Total intravenous anaesthesia in tight airway

Soorya kanth M*, S. Nirmal Kumar, Khaja Mohideen, Reshma

Department of Anesthesiology, Kauvery Hospital, Cantonment, Trichy

Background

Severe subglottic tracheal stenosis carries a significant risk of ventilation failure. Total Intravenous Anaesthesia (TIVA) with spontaneous ventilation provides a safer alternative by maintaining spontaneous breathing, minimizing anaesthetic exposure, avoiding positive-pressure ventilation, and reducing postoperative complications, particularly during tracheal balloon dilatation.

Case Presentation

A 67-year-old male with diabetes, hypertension, coronary artery disease (post-stenting), and stage 3 chronic kidney disease presented with dyspnoea, orthopnoea, and anasarca. He had a recent history of ventilator support for acute pulmonary oedema. On admission, he was stable (PR 84/min, BP 110/80 mmHg, SpO₂ 99% RA) but had severe anaemia, treated with blood transfusion. Echocardiogram showed CAD with mild LV dysfunction (EF 45%). He later developed breathlessness with bilateral crepitations and required NIV, IV diuretics, and steroids.

CT chest plain done revealed – Intraluminal focal lesion in distal trachea just proximal to bifurcation, focal tracheal narrowing in proximal trachea measuring 12mm in AP diameter & transverse diameter-9mm at D2 level and pneumonitis of right lower lobe as shown in the Figure-1

Fig (1): CT Imaging Showing Narrowing With 3D Reconstruction

Pulmonologist and ENT surgeon opinions were sorted and patient was planned for tracheal dilatation & stenosis release using coblation assisted balloon dilatation + serial rigid bronchoscopy. On Pre-operative assessment, patient was conscious, oriented, with vitals-PR-82bpm, BP-110/70mmhg, SPO2-77%-80% on RA;99% with 15L on NRBM, with bilateral wheeze. Airway assessment showed adequate neck extension, MPG class III with mouth opening more than 3finher breath and partially edentulous.

After adequate optimisation in pre-op area, pre-induction assessment done with vitals of PR-86bpm; BP-110/70mmhg; Spo2-99% with 6Lo2; patient was then given with anxiolytic dose of Inj. Midazolam 0.05mg/kg IV, Inj.Glycopyrolate 0.01mg/kg IV. Patient was then shifted to OT, ASA standard monitors were connected, induction done with Inj.Fentanyl 2mcg/kg IV; Inj.Propofol 2mg/kg IV, pre-oxygenation done for 3 minutes with 6L O2, and Laryngeal Mask Airway was introduced and patient was kept in spontaneous breathing with 100% Fio2 as shown in figure-2. Propofol infusion was initiated with iTIVA simulation software [1] shown in figure 3, guided by Eleveld [2.1] model, targeting plasma concentration of 3mcg/ml.

Fig (2): LMA with spontaneous ventilation with graphical representation

Fig (3): iTIVA simulationof TCI achieving plasma concentration

To suppress airway reflexes, a transtracheal block with 2% lidocaine was given. Balloon dilatation was initially performed under flexible bronchoscopy, after which the LMA was removed and direct laryngoscopy introduced for coblation. Propofol infusion was increased to 4 mcg/ml, and spontaneous inspiration was supported with jet ventilation (FiO₂ 100%). The stenosed trachea (≈4 mm) was incised at 9, 12, and 3 o’clock positions with electrocautery, followed by serial balloon dilatation (sizes 6–8) and coblation of residual granulation tissue. Further dilatation was achieved with rigid bronchoscopes (sizes 10–12), expanding the lumen to 12 mm. Throughout the procedure, spontaneous ventilation was preserved.

Fig (4): Pre procedural and post procedural image of tracheal stenosis dilatation

At the end of the procedure, propofol infusion was tapered to 1 mcg/ml, allowing smooth awakening with return of airway reflexes. Hemodynamic and respiratory parameters remained stable throughout. Dexamethasone 8 mg IV and Hydrocortisone 100 mg IV were given for airway inflammation, and all infusions were stopped at surgery completion.

The patient recovered uneventfully with stable vitals and adequate oxygenation on NRBM (10 L/min). Close monitoring for respiratory compromise was continued, and he was hemodynamically stable on transfer from the recovery area.

Discussion

Severe subglottic tracheal stenosis poses significant challenges in both diagnosis and anaesthetic management. The condition often develops secondary to prolonged intubation, high endotracheal tube cuff pressures, trauma, postoperative complications, or chronic airway inflammation. Among these, excessive cuff pressure during ICU ventilation is a major contributor, underscoring the importance of vigilant cuff pressure monitoring and timely tracheostomy to reduce incidence.

Diagnosis requires careful clinical evaluation, with advanced imaging techniques such as CT scan and direct airway visualization through bronchoscopy playing a crucial role. Patho-physiologically, chronic inflammation results in fibrosis and progressive narrowing, often with tracheal wall collapse, which complicates ventilation and airway instrumentation during surgical procedures.

Anaesthetic considerations in severe stenosis are complex. Propofol infusion guided by pharmacokinetic models (e.g., iTIVA) allows precise titration of anaesthesia, minimizing sedation-related apnoea. Since positive-pressure ventilation carries significant risk—where even minimal secretions may precipitate complete obstruction—maintenance of spontaneous ventilation is preferred. Thus, preparation with emergency airway devices such as cricothyrotomy kits, micro-laryngeal tubes, and rigid bronchoscopes is essential.

Total Intravenous Anaesthesia (TIVA) offers several advantages in tracheal surgery. It ensures reliable anaesthesia delivery when inhalational agents are impractical due to circuit leaks or distorted airway anatomy. TIVA avoids operating room pollution, eliminates the risk of malignant hyperthermia, and maintains hemodynamic stability. Additionally, it provides smoother emergence with reduced incidence of coughing, laryngospasm, agitation, and postoperative nausea or vomiting—benefits particularly relevant to airway and day-care procedures.

Conclusion

Anaesthetic management of severe subglottic stenosis poses significant challenges, primarily due to the need to preserve respiratory stability. This case illustrates the effectiveness of Total Intravenous Anaesthesia (TIVA) with spontaneous ventilation, facilitated by pharmacokinetic-guided propofol infusion. Close monitoring is crucial to avoid oversedation and apnoea. Successful outcomes rely on multidisciplinary planning and individualized anaesthetic strategies, which remain central to the safe management of complex airway pathology

References

  • Solache-May JE, Ayuso-Diaz VM, Magos-Gamboa V, Ayuso-Diaz ME, Moreno-Enriquez A. Anesthesia With Conscious Sedation for Balloon Dilatation in the Setting of Severe Subglottic Tracheal Stenosis: A Case Report. Cureus. 2025 Feb 22;
  • Zias N, Chroneou A, Tabba MK, Gonzalez AV, Gray AW, Lamb CR, et al. Post tracheostomy and post intubation tracheal stenosis: Report of 31 cases and review of the literature. BMC Pulmonary Medicine [Internet]. 2008 Sep 21 [cited 2019 Apr 22];8(1). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2556644/
  • Shah SB, Chawla R, Gupta M. Target-controlled infusion: A comparative, prospective, observational study of the conventional TCI pump and the novel smartphone-based application iTIVA. Journal of Anaesthesiology Clinical Pharmacology [Internet]. 2023 Dec 12 [cited 2025 Jul 25];40(1):114–9. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC11042112/
  • Schraag S, Pradelli L, Alsaleh AJO, Bellone M, Ghetti G, Chung TL, et al. Propofol vs. inhalational agents to maintain general anaesthesia in ambulatory and in-patient surgery: a systematic review and meta-analysis. BMC Anesthesiology [Internet]. 2018 Nov 8 [cited 2019 Aug 19];18(1). Available from: https://bmcanesthesiol.biomedcentral.com/articles/10.1186/s12871-018-0632-3
  • Engbers FH, Sutcliffe N, Kenny G, Schraag S. Pharmacokinetic models for propofol: defining and illuminating the devil in the detail. British Journal of Anaesthesia. 2010 Feb;104(2):261–4.
  • Mi Jin Yoo, Joffe AM, Meyer TK. Tubeless Total Intravenous Anesthesia Spontaneous Ventilation for Adult Suspension Microlaryngoscopy. Annals of Otology, Rhinology & Laryngology. 2017 Nov 24;127(1):39–45.

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