Preoperative and Perioperative Management in Patients with Previous Tracheostomy Scar

Essential Preoperative Evaluation

The American Society of Anesthesiologists recommends that patients with a previous tracheostomy scar should be considered as having a potentially difficult airway, requiring thorough preoperative evaluation of the upper airway, immediate availability of specialized equipment, and a clearly documented emergency management plan 1, 2
The patient's original laryngoscopy degree and any device or technique used successfully during the previous tracheostomy should be documented, as the original reason for the tracheostomy may have been a difficult or impossible-to-manage upper airway 3, 4
Most patients with a previous tracheostomy will have a potentially patent upper airway that could be used, but this should be confirmed preoperatively 3, 4

The following equipment should be available in the operating room before anesthesia induction: basic airway equipment, advanced airway equipment, capnography, fibrobronchoscope, tracheal dilators, and uncuffed endotracheal tubes of various sizes 4, 5, 6
Two separate oxygen sources should be available for simultaneous administration to the face and stoma if necessary 4, 6, 7

A written plan for emergency airway management should be communicated to all surgical staff, specifying who to call and how to avoid delays 3, 5, 8
The plan should include specific algorithms for managing a difficult airway in this particular patient 1, 2

The American Society of Anesthesiologists recommends orotracheal intubation under direct laryngoscopy as the safest technique, using an uncuffed endotracheal tube that is advanced beyond the site of the scarred stoma to avoid the defect in the anterior tracheal wall 7
This technique allows for the establishment of a definitive airway with confirmation via capnography, reducing the risk of creating a false passage 7

Continuous pulse oximetry should be used to evaluate response to interventions 4, 5, 6
Continuous capnography should be used to confirm adequate ventilation 4, 5, 6, 7
Close surveillance should be maintained for the development of subcutaneous emphysema, which indicates tube displacement or tracheal wall injury 8