Overview of Airway for Laser Surgery
Medical lasers are specialized tools used in a wide variety of surgeries, ranging from ear, nose, and throat procedures to eye surgeries, skin treatments, plastic surgeries, and even dental procedures. They’re also used in more complex operations within the abdomen, chest, brain, female reproductive system, and urinary system. These lasers work by producing a concentrated beam of light that transmits intense energy to a very specific area. This energy is absorbed by a target substance in the body, generating heat which can destroy or seal off tissue.
However, it’s crucial to note that lasers come with their own set of risks. For instance, they can catch flammable materials on fire. These materials can be things like breathing tubes, sponges, and catheters present during surgery. These items can either absorb the laser energy and catch fire, or a spark from the laser can set them alight. Lasers also carry the risk of causing eye injuries to both the patient and medical staff, and could potentially lead to power cuts or the release of harmful chemicals.
Lasers are particularly hazardous when used in surgeries involving the upper areas of the digestive and respiratory system. This is because lasers can cause accidental fires especially when extra oxygen is added to the air that the patient breathes during the procedure. To manage this, different techniques have been developed to ventilate anesthetized patients while also minimizing laser-related dangers. These techniques could involve standard intubation (inserting a tube into a patient’s throat), controlled administration of oxygen, periodic pause in breathing, or allowing the patient to breathe naturally.
To further manage the risks, special ‘laser-resistant’ breathing tubes have been created and are now recommended by the American Society of Anesthesiologists for use during laser surgery of the respiratory tract. The most vulnerable part of these tubes is the inflatable cuff. When the tube is inserted, the cuff is filled with air or a saline solution to block off the windpipe from the outside, directing any gases to and from the tube exclusively. In laser surgeries, the cuff is often filled with some dye to make it easily visible in case the balloon is accidentally punctured. If the cuff is damaged by the laser or other means, it won’t properly seal the windpipe, allowing oxygen-rich gas to escape which may cause a fire during the procedure. Materials like the breathing tube, gauze, and surgical drapes are most commonly involved in such fires.
Anatomy and Physiology of Airway for Laser Surgery
When a person undergoes surgery in the upper section of their airways, it’s usually too uncomfortable to do while they’re awake. Once the patient is put to sleep with anesthesia, they lose the ability to naturally guard their airway from things like choking or blockage. This is because the anesthesia affects certain reflexes. As a result, the patient might not breathe as well, which in severe cases can lead to them not breathing at all.
When this happens, the surgeon will often have to insert a special tube into the patient’s windpipe (called “endotracheal intubation”) to help them breathe and to prevent any blockage. This tube also blocks some other objects from entering the windpipe. The only issue is that this tube can make it tricky for the doctor to carry out the surgery, as it may block their view and is at risk of being accidentally damaged during the procedure.
Alternatively, a smaller device can be inserted below the patient’s voice box to pump in oxygen and allow the surgeon to see better. However, this device doesn’t fully replace the tube (it can’t fully mimic the breathing function, and it doesn’t prevent things from entering the airway) and it doesn’t provide protection from certain chemicals produced during laser surgery.
An approach some doctors use is to place a mask that provides oxygen over the patient’s airway only during breaks in surgery. This approach usually works for shorter surgeries where the risk of bleeding is small, and the patient can manage some short periods without breathing (‘apnea’). But this technique does come with its own risks, such as the patient’s throat muscles suddenly tightening and choking them (‘laryngospasm’), airway control loss, or inhalation of food or liquids (‘aspiration’). These risks mean that this method might not be suitable for several types of laser airway surgeries.
Another option is to let the patient breathe on their own during the surgery. But their breathing movements might interfere with the surgery, plus there’s a risk of harmful gases produced during the procedure being inhaled by the patient and medical team.
Why do People Need Airway for Laser Surgery
If a person is scheduled to have laser airway surgery, the doctor will use a specially designed tube, known as a “laser-safe” tube, to help them breathe during the procedure. Despite its name, it doesn’t mean there’s zero chance of a fire happening. The tube, however, is made with certain safety features and less-flammable materials like metal to minimize that risk. In some rare cases, doctors use other methods to ensure the patient can breathe during surgery.
No matter what method is used, the most important thing is that the healthcare team is familiar with how to handle any challenges or risks linked to laser airway surgery. Using a specially designed tube and having an experienced team is always the safest route to take during such procedures.
When a Person Should Avoid Airway for Laser Surgery
There are no specific reasons why certain specialized tubes used to help with breathing, known as endotracheal tubes, can’t be used, unless the patient is allergic to the material the tubes are made of. However, if a patient isn’t well enough to have the required surgery to insert these tubes into the windpipe (airway), other options should be thought about, like a tracheostomy. This is a procedure where a hole is made in the neck to allow air to directly reach the lungs.
Equipment used for Airway for Laser Surgery
Carbon dioxide (CO2) lasers are most often used in surgeries related to the ears, nose, and throat. The light they produce is infrared, which can’t be seen by the human eye, and it can cause a lot of heat damage because it interacts with water. Therefore, it’s important to use a visible light to aim and ensure its accuracy before starting the surgery. The CO2 laser can harm the eyes, both for the patient and the surgical personnel, but wearing glasses or shields made from clear glass or plastic is enough for protection.
There are other lasers in medical use (such as KTP, Ho:YAG, Nd:YAG, Argon, pulsed dye), but a discussion about them goes beyond this article.
Different types of tubes have been made to resist the heat from these lasers to prevent breathing tubes from igniting. Here are some examples:
- Rubber tubes which are fairly flexible and white, and coated with copper foil, are resistant to a few types of lasers (CO2, Nd/YAG, and Argon). They usually have a double cuff for added protection.
- Tubes made of silicone and wrapped in aluminum foil can withstand CO2 and KTP lasers.
- Stainless steel tubes (for instance, Mallinckrodt Laser Flex) also work with CO2 and KTP lasers. They are made of non-flammable metal that doesn’t bend easily. The metal can get hot and conduct heat to nearby tissues and materials, but the risk of reflecting a laser beam is very low.
Also, there are red rubber tubes that can be used safely with CO2 and KTP lasers if they’re wrapped with aluminum or copper foil.
These tubes have two cuffs, and it’s recommended to fill them with saline (saltwater solution). This extra step helps to prevent fires if the laser accidentally hits the cuff. Blue dye can be added to the saline in the cuff to help identify if the cuff is punctured. The surgical team should use surgical drapes that resist flames if possible. If not, they can cover the patient’s exposed skin with towels soaked in saline.
Everybody in the room should wear protective glasses specific to the wavelength of the laser to avoid exposure to laser radiation and potential damage to the eyes. Depending on the type of laser, different color filters for the glasses could be used.
Lastly, high-efficiency masks are needed to protect the staff from smoke that results from tissue being evaporated by the laser. This smoke can contain tiny particles that could lodge in the lungs and cause health problems. This is a particular concern when treating papillomatous disease, as there is a theorized risk of spreading the disease. Special systems to clear the smoke should be used because the normal room ventilation system isn’t enough to remove these contaminants from the air. They should also use a hose that can suck the airborne particles within two inches of the area where the surgery is happening, to safely remove the airborne contaminants caused by the lasers.
Who is needed to perform Airway for Laser Surgery?
In the operating room, aside from the usual team of the doctor performing the surgery, the person who administers sleeping medicine (anesthetist), and the nurses who assist during the surgery (scrub nurse and circulating nurse), there is also an extra team member who operates the laser machine during the surgery. It’s important that all these professionals know how to use the laser safely and are given special protective supplies that are designed to protect them from the laser’s light.
Preparing for Airway for Laser Surgery
When preparing a plan for managing a patient’s breathing during a medical procedure, specific tools are needed. This may include items like a special kind of tube that resists laser damage, or a device that helps the patient breathe (called a jet ventilator). These tools must be in the room before the procedure starts.
During procedures where lasers are used, everyone in the room must wear protective eyewear and special masks to filter the air they breathe. This safety measure is crucial to protect the eyes from laser damage, and the lungs from any harmful particles.
If an unexpected event like a fire occurs in the patient’s airway during the procedure, having syringes filled with saline (a kind of saltwater solution) ready can be crucial. These can be used to put out the fire quickly and safely. This type of preparation ensures everyone’s safety during a procedure that involves laser usage.
How is Airway for Laser Surgery performed
In certain types of surgery, such as laser surgery, it’s essential to keep the airways open and safe. The process of placing a tube into your windpipe (trachea) to help you breathe is called endotracheal intubation.
During this procedure, a special tube called an endotracheal tube (ETT) is used. But for laser surgery, a typical ETT isn’t suitable because of the risk of ignition. Instead, a special laser-resistant tube is used that provides a much lower risk of catching fire. Chances of this happening are further reduced by filling the tube’s air cuffs with a saline and dye solution. The whole point of this is to ensure you can breathe comfortably and safely, while the surgeon has an unobstructed view.
Your doctor will choose the smallest tube that functions properly so that the surgical area is as accessible as possible. In some cases, the surgeon may need to temporarily deflate the cuff or remove the tube for better access, but they’re always prepared with a spare just in case.
There’s another way to maintain an open airway during surgery called jet ventilation. This method pushes a stream of gas into your upper airway, which lets the surgeon see well while you continue to breathe. There are three methods for carrying out jet ventilation depending on what’s best for your individual case.
The first method is to use a tube positioned above your vocal cords, the second method involves a smaller tube passed below your vocal cords, and the third involves an approach called transtracheal—used for patients with challenging intubations or as a backup plan.
Another technique is the intermittent apnea technique. It’s like taking tiny breathers during the procedure. The endotracheal tube is placed and removed multiple times. When the tube is in, you are made to breathe in and out heavily and then the tube is taken out, letting you hold your breath for a short time. This short break allows the surgeon to perform the surgery without any obstruction. The maximum pause typically lasts up to 5 minutes but is continually monitored for safety.
Lastly, we have the spontaneous ventilation technique. In this method, you continue to breathe by yourself. This gives the best access to the surgeon but it also means the surgical site keeps moving which can be challenging for the surgeon.
Each technique has its benefits and risks. Your doctor will choose the one that is the most suitable for your situation keeping your safety as a priority.
Possible Complications of Airway for Laser Surgery
Medical laser procedures, while often safe and effective, can sometimes have complications. The three most common complications are the risk of a surgical fire, accidental burns to the surrounding tissues, and injuries to the eyes.
One of the fire risks in surgical procedures is lasers. In fact, lasers are considered the second most common cause of operating room fires after electrosurgical devices. The surgeries that are most at risk are those involving the throat and windpipe. If a fire happens during surgery, the steps to control it include:
- Removing anything that’s burning
- Turning off the laser, which is likely causing the fire
- Stopping the flow of any gases that may be feeding the fire
- If any fire remains, putting it out with a saline solution.
After these steps are completed, the anesthetist would continue to give the patient anesthesia through an IV line, and the patient would be given pure oxygen to breathe. The surgeon would then need to check for damage inside the throat and remove any fragments or debris. The patient might need to be re-intubated or have a laryngeal mask inserted to help with breathing. If necessary, the patient may need to be transferred to the intensive care unit, or a tracheostomy (a surgical procedure to create an opening in the neck for breathing) might be needed.
Burns can also occur during medical laser procedures. This happens when tissues are accidentally exposed to the laser, or when the laser beam reflects off other surfaces in the operating area. The use of a cuffed endotracheal tube (a medical device inserted into the patient’s windpipe during surgery) can help decrease the chance of laser burns. Using saline-soaked gauze to cover tissues near the surgery site can also be a preventive measure against accidental burns.
The last common complication is injury to the eyes. Exposure of the eyes to the laser, or a reflection of the laser beam, can result in injuries. The cornea (the clear front surface of the eye) and the retina (the layer at the back of the eye that senses light) are the most at-risk structures of the eye. Safety procedures such as posting warning signs, ensuring any windows in the laser operating room are covered, and using special safety glasses can help prevent eye injuries. Eye injuries caused by lasers are considered emergencies as they can lead to permanent blindness. If you ever experience symptoms such as a bright flash of colored light, a popping sound, loss of vision, or seeing spots or “floaters,” you should seek immediate medical assistance.
There are also other risks associated with lasers, like laser plumes (smoke that is produced during laser procedures), which may have potential cancer-causing properties. However, these risks can be significantly decreased by using special filters and masks.
What Else Should I Know About Airway for Laser Surgery?
When having surgery on the upper respiratory tract, it’s essential that the doctors keep your airway open and ensure you are breathing properly. However, it can be tricky due to the need to have a clear view of the area being operated on. Doctors usually ensure this by using a smaller, specialized tool that is resistant to lasers, along with tools designed for helping patients breathe, and techniques that allow for the patient to breathe on their own or with assistance.
Medical lasers are often used in these procedures, but they pose a risk of causing a fire due to the oxygen-rich environment. Because of these risks, there are many guidelines and recommended practices that doctors follow very carefully. This ensures your surgery is as safe as possible.
