Anesthetic and Airway Management of Microlaryngeal Surgery and Upper Airway Endoscopy

Nekhendzy, Vladimir; Kristensen, Michael Seltz; Claure, Rebecca E.

doi:10.1016/b978-1-4377-2764-7.00038-5

Cited by 4 publications

(9 citation statements)

References 271 publications

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“…Nekhendzy et al have stated that precision surgery is difficult or impossible using spontaneous ventilation. However, our surgeons were able to successfully perform a range of laryngeal framework and phonomicrosurgical procedures, similar to those reported in previous microlaryngoscopy series, including the use of laser 1,8,9,17,18 .…”

Section: Discussionsupporting

confidence: 74%

“…Key Words: anaesthesia, apnoea, barotrauma, propofol, artificial respiration Microlaryngoscopy is a core Ear, Nose and Throat (ENT) surgical procedure that typifies the shared airway scenario. Cooperation is required to ensure satisfactory surgical airway exposure while maintaining adequate anaesthesia, oxygenation, ventilation and airway protection 1,2 . Anaesthetic techniques for microlaryngoscopy are classified as "open" or "closed" based on the type of airway and ventilation used 3,4 .…”

Section: Discussionmentioning

confidence: 99%

“…This is particularly advantageous for posterior glottic or subglottic lesions, which can be more difficult to access, even with jet ventilation 4,7 . It also facilitates dynamic airway assessment, which allows distinction between fixed and functional obstructive lesions 1,2,6 . In contrast to jet ventilation (JV), intermittent ventilation (IV) and apnoeic oxygenation (AO) respectively, SV has no risk of barotrauma, requires no surgical interruption and is compatible with use of laser 1,3,6,8,9,10 .…”

Section: Discussionmentioning

confidence: 99%

“…It also facilitates dynamic airway assessment, which allows distinction between fixed and functional obstructive lesions 1,2,6 . In contrast to jet ventilation (JV), intermittent ventilation (IV) and apnoeic oxygenation (AO) respectively, SV has no risk of barotrauma, requires no surgical interruption and is compatible with use of laser 1,3,6,8,9,10 . The ability to provide total intravenous anaesthesia using propofol target-controlled infusion (TCI) and maintain SV and oxygenation with no artificial airway is useful in cases of airway stenosis.…”

Section: Discussionmentioning

confidence: 99%

“…Despite these benefits, the use of SV in adult microlaryngoscopy has generally been regarded as less favourable than other open airway techniques such as JV, IV or AO 3,4,8 . It has been associated with patient reactivity, poor operating conditions, and greater difficulty in achieving the required depth of anaesthesia for patients to tolerate microlaryngoscopy while simultaneously maintaining adequate ventilation and haemodynamic stability 1,6,14,15 .…”

Section: Discussionmentioning

confidence: 99%

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Spontaneous Ventilation Using Target-Controlled Propofol Infusion for Microlaryngoscopy in Adults: A Retrospective Audit

Booth

Vidhani

2016

Anaesth Intensive Care

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We conducted a retrospective audit of 285 adult elective microlaryngoscopy cases in our institution over a three-and-a-half year period. Conventional anaesthesia with intubation and mechanical ventilation was the most common technique, used in 71% of cases. Tubeless spontaneous ventilation during total intravenous anaesthesia with a target-controlled infusion of propofol (SVTCI) was the most common alternative. Spontaneous ventilation with target-controlled infusion was used for 79 (27.7%) anaesthetic inductions and was continued through the maintenance phase for 60 patients (21.1%). Jet and intermittent ventilation were both used infrequently (1% each). The most common SVTCI technique since 2013 involved adjusting the target-controlled infusion rate during induction using a formula we developed based on intermittently increasing the target rate, such that the predicted plasma concentration minus the predicted effect site concentration was maintained at 1 μg/ml. We found that this method maintained ventilation during induction more reliably than other SVTCI strategies, and was associated with fewer complications than other spontaneous ventilation techniques or mechanical ventilation: it was associated with only one (3.1%) failed induction and one (3.9%) episode of apnoea. Jet ventilation was associated with the most severe complications, including two cases of barotrauma.

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Section: Discussionsupporting

confidence: 74%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 3 more Smart Citations

Spontaneous Ventilation Using Target-Controlled Propofol Infusion for Microlaryngoscopy in Adults: A Retrospective Audit

Booth

Vidhani

2016

Anaesth Intensive Care

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Glottic visibility for laryngeal surgery

Schmidt

Günther

Weber

et al. 2019

European Journal of Anaesthesiology

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BACKGROUND Good visibility is essential for successful laryngeal surgery. A Tritube with outer diameter 4.4 mm, combined with flow-controlled ventilation (FCV), enables ventilation by active expiration with a sealed trachea and may improve laryngeal visibility.OBJECTIVES We hypothesised that a Tritube with FCV would provide better laryngeal visibility and surgical conditions for laryngeal surgery than a conventional microlaryngeal tube (MLT) with volume-controlled ventilation (VCV). DESIGN Randomised, controlled trial. SETTING University Medical Centre. PATIENTS A total of 55 consecutive patients (>18 years) undergoing elective laryngeal surgery were assessed for participation, providing 40 evaluable data sets with 20 per group. INTERVENTIONS Random allocation to intubation with Tritube and ventilation with FCV (Tritube-FCV group) or intubation with MLT 6.0 and ventilation with VCV (MLT-VCV) as control. Tidal volumes of 7 ml kg À1 predicted body weight, and positive end-expiratory pressure of 7 cmH 2 O were standardised between groups. MAIN OUTCOME MEASURES Primary endpoint was the tube-related concealment of laryngeal structures, measured on videolaryngoscopic photographs by appropriate software. Secondary endpoints were surgical conditions (categorical four-point rating scale), respiratory variables and change of end-expiratory lung volume from atmospheric airway pressure to ventilation with positive end-expiratory pressure. Data are presented as median [IQR]. RESULTS There was less concealment of laryngeal structures with the Tritube than with the MLT; 7 [6 to 9] vs. 22 [18 to 27] %, (P < 0.001). Surgical conditions were rated comparably (P ¼ 0.06). A subgroup of residents in training perceived surgical conditions to be better with the Tritube compared with the MLT (P ¼ 0.006). Respiratory system compliance with the Tritube was higher at 61 [52 to 71] vs. 46 [41 to 51] ml cmH 2 O À1 (P < 0.001), plateau pressure was lower at 14 [13 to 15] vs. 17 [16 to 18] cmH 2 O (P < 0.001), and change of end-expiratory lung volume was higher at 681 [463 to 849] vs. 414 [194 to 604] ml, (P ¼ 0.023) for Tritube-FCV compared with MLT-VCV.CONCLUSION During laryngeal surgery a Tritube improves visibility of the surgical site but not surgical conditions when compared with a MLT 6.0. FCV improves lung aeration and respiratory system compliance compared with VCV.TRIAL REGISTRY NUMBER DRKS00013097.

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The Effect of High-Flow Nasal Oxygen on Carbon Dioxide Accumulation in Apneic or Spontaneously Breathing Adults During Airway Surgery: A Randomized-Controlled Trial

Booth

Vidhani

Lee³

et al. 2020

Anesthesia &Amp; Analgesia

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BACKGROUND: High-flow nasal oxygen (HFNO) is an emerging technology that has generated interest in tubeless anesthesia for airway surgery. HFNO has been shown to maintain oxygenation and CO2 clearance in spontaneously breathing patients and is an effective approach to apneic oxygenation. Although it has been suggested that HFNO can enhance CO2 clearance during apnea, this has not been established. The true extent of CO2 accumulation and resulting acidosis using HFNO during prolonged tubeless anesthesia remains undefined. METHODS: In a single-center trial, we randomly assigned 20 adults undergoing microlaryngoscopy to apnea or spontaneous ventilation (SV) using HFNO during 30 minutes of tubeless anesthesia. Serial arterial blood gas analysis was performed during preoxygenation and general anesthesia. The primary outcome was the partial pressure of CO2 (Paco 2) after 30 minutes of general anesthesia, with each group compared using a Student t test. RESULTS: Nineteen patients completed the study protocol (9 in the SV group and 10 in the apnea group). The mean (standard deviation [SD]) Paco 2 was 89.0 mm Hg (16.5 mm Hg) in the apnea group and 55.2 mm Hg (7.2 mm Hg) in the SV group (difference in means, 33.8; 95% confidence interval [CI], 20.6–47.0) after 30 minutes of general anesthesia (P < .001). The average rate of Paco 2 rise during 30 minutes of general anesthesia was 1.8 mm Hg/min (SD = 0.5 mm Hg/min) in the apnea group and 0.8 mm Hg/min (SD = 0.3 mm Hg/min) in the SV group. The mean (SD) pH was 7.11 (0.04) in the apnea group and 7.29 (0.06) in the SV group (P < .001) at 30 minutes. Five (55%) of the apneic patients had a pH <7.10, of which the lowest measurement was 7.057. No significant difference in partial pressure of arterial O2 (Pao 2) was observed after 30 minutes of general anesthesia. CONCLUSIONS: CO2 accumulation during apnea was more than double that of SV after 30 minutes of tubeless anesthesia using HFNO. The use of robust measurement confirms that apnea with HFNO is limited by CO2 accumulation and the concomitant severe respiratory acidosis, in contrast to SV. This extends previous knowledge and has implications for the safe application of HFNO during prolonged procedures.

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Anesthetic and Airway Management of Microlaryngeal Surgery and Upper Airway Endoscopy

Cited by 4 publications

References 271 publications

Spontaneous Ventilation Using Target-Controlled Propofol Infusion for Microlaryngoscopy in Adults: A Retrospective Audit

Spontaneous Ventilation Using Target-Controlled Propofol Infusion for Microlaryngoscopy in Adults: A Retrospective Audit

Glottic visibility for laryngeal surgery

The Effect of High-Flow Nasal Oxygen on Carbon Dioxide Accumulation in Apneic or Spontaneously Breathing Adults During Airway Surgery: A Randomized-Controlled Trial

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