ANESTHETIC MANAGEMENT OF A PATIENT WITH MYASTHENIA-GRAVIS AND TRACHEAL STENOSIS

Purpose: The combination of myasthenia gravis and tracheal obstruction presents a number of difficulties for anaesthetic management. This ca se illustrates the advantages of careful planning. Clinical features: A 66-yr-old man with myasthenia gravis required resection of a stenosi s at the site of an old tracheostomy. The primary goal was to accompli sh safe management of the airway, a task made more difficult because t he airway was shared with the surgeon. Awake fibreoptic examination of the tracheal stenosis performed in the operating room provided useful information in planning the subsequent anaesthetic. From this examina tion, it was found that the trachea could be intubated by a normal end otracheal tube passed through the stenosis over the fibreoptic broncho scope. Intraoperatively, the orotracheal tube was withdrawn temporaril y and replaced with an endotracheal tube placed by the surgeon into th e distal trachea. Extubation was carried out judiciously and a plan fo r reintubation prepared in advance. The anaesthetic plan was modified because of the myasthenia gravis. Following careful investigation of t he extent of the patient's disease and its treatment, an assessment wa s made of the patient's need for postoperative ventilation. The anaest hetic plan included maintenance of anticholinergic medications until t he time of surgery and their early resumption postoperatively, avoidan ce of neuromuscular blocking agents, and careful monitoring of neuromu scular function during the anaesthetic. Conclusion: Careful examinatio n of the area of tracheal stenosis and a carefully considered plan for reintubation are prerequisites for this type of surgery. Clinically w ell controlled myasthenia gravis was managed successfully using famili ar principles.