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Ann Thorac Surg 2010;89:387-391. doi:10.1016/j.athoracsur.2009.10.044
© 2010 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Awake Upper Airway Surgery

Paolo Macchiarini, MD, PhDa,*, Irene Rovira, MD, PhDb, Sante Ferrarello, MDc

a Department of General Thoracic Surgery, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
b Department of Anesthesia, Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
c Department of Anesthesia, Azienda Ospedaliera Careggi, Firenze, Italy

Accepted for publication October 16, 2009.

* Address correspondence to Dr Macchiarini, Department of General Thoracic Surgery, Hospital Clinic, University of Barcelona, Villarroel 170, Barcelona, E-08036, Spain (Email: pmacchia{at}thoraxeuropea.eu).

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.

Background: The need to compromise between surgical and anesthetic access in airway surgery is an important clinical problem. We wanted to determine the feasibility of performing upper airway surgery under awake anesthesia and spontaneous respiration.

Methods: This was a prospective, clinical feasibility study. Patients with upper tracheal stenosis were managed through cervical epidural anesthesia and conscious sedation, and atomized local anesthetic. No intraoperative intubation or jet ventilation was required. Outcome measures were ease of surgery, observer-rated functional result, early (less than 30 days) complications, and patient-reported satisfaction.

Results: Twenty consecutive patients with idiopathic (n = 4) or postintubation (n = 16) complete (n = 3) or severe (>80%, n = 17) subglottic (n = 12) or upper trachea (n = 8) stenosis were enrolled. Operations included 12 subglottic and 8 segmental resections with primary anastomosis. Permissive hypercapnia was well tolerated. Median length of resection was 4.5 cm (range, 2 to 6 cm), and 12 releases (8 thyrohyoid, 4 suprahyoid) were required. One patient required a nasotracheal tube for 36 hours. All but 1 were able to cough and talk immediately, and to swallow fluids and solids, and were fully mobilized at 6 hours. There were no early complications. Median hospitalization was 3.1 days (range, 2 to 15). Patients had excellent (n = 16) or good (n = 4) functional (n = 20) outcomes, with no early relapse of stenosis. Median self-reported satisfaction at median 12 months was 9.5 ± 1.0 (scale, 0 to 10). All patients indicated that they would be happy to repeat the procedure.

Conclusions: Awake and tubeless upper airway surgery is feasible and safe, and has a high level of patient satisfaction. If supported by randomized controlled trial, this method will change the way airway stenosis surgery is approached by both surgeons and anesthesiologist.






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