Endotracheal Tube
Ignition During Laser Surgery of the Larynx George
E.
Burgess III, MD, Francis
E.
LeJeune, Jr, MD
ignition of an endotracheal tube by laser penetration of an unprotected portion of the tube during resection of laryngeal papillomas. We \s=b\ The
was
caused
discuss the factors that contributed to the ignition, the hazards that were encountered, and the methods of prevention that were
used.
(Arch Otolaryngol 105:561-562, 1979) benefits of the carbon dioxide laser for microsurgery on the larynx are its precision, control, and hemostatic properties.12 Most of the reported and potential complications result from the laser beam inadver¬ tently falling on areas that are not intended to be exposed. These areas can be on the aimed path of the beam, proximal or distal to the site of surgery, or areas that are subject to a reflected path of the beam. The site of surgery and the focus of the beam place the endotracheal tube and cuff at a high risk for laser penetration. In the following case, the ignition of an endotracheal tube was caused by the laser beam falling on an unprotected portion of the tube.
The
REPORT OF A CASE A 6-year-old girl was admitted to the Ochsner Foundation Hospital, New Or¬ leans, for elective resection of laryngeal papillomas by carbon dioxide laser surgery. She had received general anesthetics four
times between 1975 and 1978 for laser excision of papillomas and once for a tracheostomy. An intraoperative cardiac problem of unknown origin had occurred during operation at another hospital. The remainder of her history was unremark¬ able. Admission laboratory values were within normal limits. Before operation, the patient was given
Accepted for publication Sept 21, 1978. From the Departments of Anesthesiology (Dr Burgess) and Otorhinolaryngology (Dr LeJeune),
Ochsner Medical Institutions, New Orleans. Reprint requests to Department of Anesthesiology, Ochsner Clinic, 1514 Jefferson Hwy, New Orleans, LA 70121 (Dr Burgess).
30 mg of meperidine hydrochloride, 30 mg of hydroxyzine hydrochloride, and 0.3 mg of atropine sulfate intramuscularly (IM). Anesthesia was induced with ketamine hydrochloride, 175 mg IM, and maintained with halothane and oxygen by mask. After intravenous (IV) administration of 30 mg of succinylcholine chloride, a 40-mm inter¬ nal diameter, disposable, Polyvinylchloride endotracheal tube that was wrapped with aluminum foil tape to within 1 cm of the tip was placed into the trachea. Three loose deciduous teeth were noted before intuba¬ tion. The patient's ECG, breath sounds, heart tones, and temperature were contin¬ uously monitored during operation. Laryngoscopy disclosed massive recur¬ rence of juvenile papillomas on both the right and left vocal cords and on the right posterior portion of the arytenoid fold supraglotticly (Fig 1). After tissue was removed for histologie study, the papillo¬ mas were excised by carbon dioxide laser radiation until the free edges of the vocal cords appeared to be clean and free of residual papillomas (Fig 2). When the papillomas that extended into the subglot¬ tic region were excised, however, heat from the laser beam melted and then ignited the endotracheal tube tip, which had become exposed below the area that was protected by tape. The tube was immediately with¬ drawn (Fig 3 and 4). Careful inspection of the trachea with a 5-mm bronchoscope showed no significant thermal injury in the subglottic area. Indeed, the area appeared to be notably improved by the surgery. The patient's trachea was reintubated, and the oropharynx was inspected and found to be uninjured. To prevent inflammation, dexamethasone, 8 mg IV, was given intraoperatively and continued for two days postoper¬ atively in a dose of 2 mg IV every six hours. The three loose teeth were carefully extracted to prevent their being aspirated into the tracheobronchial tree. The trachea was extubated and the patient was given cool mist oxygen (40%) for the next 48 hours. Arterial blood gases remained satis¬ factory. Ampicillin sodium, 250 mg four times daily, was administered for the next ten days. Postoperatively, the patient breathed easily with a barely audible stridor. Treat-
epinephrine (Vaponefrin) hydrochloride solution inhalation were given. Chest x-ray film was clear. The patient's temperature was 38.2 °C (rectal) on the first postoperative day, but by the third postoperative day, she was afebrile and breathing without difficulty. Her voice improved, and she was discharged on the fifth postoperative day. Three weeks later, her voice was husky but improving.
ments of racemic
COMMENT Protection of the endotracheal tube by moist, selvage gauze has been suggested by some authors.35 An¬ drews and Moss3 and Snow et al6 suggested wrapping the endotracheal tube with aluminum foil tape so that the laser beam is reflected, and the energy is dissipated. However, balloon rupture due to laser penetration was reported in four of 392 laser surgical procedures,4 and endotracheal tube fires occurred in four of 700 laser operations.8 The fires caused burns of the trachéal mucosa, which healed uneventfully.6 In each instance, a red rubber endotracheal tube was either not wrapped with aluminum foil tape or was wrapped so that a portion of the tube became exposed to the laser beam. According to Andrews et al' and Strong and Jako,5 unprotected plastic endotracheal tubes are more vulnerable to laser penetration than are unprotected red rubber tubes. To our knowledge, the present case is the first instance of endotracheal tube ignition that has occurred at our hospital in approximately 250 cases of laser laryngeal surgery. Several fac¬ tors contributed to the ignition of the plastic endotracheal tube. Because the patient's larynx was narrowed by papillomas, a small endotracheal tube (internal diameter, 4 mm) was the only size that could be used without causing laryngeal trauma. This small tube is also shorter than the tube that would ordinarily be used for a 6-yearold child. Although the tube was
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Fig 1—Larynx is shown as viewed through operating microscope prior to initiation of laser resection. Foil-wrapped endotracheal tube is seen extending into trachea. No unprotected tube surface is seen. Both vocal cords are covered with papillomas.
Fig 3—Endotracheal tube after removal shows that normally clear, colorless interior of tube has been blackened by combustion in increased oxygen environment. Tip of tube has melted. Aluminum foil tape is seen from middle of tube to within 1 cm of tip.
Fig 2.—Larynx is shown after partial resec¬ tion of papillomas by laser. Portion of trachea past vocal cords can now be seen. Tube still appears to be protected by foil.
Fig 4.—Tip of endotracheal tube shows aluminum foil tape near end of tube. Beveled end and normal side hole of tube are intact. Superior portion of tube, approximately 7 mm from bevel, has been melted by laser heat, with complete occlusion of tube's lumen as walls collapsed inward.
wrapped with aluminum foil tape to within 1 cm of the tip, after intuba¬ tion the protected portion of the tube ended just below the vocal cords. However, this was not apparent on initial laryngoscopy. When the papil¬ lomas were resected, the unprotected part of the tube was exposed to and penetrated by the laser beam. The fire, which blackened the inside of the tube, was fueled by 100% oxy¬ gen (Fig 3). The high, inspired oxygen fraction had been selected because of the patient's history of intraoperative cardiac problems. Ideally, the inspired oxygen fraction should be between 30% and 50%. When the tube was melted and closed by the heat from the fire, we were unable to ventilate the patient through the tube (Fig 4). In such instances, the patient's tra¬ chea should be immediately extubated and a new, protected endotracheal tube inserted. Bronchoscopy should be performed to rule out the presence of
trachéal burns and damage by smoke inhalation. Additional treatment with continuous cool oxygen mist, steroid injections, or racemic epinephrine may be indicated. A metal endotracheal tube that is currently being tested may not require wrapping with tape.8 Howev¬ er, plastic and red rubber endotra¬ cheal tubes should be wrapped with aluminum foil tape to at least 1 cm below the vocal cords to prevent endo-
trachéal tube ignition by laser. The inspired oxygen fraction should be kept between 30% and 50%, and the arterial blood gases should be moni¬ tored to avoid hypoxemia. Name and Trademarks of Drug
Nonproprietary
Ampicillin sodium—Amcill-S, Omnipen-N, Penbritin-S, Polycillin-N, Principen IN.
References 1. Birch AE: Anesthetic considerations during laser surgery. Anesth Analg 52:53-58, 1973. 2. LeJeune FE Jr: Intralaryngeal surgery 1977. Laryngoscope 87:1815-1820, 1977. 3. Andrews AH Jr, Moss HW: Experiences with the carbon dioxide laser in the larynx. Ann Otol Rhinol Laryngol 83:462-470, 1974. 4. Snow JC, Kripke BJ, Strong MS, et al: Anesthesia for carbon dioxide laser microsurgery on the larynx and trachea. Anesth Analg 53:507\x=req-\ 512, 1974. 5. Strong MS, Jako GJ: Laser surgery in the larynx: Early clinical experience with continuous
CO2 laser. Ann Otol Rhinol Laryngol 81:791-798, 1972. 6. Snow JC, Norton ML, Saluja TS, et al: Fire hazard during CO2 laser microsurgery on the larynx and trachea. Anesth Analg 55:146-147, 1976. 7. Andrews AH Jr, Goldenberg RA, Moss HW, et al: Carbon dioxide laser for laryngeal surgery. Surg Annu 6:459-476, 1974. 8. Norton M, DeVos P: A new endotracheal tube for laser surgery of the larynx. Read before
the American Bronchoesophageal Association, Palm Beach, Fla, April 25, 1978.
Downloaded From: http://archotol.jamanetwork.com/ by a Monash University Library User on 06/20/2015
Ignition During Laser Surgery of the Larynx George
E.
Burgess III, MD, Francis
E.
LeJeune, Jr, MD
ignition of an endotracheal tube by laser penetration of an unprotected portion of the tube during resection of laryngeal papillomas. We \s=b\ The
was
caused
discuss the factors that contributed to the ignition, the hazards that were encountered, and the methods of prevention that were
used.
(Arch Otolaryngol 105:561-562, 1979) benefits of the carbon dioxide laser for microsurgery on the larynx are its precision, control, and hemostatic properties.12 Most of the reported and potential complications result from the laser beam inadver¬ tently falling on areas that are not intended to be exposed. These areas can be on the aimed path of the beam, proximal or distal to the site of surgery, or areas that are subject to a reflected path of the beam. The site of surgery and the focus of the beam place the endotracheal tube and cuff at a high risk for laser penetration. In the following case, the ignition of an endotracheal tube was caused by the laser beam falling on an unprotected portion of the tube.
The
REPORT OF A CASE A 6-year-old girl was admitted to the Ochsner Foundation Hospital, New Or¬ leans, for elective resection of laryngeal papillomas by carbon dioxide laser surgery. She had received general anesthetics four
times between 1975 and 1978 for laser excision of papillomas and once for a tracheostomy. An intraoperative cardiac problem of unknown origin had occurred during operation at another hospital. The remainder of her history was unremark¬ able. Admission laboratory values were within normal limits. Before operation, the patient was given
Accepted for publication Sept 21, 1978. From the Departments of Anesthesiology (Dr Burgess) and Otorhinolaryngology (Dr LeJeune),
Ochsner Medical Institutions, New Orleans. Reprint requests to Department of Anesthesiology, Ochsner Clinic, 1514 Jefferson Hwy, New Orleans, LA 70121 (Dr Burgess).
30 mg of meperidine hydrochloride, 30 mg of hydroxyzine hydrochloride, and 0.3 mg of atropine sulfate intramuscularly (IM). Anesthesia was induced with ketamine hydrochloride, 175 mg IM, and maintained with halothane and oxygen by mask. After intravenous (IV) administration of 30 mg of succinylcholine chloride, a 40-mm inter¬ nal diameter, disposable, Polyvinylchloride endotracheal tube that was wrapped with aluminum foil tape to within 1 cm of the tip was placed into the trachea. Three loose deciduous teeth were noted before intuba¬ tion. The patient's ECG, breath sounds, heart tones, and temperature were contin¬ uously monitored during operation. Laryngoscopy disclosed massive recur¬ rence of juvenile papillomas on both the right and left vocal cords and on the right posterior portion of the arytenoid fold supraglotticly (Fig 1). After tissue was removed for histologie study, the papillo¬ mas were excised by carbon dioxide laser radiation until the free edges of the vocal cords appeared to be clean and free of residual papillomas (Fig 2). When the papillomas that extended into the subglot¬ tic region were excised, however, heat from the laser beam melted and then ignited the endotracheal tube tip, which had become exposed below the area that was protected by tape. The tube was immediately with¬ drawn (Fig 3 and 4). Careful inspection of the trachea with a 5-mm bronchoscope showed no significant thermal injury in the subglottic area. Indeed, the area appeared to be notably improved by the surgery. The patient's trachea was reintubated, and the oropharynx was inspected and found to be uninjured. To prevent inflammation, dexamethasone, 8 mg IV, was given intraoperatively and continued for two days postoper¬ atively in a dose of 2 mg IV every six hours. The three loose teeth were carefully extracted to prevent their being aspirated into the tracheobronchial tree. The trachea was extubated and the patient was given cool mist oxygen (40%) for the next 48 hours. Arterial blood gases remained satis¬ factory. Ampicillin sodium, 250 mg four times daily, was administered for the next ten days. Postoperatively, the patient breathed easily with a barely audible stridor. Treat-
epinephrine (Vaponefrin) hydrochloride solution inhalation were given. Chest x-ray film was clear. The patient's temperature was 38.2 °C (rectal) on the first postoperative day, but by the third postoperative day, she was afebrile and breathing without difficulty. Her voice improved, and she was discharged on the fifth postoperative day. Three weeks later, her voice was husky but improving.
ments of racemic
COMMENT Protection of the endotracheal tube by moist, selvage gauze has been suggested by some authors.35 An¬ drews and Moss3 and Snow et al6 suggested wrapping the endotracheal tube with aluminum foil tape so that the laser beam is reflected, and the energy is dissipated. However, balloon rupture due to laser penetration was reported in four of 392 laser surgical procedures,4 and endotracheal tube fires occurred in four of 700 laser operations.8 The fires caused burns of the trachéal mucosa, which healed uneventfully.6 In each instance, a red rubber endotracheal tube was either not wrapped with aluminum foil tape or was wrapped so that a portion of the tube became exposed to the laser beam. According to Andrews et al' and Strong and Jako,5 unprotected plastic endotracheal tubes are more vulnerable to laser penetration than are unprotected red rubber tubes. To our knowledge, the present case is the first instance of endotracheal tube ignition that has occurred at our hospital in approximately 250 cases of laser laryngeal surgery. Several fac¬ tors contributed to the ignition of the plastic endotracheal tube. Because the patient's larynx was narrowed by papillomas, a small endotracheal tube (internal diameter, 4 mm) was the only size that could be used without causing laryngeal trauma. This small tube is also shorter than the tube that would ordinarily be used for a 6-yearold child. Although the tube was
Downloaded From: http://archotol.jamanetwork.com/ by a Monash University Library User on 06/20/2015
Fig 1—Larynx is shown as viewed through operating microscope prior to initiation of laser resection. Foil-wrapped endotracheal tube is seen extending into trachea. No unprotected tube surface is seen. Both vocal cords are covered with papillomas.
Fig 3—Endotracheal tube after removal shows that normally clear, colorless interior of tube has been blackened by combustion in increased oxygen environment. Tip of tube has melted. Aluminum foil tape is seen from middle of tube to within 1 cm of tip.
Fig 2.—Larynx is shown after partial resec¬ tion of papillomas by laser. Portion of trachea past vocal cords can now be seen. Tube still appears to be protected by foil.
Fig 4.—Tip of endotracheal tube shows aluminum foil tape near end of tube. Beveled end and normal side hole of tube are intact. Superior portion of tube, approximately 7 mm from bevel, has been melted by laser heat, with complete occlusion of tube's lumen as walls collapsed inward.
wrapped with aluminum foil tape to within 1 cm of the tip, after intuba¬ tion the protected portion of the tube ended just below the vocal cords. However, this was not apparent on initial laryngoscopy. When the papil¬ lomas were resected, the unprotected part of the tube was exposed to and penetrated by the laser beam. The fire, which blackened the inside of the tube, was fueled by 100% oxy¬ gen (Fig 3). The high, inspired oxygen fraction had been selected because of the patient's history of intraoperative cardiac problems. Ideally, the inspired oxygen fraction should be between 30% and 50%. When the tube was melted and closed by the heat from the fire, we were unable to ventilate the patient through the tube (Fig 4). In such instances, the patient's tra¬ chea should be immediately extubated and a new, protected endotracheal tube inserted. Bronchoscopy should be performed to rule out the presence of
trachéal burns and damage by smoke inhalation. Additional treatment with continuous cool oxygen mist, steroid injections, or racemic epinephrine may be indicated. A metal endotracheal tube that is currently being tested may not require wrapping with tape.8 Howev¬ er, plastic and red rubber endotra¬ cheal tubes should be wrapped with aluminum foil tape to at least 1 cm below the vocal cords to prevent endo-
trachéal tube ignition by laser. The inspired oxygen fraction should be kept between 30% and 50%, and the arterial blood gases should be moni¬ tored to avoid hypoxemia. Name and Trademarks of Drug
Nonproprietary
Ampicillin sodium—Amcill-S, Omnipen-N, Penbritin-S, Polycillin-N, Principen IN.
References 1. Birch AE: Anesthetic considerations during laser surgery. Anesth Analg 52:53-58, 1973. 2. LeJeune FE Jr: Intralaryngeal surgery 1977. Laryngoscope 87:1815-1820, 1977. 3. Andrews AH Jr, Moss HW: Experiences with the carbon dioxide laser in the larynx. Ann Otol Rhinol Laryngol 83:462-470, 1974. 4. Snow JC, Kripke BJ, Strong MS, et al: Anesthesia for carbon dioxide laser microsurgery on the larynx and trachea. Anesth Analg 53:507\x=req-\ 512, 1974. 5. Strong MS, Jako GJ: Laser surgery in the larynx: Early clinical experience with continuous
CO2 laser. Ann Otol Rhinol Laryngol 81:791-798, 1972. 6. Snow JC, Norton ML, Saluja TS, et al: Fire hazard during CO2 laser microsurgery on the larynx and trachea. Anesth Analg 55:146-147, 1976. 7. Andrews AH Jr, Goldenberg RA, Moss HW, et al: Carbon dioxide laser for laryngeal surgery. Surg Annu 6:459-476, 1974. 8. Norton M, DeVos P: A new endotracheal tube for laser surgery of the larynx. Read before
the American Bronchoesophageal Association, Palm Beach, Fla, April 25, 1978.
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