Leiomyoma of trachea: An anaesthetic challenge
A 23-year-old, 54 kg and 153 cm height girl presented for resection of a primary tracheal tumour. She reported a history of dry cough for 2 years with progressive dyspnoea, hoarseness of voice and wheezing for last 3 months. Patient had received treatment with bronchodilators and steroids and was being managed on the lines of bronchial asthma with no relief. Auscultation of chest revealed bilateral wheeze. Chest X-ray was normal, computerized tomography of chest and lower neck revealed a soft-tissue mass close to thoracic inlet, attached to left posterior wall in upper trachea causing luminal compromise. Positron emission tomography scan revealed 1.2 cm × 1.1 cm size soft-tissue mass at the level of C7 to D1 projecting into the tracheal lumen. On room air SpO2 was 95.3% while the arterial blood gas analysis showed PaO2 of 86 mmHg, PaCO2 40 mmHg, pH 7.42.\nPre-operative fiberoptic bronchoscopy was not done so as to avoid any airway irritation, which might have led to critical or complete airway obstruction.\nIn the operation theatre, patient was placed in supine position and standard monitoring including pulse oximetry, electrocardiography and non-invasive blood pressure was connected. An intravenous access was obtained followed by commencement of intravenous fluid. Injection fentanyl in slow incremental doses up to 100 μg and injection midazolam 1.5 mg intravenous bolus was given. This was followed by propofol infusion starting at 10 mg/kg/h until patient slept and gradually titrating it to 6 mg/kg/h followed by 1.5 mg/kg/h, at which level it was maintained throughout the procedure. After obtaining an adequate depth of anaesthesia an appropriate size nasopharyngeal airway was inserted, which was connected to anaesthesia circuit for delivery of air-oxygen mixture while maintaining spontaneous ventilation. Local anaesthetic spraying of airway with 4% lignocaine spray was done before insertion of rigid bronchoscope to prevent any stimulation of airway. This was followed by connection of anaesthesia circuit to the side arm of rigid bronchoscope and 2-4% sevoflurane with air O2 mixture was given to supplement intravenous propofol infusion for prevention of any stimulation of airway, which could precipitate complete obstruction.\nA tracheostomy tray was prepared and kept ready in the event of failure to control airway. Tumour tissue [] was extracted with rigid bronchoscopy forceps; bleeding was controlled by using adrenaline soaked gauze pieces and cautery. Seepage of blood and tissue distally into the trachea-bronchial tree was prevented by using judicious suctioning. A flexible bronchoscope was introduced through the barrel of rigid bronchoscope for further evaluation and suctioning.\nThe whole procedure was completed in 1 h during which time patient maintained oxygen saturation within normal range. Arterial blood gas analysis done during and completion of the procedure showed no retention of carbon dioxide. There were no episodes of desaturation, hypoxia or airway obstruction and patient was discharged home after 2 days. Histopathological evaluation of the excised tissue revealed it as tracheal leiomyoma.