|Year : 2014 | Volume
| Issue : 3 | Page : 356-361
Neostigmine/rocuronium versus TIVA for tracheal stenting and dilatation
John N Bestarous, Ashraf A Abou Slemah
Department of Anesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
|Date of Web Publication||27-Aug-2014|
John N Bestarous
Square 1224, Building 2, Apartment 102, Flat 1, Sheraton Heliopolis Buildings, Postal code 11351
Source of Support: None, Conflict of Interest: None
Usage of airway stents in cases with tracheobronchial stenoses or obstruction has evolved rapidly. General anaesthesia has become less hazardous, particularly with recent developments in total intravenous anaesthetic agents and nondepolarizing neuromuscular blocking drugs. This study aimed at comparing the effectiveness of neostigmine/rocuronium technique to TIVA technique for tracheal stenting and dilatation.
Patients and methods
This prospective study was carried out on 80 patients scheduled for tracheal dilatation and stenting. Cases were randomly categorized into two equal groups. Group I (TIVA) received fentanyl and propofol with bilateral superior laryngeal nerve block. Group II (muscle relaxant) received rocuronium and sevoflurane 2% in 100% O 2 . Heart rate, mean arterial pressure and oxygen saturation were assessed, and PaCO 2 readings were taken through arterial blood gases at regular intervals intraoperatively. Recovery profile, perioperative complications and patient and doctor satisfaction were recorded in both groups.
Both techniques offered haemodynamic stability. PaCO 2 readings were significantly higher (P < 0.001) in group II. Earlier recovery was recorded in group I (P < 0.001). Incidence of complications was generally higher in group II (P > 0.05), except hypotension (higher in group I; P < 0.05). Patient and doctor satisfaction were comparable (P > 0.05).
Both the TIVA and neostigmine/rocuronium techniques were used successfully. The TIVA technique had the advantages of earlier recovery, less hypercapnia, desaturation, distal total obstruction and stridor on recovery, whereas the muscle relaxant technique offered less hypotension and hemoptysis. Thus, we strongly recommend the TIVA technique for such operations.
Keywords: neostigmine, rocuronium, total intravenous anaesthesia, tracheal stenting
|How to cite this article:|
Bestarous JN, Abou Slemah AA. Neostigmine/rocuronium versus TIVA for tracheal stenting and dilatation. Ain-Shams J Anaesthesiol 2014;7:356-61
|How to cite this URL:|
Bestarous JN, Abou Slemah AA. Neostigmine/rocuronium versus TIVA for tracheal stenting and dilatation. Ain-Shams J Anaesthesiol [serial online] 2014 [cited 2019 May 23];7:356-61. Available from: http://www.asja.eg.net/text.asp?2014/7/3/356/139566
| Introduction|| |
During the last decade, airway stents suitable for the management of tracheobronchial stenoses and obstruction have evolved rapidly.
Stents are used for both benign (webs, granulation tissue as tracheal tube, foreign body and lymphadenopathy) and malignant diseases, such as metastatic carcinoma and mediastinal tumours, for intrinsic airway lesions, extrinsic compression and tracheomalacia. However, palliating respiratory symptoms of malignant disease remains the most common indication for the use of airway stents. General anaesthesia is usually required for stent placement, and patients with stents in situ may be anaesthetized for unrelated procedures too .
Modern stents are self-expanding and made of metal (nitinol) in a mesh structure that are either uncovered or covered with polyurethane. An uncovered mesh will become epithelialized to some extent where it is in contact with the tracheobronchial mucosa, and the stent may be occluded with tumour growth through the mesh leading to airway reobstruction. Silicone stents are also available. They are easier to remove and generally indicated in benign diseases. They are predisposed to migration and have a smaller internal diameter than a similarly sized metal stent .
General anaesthesia has become less hazardous and notably simplified by developments in pharmacology, particularly in total intravenous anaesthetic agents and nondepolarizing neuromuscular blocking drugs .
The aim of this study was to compare the effectiveness of the neostigmine/rocuronium technique to the TIVA technique for tracheal stenting and dilatation.
| Patients and methods|| |
After ethical committee approval and obtaining an informed written consent from all patients, this prospective randomized controlled study was carried out in Ain-Shams University Hospitals on 80 patients of both sexes, with their ages ranging from 30 to 65 years of ASA II-III, with average body weight between 60-80 kg, with tracheostomy who were scheduled for dilatation and stenting of the upper trachea owing to previous tracheal stenosis, usually from previous prolonged intubation.
Severe chest infection, coagulation disorders, psychiatric, apprehensive or uncooperative patients, and severe spine and chest deformity were the exclusion criteria from the study.
Preoperative investigations were carried out in the form of complete blood picture, coagulation profile, metabolic profile, ECG, beyond chest radiographs and computed tomographic scans, and other radiologic techniques, which could give very good representations of the pathologic anatomy.
After insertion of intravenous line, all patients of both groups were intravenously premedicated with atropine (0.5 mg), midazolam (0.01 mg/kg) with 10 mg metaclopramide and 150 mg ranitidine 15 min before the start of the intended anaesthetic technique. In the operating room, basic monitors were applied to the patients (ECG, pulse oximeter, non-invasive blood pressure (NIBP)). An arterial cannula in the right radial artery was applied to all patients for serial arterial blood gases sampling. All of them received 100% oxygen through the tracheostomy tube till application of the rigid bronchoscope and removal of the tracheostomy tube.
The selected cases were randomly categorized (by closed envelops) into two groups, with 20 patients in each group.
Group I received fentanyl+propofol with bilateral superior laryngeal nerve block.
Group II received rocuronium+sevoflurane 2% in 100% O 2 .
In group I, the superior laryngeal nerve was blocked bilaterally with 10 ml of xylocaine 2%, with additional 5 ml in the tracheostomy tube. Anaesthesia was induced with 100 µg fentanyl intravenously and 1 mg/kg of propofol intravenously followed by propofol infusion at a rate of 25-50 mcg/kg/min, with additional incremental doses of 20 mg if required to maintain normal pulse rate and blood pressure. The patients were spontaneously breathing.
In group II, anaesthesia was intravenously induced with 100 µg fentanyl, propofol (1 mg/kg) and rocuronium in a rapid intubating dose (0.6-1.2 mg/kg). Ventilation was carried out initially manually through a bag (Bain circuit) through the tracheostomy tube in the presence of 3% sevoflurane in 100% O 2 , and then anaesthesia was maintained with 2% sevoflurane in 100% O 2 through the side port of the bronchoscope with controlled mechanical ventilation. Maintenance doses of rocuronium (10 mg/30 min) were administered to maintain muscle relaxation. Once the patient had relaxed, a rigid bronchoscope was inserted. High-frequency positive pressure ventilation, driven by 100% oxygen, was attached to the ventilation port of the bronchoscope.
The airway had been secured and maintained, and the tracheostomy tube was removed.
From the time of admission till the end of surgical procedure, the following were assessed: heart rate (HR) in beats/min, ECG lead II monitoring was recorded, mean arterial pressure (MAP) in mmHg and oxygen saturation (SpO 2 ) in %. These variables were assessed before the insertion of the bronchoscope and then every 5 min till the end of the procedure. A series of readings of PaCO 2 was taken through arterial blood gases every 10 min throughout the procedure. In group II, a nerve stimulator was applied to maintain full muscle relaxation.
Assessment and recording of possible intraoperative complications such as hypotension, bradycardia, desaturation, and distal total obstruction were carried out and promptly corrected. Hypotension was corrected with intravenous fluids and/or ephedrine (5 mg in increments). Bradycardia was corrected with atropine (0.4-0.6 mg). Distal total obstruction was surgically treated with electro-cautery, laser or cryo-ablation with continuous suction.
On recovery, group I patients were assisted with a bag and mask after removal of the bronchoscope till they became fully conscious, and in group II patients sevoflurane was stopped, neostigmine was administered to antagonize the muscle relaxation (0.05 mg/kg) and ventilation was just assisted till full recovery. Recovery profile - time to eye opening, obeying commands, and reaching Aldrete score of 9  - was recorded in both the groups to detect delayed recovery. Any other complications, such as hypotension, bradycardia, desaturation, hemoptysis and stridor, on recovery were checked and recorded too. The surgeon remained present, and the rigid bronchoscope was still available until recovery was deemed satisfactory.
Operative time and patient and doctor satisfaction in both techniques were recorded.
Postoperatively, the patients were transferred to the ICU to be kept under observation; any signs of respiratory obstruction would be detected and treated immediately by endotracheal intubation and vigorous airway suction. For hemoptysis, fibreoptic bronchoscopy was indicated.
The required sample size was calculated using the G*Power© software version 3.1.0 (Institut für Experimentelle Psychologie, Heinrich Heine Universität, Düsseldorf, Germany). The primary outcome measure was the difference between the two study groups with regard to end-tidal carbon dioxide tension. It was estimated that a sample size of 40 patients in each study group would achieve a power of 82% to detect an effect size (d) of 0.65 using a two-sided t-test at a significance level of 0.05.
Statistical analysis was performed on a personal computer using MedCalc© version 12.5 (MedCalc© Software, Ostend, Belgium). Normality of numerical data distribution was tested using the D'Agostino-Pearson test. Normally distributed numerical data were presented as mean and SD, and intergroup differences were compared using the independent samples Student t-test. Non-normally distributed numerical data were presented as median and interquartile range, and intergroup differences were compared nonparametrically using the Mann-Whitney U-test. Categorical data were presented as number and percentage, and differences between the two groups were compared using the Pearson χ2 -test.
All P-values are two sided. P-value of 0.05 or less is considered statistically significant.
| Results|| |
In the present study, there were statistically insignificant differences (P > 0.05) between the two groups regarding age (years), sex, BMI (kg/m 2 ), ASA status II/III and operative time (min) [Table 1].
SpO 2 was maintained between 95 and 100% during the whole procedure in all patients without reported cases with respiratory depression, apnoea or progressive desaturation intraoperatively ([Figure 1], [Table 2]).
|Figure 1: Changes in arterial oxygen saturation in both groups. Markers represent mean. Error bars represent SEM. P ≤ 0.05 considered statistically signifi cant; at 10 min (T4), P-value was 0.004; at 20 min (T6), P-value was 0.018; at 30 min (T8), P-value was 0.023; at 65 min (T15), P-value was 0.010; and at 70 min (T16), P-value was 0.002. P ≤ 0.001 was considered highly statistically signifi cant; baseline, P < 0.001; at induction, P < 0.001; and at 35 min (T9), P-value was 0.00 1.|
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Regarding MAP, there were statistically insignificant differences (P > 0.05) between the baseline and induction values of MAP in both groups. There was a statistically significant increase in MAP in group II in comparison with group I at 15, 20, 25 and 35 min (P < 0.05), and 40 min (P < 0.001) after induction [Figure 2].
|Figure 2: Changes in mean arterial pressure in both groups. Markers represent mean. Error bars represent SEM. P ≤ 0.05 was considered statistically signifi cant. At 15 min (T5), P-value was 0.027; at 20 min (T6), P-value was 0.045, at 25 min (T7), P-value was 0.047; and at 35 min (T9), P-value was 0.007. P ≤ 0.001 was considered highly statistically signifi cant; at 40 min (T10), P-value was <0.0 01.|
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In this study, there were statistically insignificant differences (P > 0.05) between the two groups regarding the baseline and induction HR. There was a significant increase in HR in group II in comparison with group I at 45 min (P < 0.05) and 80 min (P = 0.001) after induction [Figure 3].
|Figure 3: Changes in heart rate in both groups. Markers represent mean. Error bars represent SEM. P ≤ 0.05 was considered statistically signifi cant; at 45 min (T11), P-value was 0.034. P ≤ 0.001 was considered highly statistically signifi cant; at 80 min (T18), P-value was 0. 001.|
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In this study, there were highly statistically significant differences (P < 0.001) in arterial carbon dioxide tension in group II compared with group I, starting from 10 min postinduction. The arterial carbon dioxide tension had risen to higher levels in group II, whereas it remained low in group I [Table 3].
In the present study, there were highly statistically significant differences (P < 0.001) between both groups regarding recovery criteria in the form of time to eye opening, obeying commands and reaching Aldrete score of 9. All times were longer in group II than group I [Table 4].
Regarding perioperative complications, the incidence of hypotension was significantly higher (P < 0.05) in group I. There were no significant differences (P > 0.05) in the incidence of other complications in both groups. The incidence of bradycardia, desaturation, distal total obstruction and stridor on recovery was still higher in group II, whereas the incidence of hemoptysis was higher in group I. Patient and doctor satisfaction scores were comparable between both the groups (P > 0.05) [Table 5].
|Table 5 Perioperative complications, and patient and doctor satisfaction|
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| Discussion|| |
The purpose of airway stenting is to relieve airway obstruction caused by strictures not suitable for resection and reconstruction .
In the present study, both anaesthetic techniques offered haemodynamic stability; however, there was a tendency towards hypotension in group I (TIVA); the number of patients with hypotension was 25 (62.5%) of 40 in group I (TIVA), whereas the number of patients was 15 (37.5%) of 40 in group II (muscle relaxant) (P < 0.05), which can be explained by the side effect of severe hypotension of propofol in addition to the vasovagal effect of rigid bronchoscopy.
In this study, PaCO 2 readings were significantly higher (P < 0.001) in group II compared with group I, starting 10 min after induction. PaCO 2 had risen to higher levels in group II, whereas it remained low in group I, indicating a problem of hypercarbia with group II (muscle relaxant). Uncorrected hypercarbia can lead to delayed recovery, disturbed consciousness and cardiac arrhythmias.
Nethercott et al.  stated that if rigid bronchoscopy is favoured, then intravenous induction in addition to a neuromuscular blocking agent provide the best operating conditions, as coughing and movement cause problems for the surgeon and can result in total airway obstruction. However, intravenous induction can precipitate total airway obstruction in patients with compromised upper airway (it can intubate but cannot ventilate scenario) and can interfere with the safety of the patient.
Inhalation induction with continuous assessment of ventilation provides the safest and most recommended method for patients with compromised upper airway ; however, it is not suitable if there is central airway obstruction (tracheal stenosis), which mimics the 'can't intubate-can't ventilate' scenario . Conacher et al.  concluded that, in the 'can't intubate-can't ventilate' scenario, instillation of local anaesthetics for securing airway and inhalational induction are usually contraindicated, as with either of the two, the risk of precipitating a life-threatening coughing fit remains very high. However, with the introduction of sevoflurane into clinical practice, this advice could be qualified [8,9].
In this study, the recovery profile - time to eye opening, obeying commands and reaching Aldrete score of 9 - was better in group I (TIVA) than group II (muscle relaxant), indicating generally delayed recovery in muscle relaxant group; all times were longer in this group (P < 0.001). This can be explained by the encountered progressive hypercapnia that may be a result of accidental airway obstruction and subsequently impaired ventilation in the muscle relaxant group.
The central airway may become completely obstructed intraoperatively or during the early recovery period by new sputum or blood clots, and the release of old sputum from the obstructed airway is commonly the cause. In recovery, this obstruction can mimic partial reversal of neuromuscular block. This necessitates reintubation with the rigid bronchoscope and vigorous airway suction, as worsening hypoxia and hypercarbia can eventually lead to cardiovascular collapse . We ensured complete reversal of neuromuscular block in our study with the use of a nerve stimulator in group II (muscle relaxant).
In this study, the incidence of perioperative complications (apart from hypotension) was comparable in both groups (P > 0.05); however, the incidence of desaturation, distal total obstruction and stridor on recovery was still higher in the muscle relaxant group, and the incidence of hemoptysis was higher in the TIVA group. Patient and doctor satisfaction scores were comparable between both groups (P > 0.05) too.
Some authors believe that the only surest way to guarantee an unobstructed airway and ventilation is to use rigid bronchoscopy with controlled jet ventilation under total intravenous anaesthesia in patients having tenuous airway or tracheal stenosis [7,11].
For tracheal dilatation and stenting with rigid bronchoscopy, the patient can be spontaneously breathing with a volatile anaesthetic or given neuromuscular blocking agents and ventilated with various modes of positive pressure ventilation, including manual ventilation, jet ventilation and high-frequency ventilation applied through various conduits [12-15], and even cardiopulmonary bypass [14, 16, 17].
We did not monitor bispectral index to check the risk of awareness with the TIVA technique in such procedures  that remains high owing to high variability in the patients' response to drugs, and a shared airway and a highly stimulating intervention in a frail (ASA II-III) patient. This may limit our study.
| Conclusion|| |
Both the TIVA and muscle relaxant (neostigmine/rocuronium) techniques were effective for anaesthetic management of tracheal stenting and dilatation with rigid bronchoscopy. Patient and doctor satisfaction were comparable in both groups. However, the TIVA technique had the advantages of earlier recovery, less hypercapnia and lower incidence of desaturation, distal total obstruction and stridor on recovery, whereas the muscle relaxant technique offered less hypotension and lower incidence of hemoptysis. Hence, the use of either technique is a matter of anaesthetist experience, facilities, and depends on contraindications of each technique too.
| Acknowledgements|| |
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]