Successful tracheal stent placement for central airway obstruction using dexmedetomidine and regional airway anesthesia.

Sir,

Anesthesia for tracheal stenting is challenging due to fear of loss of airway control. Here, we report a case of a successful awake tracheal stenting in sitting position using dexmedetomidine and airway block.

A 40-year-old male ASA grade II patient presented with cough and breathing difficulty and inability to lie flat for last 6 months. On examination, dyspnea and bilateral rhonchi were present. CT thorax [Figure 1] showed a right paracentral mass (measuring 4.7 × 4.8 × 5 cm) causing narrowing of tracheal lumen suggestive of suspected lymph nodal mass/exophytic esophageal or tracheal wall lesion. The patient was planned for awake fiberoptic guided tracheal stenting in sitting position as a temporary measure. The patient was given inj Glycopyrrolate 0.2 mg intravenous and started on infusion dexmedetomidine 1 μg/kg over 20 minutes in the preoperative area under monitoring and then maintenance @ 0.5 μg/kg/hour continued in the operation theatre. The patient was monitored with Bispectral Index (Aspect Medical System. Norwood, USA) of 80-90 and Ramsay scoring (2-3). In the preoperative area, lignocaine nebulization was given by a face mask nebulizer. Inside operation theatre, after adequate oropharyngeal anesthesia was achieved superior laryngeal nerve block, intratracheal block, glossopharyngeal nerve block with lignocaine were given. The patient was administered O2 through nasal prongs @ 4 lit/min. When airway anesthesia was achieved, fiberoptic bronchoscope was introduced through orotracheal route and metallic self expandable stent (NITI-S, Taewood Medical, Seoul, Korea) was introduced at the level of obstruction under the vision and under fluoroscopy guidance [Figure 1]. The mass was found to be invading the tracheal wall and causing intraluminal, as well as extraluminal obstruction. The patient was hemodynamically stable. The patient was shifted to ICU on oxygen with Face Mask @ 6 lit/min. Stridor was relieved and patient was advised to follow up in the OPD after discharge.

Figure 1

Tracheal stenosis and placement of stent

Tracheal stenosis can result from benign and malignant conditions. In advanced cases surgery would not be so helpful, but balloon dilatation and tracheal stenting has become an accepted method of palliation.[1] The need for anesthesia in these patients depends on the patient's condition and a communication between the anesthesiologist, surgeon and interventional radiologist is essential. C. Voscopoulos et al.[2] and Basem Abdalmalak et al.[3] have successfully used dexmedetomidine based technique in tracheobronchial stenting in the cases of central airway obstruction. Bergese SD et al.[4] evaluated the safety and efficacy of dexmedetomidine for sedation during awake fiberoptic intubation and they found that dexmedetomidine is effective as the primary sedative in the patients undergoing the awake fiberoptic intubation with difficult airway.

In our case, as the patient was not able to lie down, it was challenging to maintain the airway as well as to make the anxious patient comfortable. Dexmedetomidine possesses anxiolytic, sedative, analgesic, and sympatholytic properties. The Federal Drug Administration has approved the use of dexmedetomidine as a sedative-analgesic and/or total anesthetic in adults and pediatric patients undergoing small minimally invasive procedures, with or without the need for tracheal intubation. It is a safe sedative alternative to benzodiazepine/opioid combinations in the patients undergoing monitored anesthesia care for a multitude of procedures because of its analgesic, “cooperative sedation,” and lack of respiratory depression properties.[5] Dexmedetomidine, coupled with local anesthesia, provided excellent sedative and operative conditions for awake laryngeal framework procedures.

To conclude, dexmedetomidine along with adequate airway anesthesia can be an alternative in awake tracheal stenting.