Anesthesia for reconstructive airway surgery in pediatrics

Introduction/background Reconstructive surgery for the airway first began being performed in children in the early part of the twentieth century. At that time the chief cause of laryngeal or tracheal pathology was diphtheria. In the 1920s and 1930s a variety of surgical techniques were developed by Jackson and Arbuckle to correct laryngotracheal stenosis resulting from diphtheria. Using resection of diseased tissue as well as skin grafts, this allowed many of these children to no longer require a tracheostomy. With the diphtheria vaccine, the incidence of infectious laryngeal stenosis declined. However, in the 1930s to the 1960s airway injuries from automobile accidents increased. Techniques to correct posttraumatic stenosis using rib cartilage grafts were developed during this time. In the 1960s premature babies began being managed by prolonged intubation for ventilatory support. Subglottic stenosis from prolonged intubation soon became a serious problem as these babies survived to childhood. Often these children required a permanent tracheostomy. However, airway operations such as the anterior cricoid split were developed by otolaryngologists that allowed an infant with subglottic stenosis to have an adequate airway and often forgo a tracheostomy. Cricoid resection is now also utilized in infants and children with severe subglottic stenosis as well, as are resections of short segments of the trachea for acquired or congenital stenosis. In recent years tracheoplasty techniques that allow the reconstruction of the airway in infants or small children who have long segments of stenosis have been developed, often using a cardiopulmonary bypass. In the past these lesions were often fatal [1,2]. Infants and children undergoing reconstructive airway surgery present many challenges to the anesthesiologist. If they are not yet tracheally intubated at the time of surgery they may have stridor or some degree of airway obstruction from their stenotic lesion, making induction of general anesthesia hazardous. Anesthesiologists and surgeons must be prepared to handle a difficult airway when anesthetizing these patients. Both flexible and rigid bronchoscopy are often performed prior to beginning reconstructive airway surgery. These procedures require close cooperation between the anesthesiologist and surgeon when managing a shared airway. Often these infants require tracheal intubation for a week or two following operations on their airway. This is a challenge for the pediatric intensivist.