A 9-yr-old child, was referred to our institute with worsening dyspnea. Chest-X-ray showed right lung collapse and hyperinflation of the left lung indicating expiratory obstruction. Recent fiber-optic bronchoscopy showed the mass at carina causing severe airway obstruction. The mass was popping out of the right bronchus. He underwent emergent endobronchial debulking. Glycopyrrolate was administered, thereafter, anesthesia was induced with ketamine, fentanyl, and sevoflurane; and maintained with propofol and dexmedetomidine infusions. Oropharynx and airway were anaesthetized with 2% lignocaine. Muscle relaxant was avoided. Monitoring included electrocardiogram (ECG), SpO2, and invasive blood pressure. On attaining BIS 50%. (c) Fiberoptic bronchoscopy image following carinal tumor debulking. (d), Chest x-ray on day three following procedure, showing complete resolution of the obstruction and the re-expansion of the right lung was almost completeCentral airway obstruction poses the perioperative challenge as patients presents with severe respiratory distress. Managing such patients requires meticulous planning and a team of experienced interventionalist, anesthesiologist, technicians, nurses and standby extracorporeal membrane oxygenation (ECMO). We routinely maintain anesthesia with propofol and dexmedetomidine during airway sharing and manage them under spontaneous breathing that keeps the airway open and ensures oxygenation and ventilation.1 After achieving adequate anesthetic depth, trachea is intubated with a rigid bronchoscope in pediatric patients or with an I-gel in adults and the tumor is debulked. In pediatric patients, it is possible to intubate trachea with a rigid bronchoscope under deeper plane of anesthesia without paralyzing.2 During debulking, loss of airway can arise from bleeding, accidental dislodgement of the excised tumor into the contralateral main stem bronchus, airway disruption or trauma from rigid bronchoscope. An undersized rigid bronchoscope is always kept ready for rescue ventilation and to tamponade the bleeding. Maintaining spontaneous ventilation is crucial in critical airway obstruction. The negative intrapleural pressure exerts radial traction on the airways keeping them open; which is lost on administering muscle relaxants. This decreases the airway diameter and may cause complete loss of airway at the tumor site.3 Forceful ventilation in such scenario can result in air trapping, pneumothorax, and hemodynamic collapse. Author’s contribution Dr. Don J Palamattam: This author was involved in the management of anesthesia, conception, design of report, drafting the work, final approval of the version, maintaining accuracy and integrity of work. Dr. Tony J Joseph: This author helped in drafting the work, final approval of the version, maintaining accuracy and integrity of work, validating the data and agreement to accountability. Dr. Tinku Joseph: This author was involved in the interventional procedure, helped in final approval of the version, and maintaining accuracy and integrity of work. Dr. Praveen K Neema: This author involved in the management of anesthesia, conception, design of report, drafting the work, final approval of the version, maintaining accuracy and integrity of work. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Palamattam et al. (Wed,) studied this question.