Cross Field Ventilation For Tracheal Squamous Cell Carcinoma in Patient With Prior Single Lung Transplant

Abstract

Introduction: Resection of tracheal masses can pose a significant difficulty for the management of the airway in the intraoperative period. Cross field ventilation is a technique rarely used in patients with tracheal masses and tracheobronchial injury1 where placing an endotracheal tube orally would interfere with the surgical procedures. During cross field ventilation, the surgeon will place an endobronchial tube in the bronchus and intubate the bronchus, and a sterile circuit will be passed and connected by the anesthesiology team. Throughout this time, single lung ventilation will be provided to the patient. Important considerations include maintaining the patient’s oxygenation status with adequate ventilation and maintaining the patient overall hemodynamically stable to be able to tolerate single lung ventilation. Case Description: A 71-year-old male with a past medical history of chronic obstructive pulmonary disease (COPD) post right (R) lung transplant presented for resection of squamous cell carcinoma of the trachea. His CT scan showed a posterior tracheal mass above the carina and bronchoscopy with biopsy confirmed the diagnosis. It is thought that the mass resulted from chronic immunosuppressive therapy due to his prior lung transplant. Resection of the mass under general anesthesia with cross field ventilation was planned. The patient received 100mg of propofol for induction and 100mg of rocuronium for paralysis. An oral endotracheal tube (ETT) was placed. Maintenance of anesthesia was with sevoflurane. The patient’s blood pressure was monitored continuously throughout the case with a radial arterial line, and he remained within 20% of his baseline blood pressure. His oxygen saturation remained stable throughout the case, stating between 97-98%. Before transection of the trachea for removal of the tumor, cross field ventilation was begun. The oral ETT was pulled back. Bronchoscopy was used and an endobronchial tube was placed in the R mainstem bronchus. A sterile circuit was passed through from the surgical team and connected. One lung ventilation was used for the R transplanted lung. Once the tracheal anastomosis was complete, the oral ETT was pushed back into the distal trachea and cross field ventilation was terminated. The patient was extubated at the end of the case with no difficulty and taken to the intensive care unit for recovery. Discussion: Cross field ventilation is a unique approach that can be used during surgeries involving the tracheobronchial region. It requires constant communication between the surgery team and anesthesiologist. Additionally, remembering certain considerations such as the implications of using single lung ventilation is important, especially in this patient with prior lung transplant. References:

Sehgal S, Chance JC, Steliga MA. Thoracic anesthesia and cross field ventilation for tracheobronchial injuries: a challenge for anesthesiologists. Case Rep Anesthesiol. 2014;2014:972762. doi: 10.1155/2014/972762. Epub 2014 Jan 12. PMID: 24527234; PMCID: PMC3913496.