Management of critical tracheal stenosis with a straw sized tube (Tritube): Case report

Abstract

Imminent upper airway obstruction due to life-threatening tracheal stenosis of any cause is a challenging situation. We present a challenging case of total thyroidectomy for a malignant, invasive, and highly vascularized thyroid carcinoma that has invaded the surrounding tissues, including the sternum and mediastinum, resulting in compression of the trachea with indentation. The patient presented with a significant symptomatic tracheal stenosis, the narrowest area of that was 4 mm. Airway management in such cases presents a particular challenge to the anesthesiologists, especially considering that the option of tracheostomy is very difficult most of the time due to the highly swollen thyroid and distorted anatomy. A meticulous history of the patient's illness had been taken, and a comprehensive preoperative evaluation was conducted, including construction of a 3D model airway, virtual endoscopy, and transnasal tracheoscopy. On the day of the surgery, the airway was managed through spontaneous respiration using intravenous anesthesia and the high-flow nasal oxygen (STRIVE-Hi) technique. It was then secured with intubation using a straw endotracheal tube (Tritube®) with an internal diameter (ID) of 2.4 mm and an outer diameter of 4.4 mm with the help of a fiberscope and D-MAC blade of a video laryngoscope. At the end of the procedure, the airway was checked with a fiber optic scope, which showed an improvement in the narrowed area. This enabled us to replace the Tritube with an adult cuffed ETT of size 6.5 mm ID, and the patient was transferred intubated to the surgical ICU. Two days later, the patient's tracheal diameter was evaluated with the help of a fiberoptic scope and extubated successfully in the operating theater.

Near total intrathoracic airway obstruction managed with a Tritube (R) and flow‐controlled ventilation: a reply.

“…Finally, we agree with the authors that flow-controlled ventilation using Evone in combination with Tritube represents a valuable solution for managing complex difficult airway cases, as it has been successfully used by others for this purpose [8][9][10].…”

Flow-controlled ventilation – a new and promising method of ventilation presented with a review of the literature

“…A recent report described the performance of a tracheotomy procedure using a tube-in-tube technique (Tritube through a large-bore endotracheal tube), enabling minimal production of airway aerosols and thus increasing the safety of personnel, in addition to providing easy surgical access [ 40 ]. Furthermore, in cases of severe stenosis, the Tritube might prevent the need for ECMO during surgery, as described in a case of critical tracheal stenosis of 4 mm [ 41 ].…”

The Tritube: Facilitating Upper Airway Surgery With an Ultrathin Cuffed Airway Device

“…If necessary, a small-bore flexible bronchoscope may be used to check tip and cuff placement. 13 In our view, most difficulties with FCV seem to arise from obstruction of the ventilation and/or pressure monitoring channels or from tube malpositioning. FCV may fail if the tube lies against the carina or is displaced by a tumoral mass.…”