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Balloon dilatation of tracheal restenosis in a patient with unilateral lung agenesis – an anesthetic challenge

The patient, born at term was diagnosed with micrognathia, cleft palate, and dextrocardia and soon developed respiratory distress requiring intubation and ventilation. CXR revealed a hypoplastic right lung. Bronchoscopy revealed critical tracheal stenosis 2 cm below the cords, and MRI showed the stenotic segment extending to just proximal to the upper lobe bronchus with absent carina, right bronchus, right lung, and right pulmonary artery. Echocardiogram revealed common atrium, AV, and ventriculoarterial concordance. The patient underwent tracheal reconstruction in 2 weeks time followed by stenting and repeated balloon dilatation of the stent and went on to have fundoplication for reflux disease, gastrostomy, Broviac line insertions, tracheostomy, second stent insertion distal to the first, cleft palate repair, and further tracheoplasty by the age of 5. Since then, the patient has been on nocturnal BIPAP and requires tracheal balloon dilatation every 6–12 weeks because of narrowing of the tracheal lumen by granulation tissue growth. Anesthesia is induced via the inhalational route through the tracheostomy with oxygen and sevoflurane 2–8% mixture. After establishing peripheral cannulation, remifentanil infusion is commenced and atracurium is given and the trachea is intubated orally with a 6.0-mm I.D cuffed portex tube. After capnographic confirmation and ability to ventilate adequately, the tracheostomy tube is removed and the site sealed with sterile dressing. Anesthesia is maintained with 100% oxygen/sevoflurane (2–3%) and ventilated with AESTIVA 5 ventilator with inspiratory pressures of 20– 25 cm H2O and PEEP of 5 cm H2O. If adequate tidal volumes are not achieved, which depends very much on the extent of narrowing of the trachea, manual hand ventilation with a T piece is used. The endotracheal tube is connected to a swivel connector, to facilitate passing the fibreoptic scope loaded with the balloon catheter, without interruption of ventilation. Under continuous imaging a flexible bronchoscope is passed through the endotracheal tube and a wire is passed through it. After ventilating with 100% oxygen for a minute, the balloon catheter is passed over the wire and positioned at the stenotic site. The balloon is inflated to achieve required pressures (usually 10–20 cm H2O) which is determined by the degree of stenosis. There is no fresh gas delivered to the patient at this time. The balloon is then removed after deflation and the sequence repeated. After completion of procedure, the trachea is extubated and tracheostomy tube reinserted in theater and the patient is transferred to the pediatric intensive care unit.