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Anaesthesia for Bronchoscopy & Laser Airway Surgery

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ivy lam

on 17 July 2014

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Transcript of Anaesthesia for Bronchoscopy & Laser Airway Surgery

Anaesthesia for Bronchoscopy & Laser Airway Surgery
Prologue
Laser is an acronym for
Light Amplification by Stimulated Emission of Radiation
.
In simpler language, lasers are devices that produce light that gets transformed into heat upon interacting with living tissue.
Anaesthetic Management of LASER airway surgery
Stimulation of surgery
Difficult intubation
Airway competition
Potential loss of airway
Positioning
Emergence timing issues
Perioperative Evaluation
High-frequency jet ventilation (HFJV)
Advantages of Laser
Precise lesion targeting
Minimal bleeding
Minimal edema/tissue reaction
Preservation of surrounding structures and normal tissues
Rapid healing/less postop pain
Laser Applications
Laparoscopy
Endoscopy
Thoracic surgery
Ophthalmology
Gynecology
Plastic surgery
Urology
Neurosurgery
ENT
LASER ENT Surgery
Laryngeal or vocal cord papillomas
Laryngeal webs
Redundant subglottic tissues
Debulking of tumors
What are the special consideration for LASER surgery?
surgical procedure
Patient’s pre-existing conditions
Hazards of laser surgery to the patient, OR personnel and equipment
risk of airway fire
protective equipment for OR personnel
Endotracheal Intubation
Advantages

secured airway
ability to monitor ETCO2 and O2 concentration
decreased risk of soiling the distal airway with debris, blood, or gastric contents.
Disadvantages

risk of an ETT fire
high resistance with spontaneous ventilation
difficulty in suction

1)Ventilating bronchoscope
2)Jet ventilation

Advantages
Surgical convenience
No risk of ETT fire

Disadvantages
Unable to monitor pCO2
Contamination of lower resp. tract
Bronchoscopic surgery
What is LASER and its application
Anaesthetic considerations
Anaesthetic management in LASER airway surgery
Safety protocol
Airway Surgery Issues
It can be delivered via
supraglottic route
transtracheal route
subglottic route
This is delivered via a narrow cannula attached to a
suspension laryngoscope
, a longer catheter placed sub-glottically or via a crico-thyroid cannula. Instead of a hand-held switch, the onset and offset of inspiration are controlled by a
high-frequency flow interrupter
(which may be pneumatically or electronically controlled). Air is still entrained, although generated tidal volumes are much smaller than those used in conventional ventilation. Parameters that may be altered include inspired oxygen concentration, driving pressure of gas, frequency of ventilation (usually 60–600 breaths min−1), and inspiratory time (usually 30% of the cycle
Low-frequency jet ventilation (LFJV)
This is frequently delivered using a
high-pressure gas
source via a narrow cannula attached to a suspension laryngoscope or bronchoscope. Gas is delivered by operation of a hand-operated switch at a rate of 10–20 breaths/min. This stream of high-velocity gas entrains air, increasing the tidal volume generated and diminishing the oxygen concentration of the inspired gas.
Advantages
allows the operating field to be immobile for short periods.
LFJV is easy to perform, requiring uncomplicated anaesthetic equipment.
It produces an unobstructed view of the operative field.
Disadvantages
risk of barotrauma with use of a high-pressure gas system, especially if the jet is below the larynx. Therefore, the upper airway must remain patent.
Adequacy of ventilation is difficult to assess owing to the lack of end-tidal CO2 monitoring.
Inhalational anaesthesia may not be delivered via LFJV, so total intravenous anaesthesia (TIVA) is required.
movement of the operative field and gastric insufflation if the suspension laryngoscope is poorly aligned.
Intermittent, positive-pressure ventilation

This is usually delivered using a micro-laryngoscopy tube (MLT). This allows the use of standard anaesthetic equipment in normal operating mode. However, there is often reduced access to the surgical field and the tracheal tube obscures the posterior one-third of the glottis. The operative field is relatively mobile, moving with respiration.
Hazards of Laser
Eyes are vulnerable to misdirected beam
Fire hazard (up to 0.4%)
Damage by reflection of light by tube, instruments
Laser smoke may damage lungs
Hypoxic mixture of inhaled gases
Vaporization of cancers may aerosolize carcinogens (plume, fine particles)

Commonly used medical LASER
"The advantages of the laser compared to electrical surgery are a smaller postoperative oedema and less pain, as well as good spontaneous epithelialisation of defects"
Laryngol Rhinol Otol (Stuttg). 1988 Jun;67(6):261-8.
[Laser surgery in ENT surgery].
Anaesthesia for microlaryngeal and laser laryngeal surgery:
impact of subglottic jet ventilation
.
Results: In all the 332 patients observed, surgical access was optimised and no adverse anaesthetic outcomes were encountered.
J Laryngol Otol. 2010 Jun;124(6):641-5
Barakate M1, Maver E, Wotherspoon G, Havas T.
Without Endotracheal Intubation
Types of ETT
Modes of LASER surgery
LASER airway surgery with jet ventilation
This might happen during a LASER airway surgery..
The ETT may be caught on fire!
"The increasing use of laser therapy, particularly in ear, nose and throat surgery, and in oral surgery, has brought about a renewed awareness of the risk of fire"
A. G. MACDONALD, MB, FRCA, (GLASG) BJA Volume 73, Issue 6Pp. 847-856
References
http://ceaccp.oxfordjournals.org/content/6/1/28.full
http://www.apsf.org/newsletters/html/1993/summer/
British Journal of Anaesthesa
AnaesthesiaUK.com
Oxford Handbook of Anaesthesia
Anesthetic management of laser airway surgery
ALWAYS BE SAFE!
Intermittent Apnea Technique
Intermittent apnoea without endotracheal intubation. The patients are ventilated with 100% oxygen and the period of intermittent apnea will be guided by pulse oximetry and end tidal carbon dioxide monitoring
This has the disadvantages of poor airway protection and poor control of depth of anaesthesia but the advantage of an unobstructed surgical view.
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