Tracheal Resection and Reconstruction

The problem being fixed

Tracheal resection with primary anastomosis is performed for a narrowed or diseased segment of trachea. The commonest indications are:

• Post-intubation and post-tracheostomy stenosis — the largest group, caused by cuff pressure exceeding mucosal capillary perfusion, leading to ischaemic ulceration, cartilage damage and circumferential scar. Often presents weeks to months after decannulation, and is frequently misdiagnosed as asthma before someone listens for stridor.
• Primary tracheal tumours — squamous cell carcinoma and adenoid cystic carcinoma predominantly.
• Idiopathic subglottic stenosis, characteristically in women in middle life.
• Tracheo-oesophageal fistula and post-traumatic disruption.

Airflow limitation in a fixed upper airway narrowing is not reversible and does not respond to bronchodilators. The flow–volume loop shows flattening of both limbs, and symptoms typically begin when the lumen is reduced by about half, becoming severe below roughly 5–6 mm.

What the operation involves

The diseased segment is excised and the healthy ends anastomosed directly, usually through a low collar incision, sometimes with partial upper sternotomy for distal lesions. Where the cricoid is involved, a cricotracheal or laryngotracheal resection is performed with the anastomosis close to the vocal cords.

The limiting factor is length. Approximately half the trachea can be resected in a favourable patient using release manoeuvres — cervical flexion, suprahyoid or laryngeal release, and hilar mobilisation — but tension at the anastomosis is the principal determinant of whether it heals or fails. Every element of post-operative care follows from that single fact.¹

The neck restriction — what to know before you see the patient

Anastomotic complications

The large single-centre series that defines expectations reported anastomotic complications in a minority of patients, with identified risk factors including reoperation, resection length over 4 cm, laryngotracheal resection, diabetes and pre-operative tracheostomy; complications ranged from granulation tissue and restenosis to separation.² Recurrent laryngeal nerve injury and post-operative dysphagia are also recognised, particularly with high resections and laryngeal release.

Clinical warning signs of a failing anastomosis are new or returning stridor, worsening voice change, subcutaneous emphysema and rising work of breathing. Any of these warrant immediate surgical review rather than intensified physiotherapy.

Physiotherapy after tracheal resection

The aims are conventional — a clear airway, adequate volumes, early mobility — but several standard techniques are either modified or contraindicated. Treat this as a page where the caveats matter more than the interventions.

What to do

• Humidification is the primary intervention. A fresh anastomosis with impaired mucociliary clearance and an oedematous mucosa dries and crusts easily, and crusting at the suture line can obstruct a narrowed lumen. Systemic hydration and heated humidification do more here than any manual technique.
• Position with the neck in slight flexion, supported on pillows. Upright sitting is encouraged; the restriction is on head and neck position, not on being out of bed.
• Mobilise early. These patients are frequently fit and the operation is on the neck, so walking should start promptly.
• Breathing control, sustained maximal inspiration and gentle huffing in preference to repeated forceful coughing.
• Watch and hand over the voice and the swallow. Involve speech pathology early; dysphonia and aspiration are common after high resections and are easily attributed to normal post-operative soreness.

What to modify or avoid

• Avoid neck extension in any form — positioning, transfers, and especially any airway manoeuvre.
• Avoid vigorous, repeated maximal coughing. Effective clearance with a controlled huff is preferable to raising airway pressure and straining a tensioned join.
• Do not perform blind nasopharyngeal or tracheal suction without explicit surgical agreement; a catheter can traumatise the suture line. If suction is unavoidable it should be under direct vision by the surgical team.
• Mechanical insufflation–exsufflation and vigorous positive pressure are not routine after fresh anastomosis, and should be used only on explicit surgical instruction.

Role of the physiotherapist

Establish the neck restriction and its duration before touching the patient, and make sure it is visible to everyone at the bedside. Then treat with humidification, gentle clearance and early mobilisation rather than force — the airway you are trying to keep clear is also a healing suture line under tension. Recognise the failing anastomosis early, escalate rather than treat, and keep speech pathology involved for the voice and swallow that this operation quietly threatens.

References & evidence base

1. Grillo HC, Donahue DM, Mathisen DJ, Wain JC, Wright CD. Postintubation tracheal stenosis. Treatment and results. J Thorac Cardiovasc Surg 1995;109(3):486–492.
2. Wright CD, Grillo HC, Wain JC, et al. Anastomotic complications after tracheal resection: prognostic factors and management. J Thorac Cardiovasc Surg 2004;128(5):731–739.
3. Bibas BJ, Terra RM, Oliveira Junior AL, et al. Predictors for postoperative complications after tracheal resection. Ann Thorac Surg 2014;98(1):277–282.
4. Nseir S, Duguet A, Copin MC, et al. Continuous control of endotracheal cuff pressure and tracheal wall damage: a randomized controlled animal study. Crit Care 2007;11(5):R109.
5. Frerk C, Mitchell VS, McNarry AF, et al; Difficult Airway Society. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth 2015;115(6):827–848.

References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.