Introduction: The incidence of intratracheal tumors are rare occurrences in anesthesiology. These patients often present to the operating room in varying degrees of respiratory distress and compromise. This poses a significant airway challenge for anesthesiologists on both induction and intraoperatively.
Case Presentation: The patient is a 66 yo male with multiple comorbidities and extensive smoking history who presented with two weeks of SOB, hemoptysis, and weight loss. He was noted to be tachycardic, tachypneic, and in hypoxemic respiratory failure with SpO2 in the 50s on 15L NRB. He was temporized on BIPAP with some improvement in oxygen saturations. CT chest revealed a 13.8 cm x 11.5 cm RML mass extending into the RUL and invading into the tracheal carina wall and both mainstem bronchi resulting in significant obstruction. The patient was taken emergently to the OR with thoracic surgery for tumor debridement to relieve the obstruction.
The patient was brought into the OR on BIPAP, saturating in the 80s and sitting in the upright position. The patient would not tolerate even minimal decline from a sitting position. He was induced upright with propofol to facilitate LMA placement. An arterial line was then placed while the patient was maintained on sevoflurane. A flexible fiberoptic bronchoscope was passed through the LMA to directly visualize the mass. The tumor was noted to invade through the subcarina with 100% obstruction of the left mainstem bronchus and 70% obstruction of the right mainstem bronchus. With confirmation that adequate ventilation could be achieved intraoperatively an 8.5 ETT was placed. The surgical team utilized a flexible fiberoptic bronchoscope to begin debridement. Maintenance was achieved with sevoflurane and cisatracurium. The team then proceeded with rigid bronchoscopy for further debridement, sevoflurane was discontinued and the patient was placed on a propofol infusion. Upon completion of the procedure, an 8.5 ETT was then replaced. Intraoperatively the patient exhibited both respiratory and hemodynamic lability requiring intermittent norepinephrine boluses and multiple procedure pauses to restore adequate oxygenation. The patient was left intubated and transferred to the MICU.
Post operatively the patient was unable to be weaned from the ventilator and remained intubated. On POD #2 and #7 he returned to the OR for photodynamic therapy. He was ultimately transferred to an OSH for the remainder of his care.
Discussion: The airway management of a patient with an intratracheal tumor is challenging due to the necessity of a shared surgical field. Careful planning must be utilized and often involves the use of awake fiberoptic intubations, surgical airways and preparation for cardiopulmonary bypass. Given the metastatic extent of disease and rapid acute decline in our patient we utilized a technique which would provide the greatest degree of palliation and least invasive technique possible.
