The problems posed by tracheal intubation in the presence of a tracheal bronchus in adults are exemplified with three case histories. The anomaly has been categorized into three types on the basis of its potential to cause problems when attempting intubation. Suggestions are given for ways of securing the airway that are safe and less likely to result in obstruction and hypoxia.

In the last decade, stents suitable for the management of tracheobronchial stenoses and obstruction have evolved from bulky prostheses requiring tracheal resection to small devices that are self-expanding and can be inserted using fibreoptic techniques. The experience base for this review is more than 100 patients between 1989 and 2001 who have been anaesthetized for stent insertion. Early cases required rigid bronchoscopy for the routine of insertion. Anaesthetic techniques have evolved from those that were designed and developed for laser surgery in the central airways. The advent of modern devices now extends the variety of anaesthetic management techniques that can be used. But the original one, based on the requirement for use of a rigid bronchoscope, is best for dealing with complications and extracting problem stents. The most frequent complication of the processes of stent insertion has been respiratory failure because of carbon dioxide retention, consequent on obstruction with secretions in the area of the carina. The nature of central airway problems suggests that anaesthesia induction, management and teaching should not be founded on the conventional model-base of upper airway obstruction.

SummaryThe failure rate and complications were studied prospectively in 367paediatric and adult patients who had received a thoracic or lumbar paravertebral block. The overall failure rate was 10.1 YO; adults 10.7%; children 6.2%. The frequency of complications were: hypotension: 4.6%; vascular puncture: 3.8%; pleural puncture: 1 . 1 %; pneumothorax: 0.5%. Since these results are similar to those found with alternative methods, e.g. epidural, intrapleural and intercostal blocks, paravertebral block can be recommended as an effective, safe technique for unilateral analgesia in both adults and children.

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