Airway management algorithm during circular tracheal resection in adult patients with cicatricial stenosis (a single-center study)
Authors: Kozhanova A. V. , Khlan Т. N. , Strunin О. V. , Pechetov А. А. , Lukich К. V. , Ibragimov A. S. , Starkov Yu. G. 
Published: October 2024

The objective was to present the experience of airway management algorithm in patients with different localization of stenosis during circular tracheal resection.

Materials and methods. The retrospective analysis included 84 patients with grade II cicatricial stenosis who underwent circular tracheal resection at the period from 2018 to 2023. The patients were divided into two groups: group 1 with long-segment tracheal stenosis and group 2 with short-segment tracheal stenosis (39 and 45 patients, respectively). The age of patients in group 1 was 43 years [28–55] versus 48 [35–61] years in group 2 (p = 0.19). The patients in the groups were comparable in terms of the main parameters: gender, the ratio of women to men, BMI, class of cardiological risk, degree of risk of respiratory complications and pneumonia, degree of disability. Airway management control during surgery was provided by tracheal intubation with the installation of an endotracheal tube (ETT) proximal to tracheal stenosis or with a supraglottic airway device (laryngeal mask) i-gel (LM) before the main stage, followed by the application of the «apnea-ventilation-apnea» technique at the main stage. In patients with tracheostomy, airway management was performed by inserting endotracheal tube (ETT) into the tracheostomy opening using the «apnea-ventilation-apnea» technique until the completion of the main stage, followed by tracheal intubation through the mouth using a bronchoscope. All patients included in this study underwent tracheoplasty; patients with preserved tracheostomy were not included in the study. The choice of the method of airway management was determined after a joint discussion of the patient with the operating surgeon, endoscopists, as well as after evaluating the predictors of difficult airways and the presence of a tracheostomy in the patient.

Results. The incidence of patients with tracheostomy in group 1 – 23 (59%) was higher than in group 2 – 9 (16%) (OR 5.75, 95% CI 2.18–15.17; p < 0.0001), which influenced the choice of tactics for airway management, since LM tracheostomy was not used in this group of patients. The choice of tactics for airway management algorithm also depended on the extent of stenosis, so LM was used more often in group 2 – 28 (62.2%) than in  group 1 – 12 (30.8%) (p = 0.004). We associate such differences with the presence of a large number of patients with tracheostomy in group 1. For airway management during surgery, LM was used in 90% of cases with cervical localization of stenosis. In group 1, the time of anesthesia and mechanical ventilation increases compared to group 2: 245 [210–275] versus 215 [180–240] min (p = 0.022) and 265 [220–400] versus 210 [180–320] min (p = 0.015), respectively. The frequency of waking up in the operating room and regaining the ability to breathe independently was higher in patients in group 2: 35 (77.8%) than in group 1 22 (56.4%) (OR 2.7, 95% CI 1.05–6.97; p = 0.036). No difference in length of hospital stay was observed in the extent of stenosis and the chosen airway management algorithm.

Conclusion. The choice of airway management algorithm during circular tracheal resection in patients with grade II cicatricial stenosis is depended on the localization and extent of tracheal stenosis. The choice of laryngeal mask i-gel as the airway management algorithm is safe and alternative algorithm with tracheal intubation with short-segment cervical stenosis and absence of tracheostomy.