Airway Management for Tracheal Resections – Comments on a Controversial Approach

I have read with great interest the article by Defosse et al. As the authors emphasized, the number of tracheal resections is relatively modest and diverse practices described in the literature lack guidance from large conclusive trials. Nevertheless, studies with a few cases can provide valuable information for clinicians. The new approach in the author's study was the retrograde surgical insertion of airway exchange catheters (AECs) for high-frequency jet ventilation (HFJV), which seems to be somewhat complicated and may be risky. AECs are intended for an endotracheal tube insertion or change and are not designed for intraoperative HFJV. Instead, commercially available HFJV catheters that are thinner than AECs and have an established safety record can be employed. HFJV catheters would certainly not obstruct the surgical view and do not require extra manipulation for the insertion. Some AECs are very rigid; the Cook Airway Exchange Catheter, Extra-Firm with Soft Tip, size 14F (Cook, Bloomington, IN) used by the authors is not the softest in the market. Retrograde insertion of these catheters resulted in the proximal catheter ends emerging from either through the laryngeal mask airway or in the mouth. This observation indicated that the retrograde insertion was blind, and the surgeon could not control where the catheters went. The authors did not report any catheter-related complications, but this finding may have been due to the small sample size. Blindly inserting a relatively rigid catheter into the pharynx may be associated with naso- or oropharyngeal injuries similar to a nasogastric tube.