Cross Field Ventilation Strategy in a Transected Trachea

Background: Crossfield ventilation is a rarely used technique for management of tracheobronchial injuries. Traumatic tracheal injuries present emergently and are life threatening, with minimal preoperative evaluation and... [ view full abstract ]

Background:

Crossfield ventilation is a rarely used technique for management of tracheobronchial injuries. Traumatic tracheal injuries present emergently and are life threatening, with minimal preoperative evaluation and opportunity to plan. These cases present anesthetic challenges in intubation, maintaining ventilation and oxygenation especially during tracheal reconstruction.  We describe a case of tracheal injury requiring emergent repair and the use of crossfield ventilation for anesthetic management.

Case Description:

A 37 y/o Male with no significant medical history presented after a high speed motorcycle crash with tracheal crush injury after colliding against a barbed wire fence. Additional injuries included bilateral pneumothoraces and pneumomediastinum. He was intubated on scene of the crash by emergency personnel for agonal respirations. A follow up CT scan revealed the distal end of ETT extra-tracheal creating a false lumen. He was re-intubated in the OR at an outside hospital with a bronchoscope and transferred to our hospital. Anesthesia was induced with midazolam and fentanyl, and rocuronium was given for neuromuscular blockade.  Intravenous propofol was chosen for maintenance of anesthesia to avoid volatile contamination of surgical field and steady anesthetic depth.  Initial rigid bronchoscopy revealed tracheal disruption at 1 tracheal ring level below the cricoid cartilage.  Thoracic and otolaryngology surgical teams performed tracheal dissection.  A sterile 6.0 ETT was used for cross field ventilation. During tracheal anastomosis ventilation was maintained with SIMV-PSV and manual bag in coordination with surgical team performing intubation and extubation of the trachea. Tracheal anastomosis was performed and at the end of surgery tracheostomy was placed.

Discussion:

Cross field ventilation is an approach in tracheal reconstruction surgery that requires distal tracheal intubation and intermittent ventilation with positive pressure. Following tracheal exposure the proximal ETT is withdrawn while a new sterile ETT is inserted distally to ventilate. Intermittent apneic periods are permitted to allow insertion of sutures to distal trachea until anastomosed.  Alternative methods include jet ventilation with manual high frequency ventilation of distal lung fields. This poses the problem of exposure of a compromised trachea to high airway pressures.  Case reports of use of a foley catheter, Shiley have been reported. Sometimes oxygenation may pose a challenge, especially with ARDS, extensive pulmonary injury the patient may not tolerate intermitted ventilation. A case report described the use of veno venous ECMO to maintain oxygenation. Although cardio-pulmonary bypass was popular in the 1960s for carinal surgery, routine use brings its own risks of complications.    Spontaneous ventilation has also been described as a strategy in planned tracheal tumor surgeries, often requiring an epidural and sedation. Although this approach may improve surgical field visualization, risks include coughing and blockage of distal airway with debris or blood. The level of injury affects greatly affects ability to ventilate with more inferior or subcarinal injuries requiring one lung ventilation and therefore greater difficulty in maintaining oxygenation. Post operative mortality is related to positive pressure ventilation in cases of tracheal surgeries, so spontaneous ventilation postoperatively is desired.  These cases require meticulous communication between the surgical team and anesthesiologist and team based approach