Airway FiresA Hot Topic

Chris Bowen T?May 27th 2011

AnesthesiaKeyword Presentation

Quick Description Reported in 0.4-1.5% of laser airway cases Believed to be grossly underreported

› Risk of laser contacting ET tube 1:2 Inception

› Direct illumination› Reflected › Particles

3 things every growing fire needs:› Ignition source laser, electrocautery› Oxidant O2 , Nitrous Oxide› Fuel ET tubes, drapes, etc.

Potential Dangers

Seeding Cuff puncture releases more oxidant into

field The “blowtorch” effect Airway trauma

› Smoke and debris inhalation Death

In Case of Emergency… D/C oxygen and extubate Douse flames with saline Mask ventilation

› Assess feasibility of reintubation for… Bronchoscopy to assess extent of injury

› Supportive care› Consider leaving tube if not burning

Admit patient to ICU

An Ounce of Prevention… OR prevention

› Proper eye protection› Wet towels and minimal draping› Matte/dull finished or blackened

instruments› Signs posted› Extinguisher checked and in room› Laser set on pulse not continuous› Laser set on “standby” mode

…is Worth a Pound of Cure. Anesthesia Preventions

› Dentures and nasogastric tubes removed› Co-morbidities› Technique

Jet, apneic, spontaneous ventilation› Tube

Type Metal vs. rubber vs. PVC

Coverings› Cuff preparation

Tapes, Tips, and Tubes Tapes

› 3 major types› Inexpensive

Cuff filled with saline vs. air› Mini-extinguisher effect› Methylene blue dye

Tubes› Metal interlocking rings of stainless steel› Rubber soft, usually without cuff› PVC garden variety

Studies 46% prefer laser-safe ET, 26% prefer Jet Ventilation, 16% apneic, 12% spontaneous Sosis and Dillon Tapes

› Copper demonstrated no combustion at 60 sec.› Not FDA approved› Proper application is key

Limit flexibility Increase diameter Can come loose

Cuffs › Saline filled cuff perforation reduced combustion by 80%› Dye allows for quick assessment of cuff integrity› Dual cuffs made extubation problematic

Tubes› Metal is resistant not impervious

increased trauma upon insertion› PVC very resistant

Taping or covering recommended Application must be precise

› Rubber most flammable* Blood, mucus, and tissue increased combustion rates up to 60% The YAG laser ignited all materials within 6 sec

Conclusions Metal tubing is safe and effective

› Resistant not impervious Cuffs should be filled with saline and

dye Copper tape has superior resistance

when compared to other tapes and coverings

Nothing withstands the YAG

Food for Thought LMAs Increased muscle relaxants Are all lasers created equal? Metallic tape vs. laser-guard coverings FiO2 and inhaled anesthetic levels Tracheostomy

Thank You

Questions?

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Carin A. Hagberg, MD, Benumof's Airway Management (Second Edition) Principles and practice 2007 Mosby, Inc. pg. 901, 906-938, 1197-98.

John L. Atlee MD., Complications in Anesthesia 2nd Ed. 2006 Saunders. Pg. 750