Table 1 Surgical operations completed and anesthetic management

Day 3:

Rigid and flexible bronchoscopy for diagnosis and tracheal dilatation

General anesthesia, patient pre-intubated and transferred after extubation (SICU)

Under general anesthesia and supine patient, rigid bronchoscopy was inserted under the guidance of scope. 6.5 followed by 7.5 and 8.5 and mechanical dilatation was done. The lumen is patent and no need for more intervention. The patient tolerated well the procedure and transferred to SICU

Day 12

Rigid bronchoscopy for Stent placement

General anesthesia, transferred to SICU with 7.0 mm ET

Under GA and in supine position, flexible bronchoscopy started followed by intubation under vision by bronchoscopy. Examination was done with suction of excessive secretions. Hyperactive posterior tracheal wall was noted. Measurement was done right stem bronchus 1.5 cm wide left bronchus 4 cm wide. Trachea, from carina to vocal cord, measure 10 cm long. Stent was fashioned to these sizes and inserted into the applier but the applier did not pass through the rigid bronchoscope as it was fixed recently with narrowing of the lumen and fixation. It has been decided to abort procedure and the patient was re-intubated and transferred to SICU

Day 16

Emergency intubation and stent shortening

General anesthesia, transferred to SICU with 7.0 mm ET

Under GA in supine position rigid bronchoscopy was done under vision the area was confirmed the stent Y-stent (L110-5–50) and adjusted to 90–30-15. Deployment of stent and adjustment of position under rigid and flexible bronchoscopy was done

Day 18

Tracheostomy tube insertion

General anesthesia, transferred to SICU with 7 mm regular tracheostomy

Patient called emergently to the OR because of desaturation and CO₂ retention. Fiberoptic showed very thick secretions up to right and left main and segmental bronchus and stent is patent. Tracheostomy done and patient transferred to SICU in stable condition

Day 31

Emergency Tracheostomy tube re-insertion

General anesthesia, transferred to SICU intubated

Under GA and supine position, intubation and suctioning of secretion was done. Bronchoscopy showed stent in place and patent tracheostomy tube paten, no available size 6 or 7 tracheostomy tube so decision was taken to abort procedure

Day 34

Rigid bronchoscopy and tracheostomy tube exchange

General anesthesia, transferred to SICU with adjusted 6 tracheostomy tube

Using boggey, an old tracheostomy tube removed and new one size 6 cuffed non-fenestrated inserted and visualized in place using fiberoptic

Day 35

Fiberoptic scope and tracheostomy tube exchange

Sedation anesthesia, transferred to SICU with adjusted 6 tracheostomy tube

While maintaining spontaneous ventilation, and in supine position, tracheostomy tube was removed, stent visualized by fiberoptic scope done and size 6 cuffed tracheostomy tube inserted inside the stent. A 2nd look was done by fiberoptic, airway patency was confirmed down to the carina

Day 45

Tracheostomy tube exchange

General anesthesia

Under GA and in supine position patient was intubated with 6.5 ET and tip placement confirmed by flexible bronchoscopy to be within the pre-existing tracheal stent. Injection of local lidocaine with epinephrine 1:10,000 in the previous tracheostomy site then we proceeded with widening of tracheostomy stoma blade for skin incision and subcutaneous dissection along with tracheal dilator. Cuffed ET was visualized from stoma and was pulled gradually then a tracheostomy tube SHILEY (size 6 non-cuffed non fenestrated) was inserted through tracheal stent and the correct desired positioning has been confirmed using flexible scope down to carina with no obstruction