An example of airway management in the removal of tracheotomy tumor under thoracic mirror

Patient, male, 40 years old, 75kg, ASAII, NYHA-A grade, was admitted to hospital with "blood in sputum for more than 1 month." Patients have a history of bronchitis, a long history of smoking, about 40 units/dayAdmissiondiagnosis: the cause of hemorrhage to be investigated, chronic bronchitisChest CT reinforcement and trachea 3D reconstruction show: trachea end left irregular knots (Figure 1); fiber bronchoscoscopy examination shows: trachea end vegetable pattern new organisms, volume about 1.8 cm x 1.2 cm x 1.0 cm, upper edge distance sound door about 9.5 cm, lower edge from the altrual synapse about 0.5 cm, tactile bleeding, trachea narrowness level Cotton I gradePathological results show: tracheodosis-like cystic cancerBlood gas analysis: PaO279.9mmHg, the remaining tests and laboratory indicators did not see abnormalIt is proposed to remove the gagon altrusion altruism under the undergoing thoracic mirror under general anesthesiaFigure 1 Ct scan of a patient's trachea tumorPatients in the first 30min intramuscular injection of sodium phenobarbital 0.1g and aptopin 0.5mg, after entering the room to open the right upper extremities peripheral vein pathway, regular monitoring bp, SpO2, ECG, PETCO2Local anesthesia lower left artery puncture tube surgery, monitoring the creation of arterial pressureHemp down the right neck vein puncture tube, used for rehydration and monitoring CVPMask oxygen absorption 6L/min, deep breath after 1min, intravenous injection of midazolam 2mg, Shufentani 45 mg, relying on miede 15mg, psiprosulphate aqualku ammonium 15mg line anesthesia induction, positive pressure ventilation 3min inserted after ID7.5mm strengthening Single-cavity bronchial catheter, then inserted into the Coopech bronchial sealer (lot number: 1305EBB001B); Mechanical ventilation, inhalation of pure oxygen, oxygen flow 2L/min, double lung ventilation VT6 to 8 ml/kg, RR12 times / minute, I:E1:2, PETCO2 35 to 40mm and HgO2 100%The patient takes the left lycing position, the bronchial blocker is sealed on the right side, the left lung single lung ventilation, adjusts the breathing parameters, and maintains the stability of the life indicatorsthe use of "three-hole" thoracic incision, in-the-go mirror detection chest cavity no abnormality, free ligation cut off the odd venous arch and free the lower section of the trachea, ligation cut off the right lung upper loin after the first artery free right main bronchial tube, remove the bulging lymph nodes after free left main bronchial tubeAfter the vertical bronchial wall cuts off the left main bronchial tube, the operator inserts the ID7.0mm trachea catheter through the chest mirror operating hole into the far end trachea and places it in the left main bronchial tube, connecting the threaded tube to the ventilator to continue the left lung single lung ventilationremove the right main bronchial sealer and retract the trachea duct, the vertical bronchial wall cuts off the right main bronchial tube and breaks the trachea above the tumorIntermittent suture trachea and the front wall of the left main bronchial tube, when the left main bronchial tube is in agreement towards the end, the autonomous operation hole removes the trachea duct, and at the same time, with the assistance of the operator, the trachea tube is fed into the left main bronchi to maintain ventilation, and continues to complete the gas tube and the main bronchi end on both sides of the gapAfter the protrusion is formed, the trachea duct is retreated into the trachea above the mouth, and the two lungs are ventilated after spittingthe end of the operation to pull the lower armpitwither wire to the chest wall, keep the head bent to prevent a tie-up mouth tearIn addition to maintaining the stability of vital signs, the changes in airway pressure should also be closely observed, the moisture volume should be adjusted to maintain PETCO2 in the normal range, closely monitorblood gasThe operation lasted 180min, and the patient's life indicators were smoothly transferred to ICU monitoring treatmentAfter 12h, the trachea catheter is removed and 2d is transferred to the general wardThe patient recovered well after surgery and was discharged from the hospital after 10ddiscussion
trachea and its protrusion tumors include malignancies originating in the trachea and protrusions, as well as surrounding tissue malignancies and bulges and lower tracheaTreatments include surgical treatment, radiation therapy and bronchalycosis palliative care, where surgical excision alone may cure the patient and achieve long-term survival, but because the tumor is located in the trachea or protrusion, not only the location is special, but also affect normal ventilation, the difficulty and risk of surgical treatment is greaterTv-assisted thoracic mirror technology (video-assisted thoracic surgerg, VATS) with its small trauma, less bleeding, clear surgery, quick postoperative recovery and so on, has been widely used in breathing, cardiothoracic disease
diagnosis and treatmentIn the past, the left-row protrusion removal of the airway reconstruction due to the operation of the deep position, aortic arch blocking, revealing difficulties, and the odd vein in the right main bronchial root above the cross, once the injury caused hemorrhage, not easy to stop bleeding, high riskTherefore, the patient chose the chest mirror by the right chest tracheotomy tumor removal calosation the intubation and ventilation mode of intratube tumor surgery has always been the concern of anesthesiologists, and is also the key to the success or failure of surgery and the safety of patients In this case, the patient's airway stakes are low in the trachea, about 0.5 cm from the lower edge and need to protrusion forming, can not use the double cavity trachea tube for the of the airway management ; Select the method by which the trachea catheter is inserted through the mouth to the top of the tumor in the trachea, and then insert the Coopech bronchial blocker to the right main bronchial blocking under the guidance of the fiber bronchoscoscopy, and the process goes smoothly anesthesiologistshould be in close communication with the surgeon, familiar with the main surgical procedures and working closely together In this case, the patient's operating table by thoracic surgery hole inserted into the left main bronchial tube in the length of the trachea duct is not enough, the use of two trachea ducts head and tail contact, film closed combination of the method, the effect is satisfactory In addition to surgery in addition to the need sending tube to ensure the smooth operation of surgery and pulmonary ventilation, but also should pay attention to attract to prevent blood reflux to the health side Postoperative airway maintenance and management are equally important Patients with tracheotomy, due to the trachea partial removal and shortened, surgery must maintain the head flexion, to reduce the tension of the trachea sutures, for this end of the operation should be the lower armpit with wire pull fixed to the chest wall , the chest mirror by the right chest tracheotomy tumor removal calonthrochid altruism has been proved to be a feasible surgical method, bronchial blocker can provide a safe and effective ventilation program, for the smooth implementation of surgery to create conditions for the safety of anesthesia, as a low tumor position, can not run double cavity tracheostomy intubation patients duct management measures