Bronchoscope-assisted Tritube® placement for resection of sequential tracheal stenosis

Symptomatic tracheal stenosis is a rare but significant complication of long-term tracheal intubation and mechanical ventilation. Airway management for tracheal resection in severe tracheal stenosis, especially sequential stenoses, requires multidisciplinary planning. A valuable method of airway management is the insertion of a small-bore, cuffed tracheal tube (Tritube®, Ventinova Medical B.V., Eindhoven, The Netherlands) in combination with flow-controlled ventilation. In this case, a patient with tracheal stenosis following prolonged ventilation required resection of the stenosed tissue. A Tritube was placed via a J-tipped guidewire inserted through the working channel of a bronchoscope. Bronchoscopic cuff visualisation along the tube in severe stenosis is impossible because of the outer diameter of the tracheal tube. In this case, we therefore estimated the position of the tube tip based on the distance from the vocal cords to the carina measured on pre-operative computed tomography imaging. During completion of the dorsal tracheal anastomosis, cross field ventilation using a conventional tracheal tube had to be started due to impeded ventilation caused by the Tritube protruding distal to the carina. In severe sequential tracheal stenosis, a small-bore tracheal tube can safely be placed by guidance with a J-tipped guidewire. However, it is important to plan a backup method of ventilation, such as cross field ventilation, prior to commencing a critical procedure.