Tracheal & Complex Bronchial Resections

KEY LEARNING POINTS

All Clinicians

• Tracheal stenosis and resectable tracheal tumours are rare – approximately 7 tracheal operations per year in NZ, of which only ~2 are resectable. Diagnosis is frequently delayed by up to 12 months.

• Flow-volume loop truncation (flattening of both inspiratory and expiratory phases) is the key diagnostic clue. Consider tracheal pathology when patients fail to improve as expected.

• Up to 50% of the trachea (~6cm) can be resected with primary anastomosis.

• Every case requires a clear Plan A and Plan B for airway management, agreed upon by the entire team before the patient enters the theatre.

• Emergent ECMO for cardiovascular collapse carries 80–90% mortality. If ECMO may be needed, plan it electively.

Cardiothoracic Surgeons

• CT planning is important and positioning matters. Neck extended with hands by the side (not above the head) is the ideal acquisition position for surgical planning.

• Blood supply is via lateral pedicles – preserve them at all costs. Circumferential dissection risks ischaemia.

• Transillumination defines proximal and distal tumour extent intraoperatively.

• Release manoeuvre (neck flexion, suprahyoid release) reduces anastomotic tension.

• VATS right lateral approach for mid-tracheal lesions is feasible but carries a ~27% failure rate requiring conversion in the largest series.

• VV ECMO as primary airway management strategy allows unhurried, precise surgery.

• For right main bronchus involvement >2.5cm, double-lumen tube is preferred; for complex bronchial cases, VV ECMO.

• 75% of primary tracheal tumours are aggressive malignancies (squamous cell carcinoma most common).

• Overall 5-year survival for tracheal tumours is approximately 27%.

Anaesthetists

• Spontaneous ventilation technique: LMA + TCI. Vagus nerve blockade suppresses cough and airway reactivity.

• 50% O2 during dissection; switch to 100% O2 during open anastomosis. No diathermy with open trachea – use harmonic scalpel.

• Permissive hypercapnia is well tolerated during spontaneous ventilation.

• For awake VV ECMO cannulation: a dedicated third person should look after the patient; generous local anaesthetic; procedure is usually well tolerated. Use TTE initially, confirm with TOE once asleep.

• Percutaneous (Seldinger) VV ECMO is preferred. Obese patients may require slightly sitting-up positioning for femoral cannulation.

• Fluoroscopy is useful for cannula placement if a hybrid theatre is available; TTE/TOE is the standard alternative.

ICU

• VV ECMO is vastly preferable to VA for pure airway support: no air-blood interface, less SIRS, reduced anticoagulation requirement, and can be continued post-operatively if needed.

• VV ECMO requires ≥60–75% of cardiac output through the circuit. Target SpO2 ≥85%.

• VA ECMO: peripheral configuration risks upper body hypoxaemia – address with VAV configuration or additional jugular drainage.

• Elective indications: tracheal diameter <5mm or <50% of normal → awake VV/VA ECMO; RVOT/SVC compression without symptoms → standby ECMO.

• Emergent ECMO for collapse carries 80–90% mortality. Identify high-risk patients early: dyspnoea, stridor, respiratory distress, SVC/PA compression, or upper thoracic mass compromising jugular access.