Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++Table Graphic Jump Location|Download (.pdf)|PrintConsiderationsProcedures—direct laryngoscopy, fiberoptic bronchoscopy, rigid bronchoscopy, foreign body removal, laser surgery, airway stents, or airway traumaRequires close communication between surgeon and anesthetistIf respiratory distress—surgical airwayHigh prevalence of cigarette smoking (COPD, airway tumors)Options for ventilation: Spontaneous ventilation + local anesthesia/sedation—limited procedures that patients can tolerateSpontaneous ventilation + GA—for upper airway endoscopyPositive pressure ventilation (with small ETT) + GA—obscures surgical view but allows for standard equipmentJet ventilation + GA—unobstructed view but risk barotraumaLasers—risk of airway fire. Use minimal inspired oxygen concentration to maintain oxygenation and use specialized laser airway endotracheal tubesTIVA useful to maintain anesthesia and/or reduce pollutionHistoryLocation, size, and symptoms of airway abnormality (dyspnea, hoarseness, dysarthria, aspiration, coughing)Tumors—medications, radiation, surgery?Foreign body? Often pediatric patientsComorbid cardiopulmonary diseaseOther—cigarette smoking, alcohol usePhysical ExamVital signsAirway exam—stridor? Neck ROM, MP scoreFeatures of difficult mask ventilation—obesity, beard, or no teethCardiopulmonary examLab Tests/ImagingAirway—imaging, bronchoscopy results, fiberoptic assessmentConsultsConflict(s)Weigh pros and cons of various ventilation modes for given patient and surgical requirementsOptimizePositioning—protect neck, teeth, eyesAnesthesia—often TIVA—ensure adequate IV accessOptionsMAC/local anesthesiaGeneral anesthesia—spontaneous ventilation, jet ventilation, or with ETT or LMA as requiredPreop:PremedBloodICU/stepdown bedRoom Setup (Special Drugs/Monitors)Consider arterial line for hemodynamic monitoring or blood gases as requiredInductionDepending on assessment: surgical airwayAFOIinduce but maintain spontaneous ventilationinduce, muscle relaxants, and PPVMaintenanceTIVA or balanced technique ± muscle relaxantsShort-acting agents often preferredDexamethasone 10 mg IV—to reduce airway edemaLaser surgery—protective eye equipment for patient and staffEmergenceAssess airway—edema or bleeding may limit ability to extubateDisposition/PainAssess re: airway edema, obstructionStridor: nebulized epinephrine, helioxEmergency airway equipment available +++ References ++Moorthy SS, Gupta S, Laurent B. Management of airway in patients with laryngeal tumors. J Clin Anesth. 2005;17:604-609.++English J, Norris A, Bedforth N. Anaesthesia for airway surgery. Continuing education in Anaesthesia. Critical Care and Pain. 2006; 6(1):28-31. ++Table Graphic Jump Location|Download (.pdf)|PrintConsiderationsAnesthetics with adequate recovery profileMajor complications (MI, stroke, PE, respiratory failure) are rareMinor complications (pain, PONV, sore throat, somnolence, hypotension, hypertension, and bleeding) are commonEase of transfer in case of unplanned admission? Know your surroundings—office-based procedure, freestanding ambulatory surgery center, or hospitalPredictors of hospital admission after ambulatory surgery: >65 years, prior inpatient admission in last 6 months, invasiveness of surgery, surgery >2 hours, general anesthesia rather than regional anesthesiaUnanticipated admission causes: Medication—complications from preexisting diseaseSurgical—direct complication, pain, bleedingAnesthesia—aspiration, PONV, somnolenceSocial—no escort, long distance from homeControversial patients for ambulatory surgery—elderly, morbid obesity, severe OSA, significant COPD or asthma, and infants (risk of apnea if postconceptual age <60 weeks)ENT, urology, and generally surgery—higher rates of unanticipated admissionHistoryPlanned procedure and symptomsActive upper respiratory tract infection?... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.