The trachea tumor was removed and reconstructed 4 cases of anesthesia treatment.

. Tumors in the trachea will cause the diameter of the trachea to narrow, causing trachea stenosis, patients with breathing difficulties for aggravated visits, most patients have irritating cough, breathing difficulties and other symptoms, check the body is more end sitting, three concave signs. Ananesthesio physician shall select and develop a suitable anaesthetic induction and maintenance plan according to the site of the tumor in the trachea (distance from the sound door, bulge, tumor on sound door, under the trachea, lower section, bulge, etc.), shape, size, degree of airway obstruction, and surgical method. If induced by conventional anesthesia, it is highly likely to lead to acute respiratory distress, airway complete obstruction, leading to severe hypoxemia and even respiratory cardiac arrest and other accidents. How

do the anaesthetic of the trachea tumor removal procedure? First of all, we should strengthen and attach importance to preoperative visits, learn more about the patient's condition, develop a detailed and perfect anaesthetic program, and make various plans, and secondly, close communication and cooperation with surgeons, which is conducive to improving the safety of anesthesia. In a word, the key to trachea tumor excision anesthesia is how to ensure good ventilation and oxygenation of patients, and to ensure the smooth progress of trachea surgery while maintaining hemodynamic stability, which poses a challenge for anesthesiologists. This paper summarizes the anaesthetic treatment plan of 4 patients with intravascular tumor excision in the anesthesiology department of Tongji Hospital, and discusses how to optimize the
of the anaesthetic
management of intra-tracheal tumor excision and airway reconstruction.

. 1. Patient information

case 1: patient, male, 52 years old, height 172 cm, body mass 62kg. Patients six months ago no obvious cause of breathing difficulties, in the local hospital by anti-
infection
treatment is not effective, breathing difficulties to increase 13d admission. Check body: clear mind, good spirit, trachea center, calm breathing can smell and ring. Throat CT Tip: The left vocal cord under the area to the trachea level left edge soft tissue lump, tube cavity narrows, consider tumor lesions (Figure 1). Fiber bronchmirror: the tumor in the trachea starts under the sound door and reachs the upper nest of the chest bone. Preliminary
diagnosis
: tracheotomy lump.
Figure 1 The trachea neck section (lower left vocal cord to trachea level) tumor

. Case 2: Patient, female, 58 years old, height 165 cm, body mass 53kg. The patient had difficulty breathing without obvious causes before March, and the sexual exacerbation associated with an irritating cough was admitted to the hospital in January. Check body: poor mental health, expression anxiety, shortness of breath, wheezing, breathing difficulties accompanied by three concave signs. The patient is passive lyson and breathes lightly and quickly. Head and neck and chest CT tips: Ring cartilage below The C7-T1 horizontal main bronchial tube wall is visible size of about 20.0mm x 15.0mm soft tissue density shadow, part of the convex tube cavity, causing the neck trachea stenosis (Figure 2). Preliminary
diagnosis
: trachea tumor.
Figure 2 Tumor sepsis (C7-T1 vertebral level below ring cartilage)

. Case 3: Patient, female, 47 years old, height 158 cm, body mass 50kg. Patients 2 years ago no obvious cause of dry cough, in the local hospital to treat the disease (specifically unknown), dry cough repeated attacks, not pay attention to. The patient had breathing and breathing difficulties after the event was present two months ago. Check body: the patient's mental ity, trachea center, T3 vertebrae corresponding body surface can be smelled and bronchial breathing sound. Chest CT Tip: T3 vertebral horizontal bronchial cavity stenosis with soft tissue density shadow (Figure 3). Preliminary diagnosis: tumor in the lower part of the trachea.
Figure 3 Tumor stohing (T3 vertebral level) tumor

. Case 4: Patient, male, 49 years old, height 170 cm, body mass 54kg. The patient was admitted to hospital for six months due to intermittent cough, chest tightness, breathing difficulties and wheezing after self-incrimination. Check body: hearing double lung breathing tone decreased. Chest CT Tip: Position in the main bronchial tube (at the fork of the trachea), blocking up to 90% (Figure 4). Fiber bronchmirror: the lower part of the trachea near protrusion new organisms, the tube cavity is mostly narrow, most of the blockage. Preliminary diagnosis: Tumor in the lower part of the trachea near protrusion.
Figure 4 Tumor swells in the lower section of the trachea (near fork of the main bronchial tube)

. 2. Anaesthetic and surgical

2.1 Pre-anaesthetic preparation ventilation plan:

(1) case 1, choose in the case of appropriate sedative analgesic, the bureau underthemoric trachea cut to establish a surgical airway, re-induce; Determine the location of the trachea ducts, (3) prepare a full set of various types of trachea ducts, cyclometry puncture pack and larynx cover (3, 4) ;(4) surgeon to prepare emergency gas cut bag; (5) in vitro membrane pulmonary oxygen (ECMO) ;(6) cardiopulmonary transfer (fems transcirculation-in vitro circulation) ;(7) prepared for high-frequency ventilation ventilator ventilation. Four patients fasted 8h before surgery, and 6h was not given preoperative medication.

the upper body of the patient raised 30 degrees to 45 degrees, if the breathing difficulty can not be flat to take its relief position. ECG, noninvasive blood pressure, pulse blood oxygen saturation (SpO2) and exhalation end carbon dioxide fraction (PETCO2) were monitored. Quickly establish the venous channel and infuse the 37-degree-C compound sodium chloride injection 500mL, and give the chamber 0.01mg/kg to inhibit the secretion of the salivary glands and the airway glands. Mask to oxygen, hemp down the left side of the artery puncture tube and pressure measurement, so that SpO2 maintained at 92% and above;

2.2 anaesthetic-induced

case 1, belongs to the cervical tracheotomy tumor, the tumor is located in the left vocal cord under the region. Before surgery and surgery doctors fully communicate, choose the bureau hemp tracheotothes to open the establishment of surgical airways, and then carry out induced anesthesia program. The surgeon established the surgical airway after placing a diameter 7.0mm trachea duct, used stethoscope and PETCO2 to monitor the adjustment of the catheter position, and then gave the shufentani 0.4 sg/kg, propofol 2 mg/kg, Rocum bromonamon 0.5mg/kg, to take the ventilator mechanical ventilation.

case 2, belongs to the trachea mid-stage tumor, when induced to give propofol 2.5mg/kg, wait for the patient's consciousness to disappear after the mask ventilation test, good ventilation, give shufentani 0.3 sg/kg, heptafluee ether 8% mask inhalation 3min, and then placed in the no. 3 throat mask (LMA).

case 3, belongs to the lower section of the trachea (chest) tumor, given propofol 2mg/kg when induced, after the patient's consciousness completely disappears, the line mask ventilation test, good ventilation, give shofentanil 0.4 sg/kg, rocum brominated ammonium 0.5mg/kg The muscle relaxant preferred the rocum brominated ammonium, due to the antagonistic escort of Brittin (the general anaesthetic department of Tongji Hospital) making it an appropriate choice, inserted into the trachea duct under the guidance of a fiber bronchoscopy, and the tip of the catheter is located approximately 1 cm (depth 18 cm) above the tumor. Small moisture volume high frequency mechanical ventilation, so as to prevent high-pressure impact caused the tumor to fall off and block the airway.
. Case 4, belongs to the lower section of the trachea near protrusion tumor, the main bronchial blockage degree of up to 90%, the choice of full epithelate guided by fiberbronchology tube intubation, the tip of the catheter is located about 1 cm above the tumor (depth 21 cm), the intubation process is smooth, the patient has a mild cough reaction. After the intubation is completed, the intubation is given to Shufentani 0.4?g/kg, propofol 2 mg/kg, after determining the absence of ventilation barriers, give serombu bromine ammonium 0.5mg/kg (the anti-drug Breitin of the amcorbromamine, and take the ventilator to carry a high frequency of high tide gas mechanical ventilation.

2.3 anaesthetic maintenance

heptafluoreone ether 1.5%, propofol and rifenite and hydrochloric acid right Metomidin continuous pump injection, according to the operation and stress reaction to adjust the pump injection speed, according to the operation needs of intermittent addition of rocomine ammonium; %, and try to avoid pure oxygen ventilation, pure oxygen ventilation makes the gas in the lungs easy to absorb, resulting in the early closure of the small airway and the distant end of the alveoli withering, causing the amount of residual gas to decrease, may lead to the occurrence of pulmonary failure;

2.4 Ananesthesio and surgeon cooperation strategy

case 2, after the surgeon cut open the tumor far end trachea, the anesthesiologist will 7.0mm sterile spring trachea catheter handed to the surgeon, from the trachea to insert the trachea catheter, using the stethoscope and PETCO2 monitoring to determine the catheter position, fully attracted, connect the extension tube, while giving the abromine 0.4 mg/kg.

cases 1-2, the patient gets lying on the back, the shoulder pad is high, the neck is in the middle of the incision, the surgeon removed the trachea tumor and the surrounding soft tissue, the use of
vascular
line trachea cut near end and far end end match. Case 3, trachea lower section tumor, after anesthesia, the patient takes the left side lycacting, line right chest after the outer cut, by the 5th rib into the chest, 0.5 cm from the lower edge of the trachea tumor to break the lower end of the trachea, 0.5 cm from the upper edge of the trachea tumor off the upper end trachea, fully free upper end trachea, line-to-end match.

cases 1-3, after the trachea match, the use of fiber bronchoscopy guide through the mouth into the trachea catheter to the upper of the match mouth, pull out the tracheatic catheter, under the guidance of the fiber bronchoscopy mirror over the matching mouth, wait for the surgeon to stitch the front wall of the trachea, then the trachea catheter back to the upper of the match mouth.

case 4, the lower section near the protrusion tumor, the patient takes the left side lycacting, the right chest after the outer incision, by the fifth rib into the chest, the operation with the help of fiber bronchoscopy, the tumor is located in the protrusion on 1 cm to the upted up 4 cm, the surgeon cut the tumor After the far end trachea, the anesthesiologist will be 6.0mm and 5.5mm sterile spring trachea catheters handed to the surgeon, the surgeon placed it into the left and right main bronchial tubes, fully attracted, using a double cavity trachea catheter joint for connection, forming a homemade double cavity trachea catheter for the platform double lung ventilation.

surgery doctor to remove the tumor, the end of the line match trachea reconstruction, using fiber bronchoscopy to guide the throughthe mouth inserted into the trachea catheter to the upper of the matching mouth, pull out the tracheatic catheter, use fiber bronchoscopy to guide the trachea to the left main bronchial tube, the left lung ventilation, waiting for the surgeon to stitch the front wall of the trachea, then the trachea catheter is back to the upper of the matching mouth. The above 4 patients were monitored in surgery arterial blood gas index (Table 1, 2), adjustthed ventilation parameters, oxygen flow and concentration according to blood gas results, after the surgeon stitched the front wall of the trachea, used a fiber bronchoscopy to re-examine the location of the trachea duct, so that it is located above the match mouth, while testing the water to check whether the leakage Gas (surgical incision poured into warm salt water, with 20 to 30 cmH2O airway pressure test matching mouth for leakage); Four patients were transferred to the intensive care unit (ICU) with trachea catheters after surgery, and the trachea catheter was removed after the patient was fully awake on the second day after surgery (do a good job of pre-analgesic, maintain good tube resistance, and reduce the stress response of the trachea catheter).

1 case 1-3 patient blood gas analysis results
table 2 patients blood gas analysis results

3.Results

four patients in the anaesthetic induction period of vital signs are more stable, the second day after surgery patients are completely awake, remove trachea catheters, after treatment around 10d, all successfully recovered from the hospital.

. 4. Discussion of

primary tracheal tumoris are relatively rare, for
clinical
surgeons is a challenge, tracheotomy is the final treatment of primary tracheotomy tumors. Tumors in the trachea generally cause the trachea cavity to narrow, causing varying degrees of ventilation disorders. For anesthesiologists, the focus and difficulty of tracheotomy removal and tracheostology anaesthetic is in the airway
management
, the key is to choose what kind of anaesthetic-induced trachea intubation method and pulmonary ventilation strategy to maintain the smoothness of the respiratory tract in surgery, on the one hand, the need to relieve the patient's airway obstruction, ensure good ventilation, on the other hand, also need to reduce interference with the surgeon, and to ensure that the trachea is broken during sufficient oxygen and ventilation support. Through literature learning and combined with the case of the department, summarized below.

4.1 anaesthetic program

the development of such patients must pay attention to preoperative visit, view the patient's chest, CT tablets, fully understand the location of the tumor, size, trachea narrow tube cavity size and location, tumor blood supply and bleeding tendency and the patient's heart and lung function reserve, etc. ; Full communication with the surgeon before surgery requires all patients to carry out bronchoscoscopytesting tests, discuss the surgical procedures and programs, and develop a reasonable, effective and orderly anaesthetic program. Give moderate sedation before induction (be sure to be used with caution in monitoring) and inhibit respiratory gland secretion.

4.2 in-operative monitoring, strengthening management

intra-trachea tumor removal surgery, eCG, invasive blood pressure, SpO2 and PETCO2 must be continuously monitored. In the airway reconstruction process, ventilation program and normal patients there are differences, and due to the operation of the surgeon, can lead to trachea catheter pull and compression, during this period, the need for intermittent blood gas analysis, in order to timely reflect the respiratory conditions, prevent hypoxia and CO2 retention, timely correction of acid and alkali balance and electrolyte disorders.
. 4.3 intubation and ventilation method s/he s/

in the past in order to avoid the use of muscle relaxing drugs leading to complete obstruction of the airways, more use of the throat and trachea surface anesthesia after-line fiber optic mirror guidance of the sober trachea intubation;