Airway management and anesthesia for airway surgery: a narrative review

OBJECTIVE: To discuss and summarize the literature for airway and anesthetic management tools the anesthesiologist can use for airway surgery to both successfully manage the patient’s physiological needs and provide the surgeon the optimal surgical conditions with which to perform the surgery safely. BACKGROUND: The airway and anesthetic management of patients presenting for thoracic surgery poses the anesthesiologist with a unique set of challenges, but also a unique set of opportunities to artfully utilize and adapt a variety of management options that has developed over several decades of innovation. Sixty years ago, airway surgery was initially performed with the patient spontaneously breathing and providing anesthesia with halogenated agents and airway topicalization. As medicine entered the latter half of the twentieth century with its development of new airway devices and modern anesthetic agents, most airway surgeries could be safely performed under general anesthesia with secured airways. Today, with continued technological advancements in surgical techniques and an expanding population of challenging patients, the application of nonintubated anesthetic techniques and extracorporeal support is on the rise. METHODS: We conduct a narrative review of the literature on the history of airway and anesthetic management for thoracic surgery, the current management methods and evidence for each modality, and discuss future directions for the field. CONCLUSIONS: While the airway and anesthetic management for airway surgery is challenging, the anesthesiologist has a variety of options including cross-field ventilation, jet ventilation, nonintubated techniques, and extracorporeal support to safely care for the patient. Whichever methods are chosen for the patient and surgery, thoracic surgery remains uniquely positioned in its need for close sharing and collaboration of all airway and anesthetic management decisions between the anesthesiologist and the surgeon.