wedecided to let the surgeons to perform the surgery. All parame-tersremainedstableduringsurgery.Afterthesurgery,the patient was safely extubated with sugammadex and fol-lowedupintheintensivecareunit.Herarterialbloodgas levelswereinthenormalranges.Shestayedintheintensive careunitfor2daysbeforetransfer.
Discussion
Thiscaseisaboutastenosisthatwaslocated2cmdistalto thevocalcordsandcouldbeeasilyseenwithlaryngoscopy. Afterpreparingtheappropriateequipmentfordifficult intu-bationandattemptingtoestablishtheairwaywithvarious tubesizes,asuitabletubewithwhichtomaintainan accept-ableairwaypressurewasfound.Afterattemptingtopassa no.5.5tube,wedidnottryasmalleronebecauseof con-cernsaboutincreasingthepeakpressureoftheairway.We decidedinsteadtomonitorthepressuresasdisplayedonthe ventilator.Thepeakpressurewasmaintainedat27mmHg, andtheETCO2was35---38.Aftermonitoringthesevaluesfor sometime,weallowedthesurgeonstoperformthesurgery. Noproblemswereencounteredduringsurgery.
Weplannedtocreateatracheostomyunderthestenosis ifanyproblemswiththeairwaypressuresoccurred.Because thisprocedureismoreinvasiveandcomplicated,itwasnot ourfirstchoice.
Maintaining cerebral hemodynamics during craniotomy is important in the field of neuroanesthesia. Appropriate managementofhemodynamicvariablesisacornerstoneof anesthesiaforpatientsundergoingcraniotomyandincludes manipulation of the arterial blood pressure, airway pres-sure, and cerebral blood flow. In addition, intracranial dynamics are related to respiratory dynamics. When the ETCO2 risesin association withanychanges inrespiratory function, cerebral vasodilation occurs and the intracra-nialpressurerises,compromisingthecerebralmetabolism. Achievingstable respiratory dynamics is important in the performanceofcraniotomy.2
94 C¸.Y.Güc¸lüetal.
stenosisatvariouslevelswithinthetrachea.4Otherfactors
promotestenosisinclude;ahistoryofpreviousintubationor tracheostomy,excessivecorticosteroiduse,advancedage, theestrogeneffectin femalepatients, severerespiratory failure,severerefluxdisease,autoimmunedisease, obstruc-tivesleepapnea,andradiation therapy fororopharyngeal andlaryngealcancer.1
Stenosiscanoccuranywherefromthelevelofthe endo-trachealtube,butthemostcommonsites aretheareaof contactbetweenthe endotracheal tube cuffandtracheal wall. The American Society of Anesthesiologists practice guidelinesfor managementof thedifficult airway primar-ilyfocusonproblemsintheextrathoracicairwayandmay notbehelpfulforthemanagementofpatientswith intratho-racictrachealstenosis.5
For patients with tracheal stenosis, the anesthesiolo-gist must be prepared for a difficult airway and difficult intubation,andhavespecializedequipmentavailable.The anesthesiologistmustalwaysbepreparedwithotherplans in case of failure. Different sizes of endotracheal tubes, varioussupraglotticairwaydevices,andbronchoscopyand tracheostomyequipmentmustbereadyforairway manage-ment.
The maintenance of stablehemodynamicsand ventila-tionparametersisimportantinthefieldofneuroanesthesia. Anyincreasein thepeakpressure ofthe airwayor ETCO2 willresultinanincreaseintheintracranialpressure,which
mustbeavoidedduringcraniotomy.Tracheal stenosismay increasetheairwaypressure.Patientswithtracheal steno-sisundergoingcraniotomyrequirespecialattentioninthis respect.Carefulpreparationfor apossibledifficultairway andintubation,stabilizationofairwaydynamics,andcareful attentiontothetimingofsurgeryareimportant.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.KoshkarevaY, Gaughan JP, Soliman AM.Risk factors for adult laryngotrachealstenosis:areviewof74cases.AnnOtolRhinol Laryngol.2007;116:206---10.
2.WijayatilakeDS,ShepherdSJ,SherrenPB.Updatesinthe man-agementofintracranialpressureintraumaticbraininjury.Curr OpinAnesthesiol.2012;25:540---7.
3.MacEwenW.Clinicalobservationsontheintroductionoftracheal tubesbythemouthinsteadofperformingtracheotomyor laryn-gotomy.BrMedJ.1880;2:122---4.
4.PoetkerDM,EttemaSL,BluminJH,etal.Associationofairway abnormalitiesandriskfactorsin37subglotticstenosispatients. OtolaryngolHeadNeckSurg.2006;135:434---7.
