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Procedures

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Considerations

  1. Procedures—direct laryngoscopy, fiberoptic bronchoscopy, rigid bronchoscopy, foreign body removal, laser surgery, airway stents, or airway trauma

  2. Requires close communication between surgeon and anesthetist

  3. If respiratory distress—surgical airway

  4. High prevalence of cigarette smoking (COPD, airway tumors)

  5. Options for ventilation:

    • Spontaneous ventilation + local anesthesia/sedation—limited procedures that patients can tolerate
    • Spontaneous ventilation + GA—for upper airway endoscopy
    • Positive pressure ventilation (with small ETT) + GA—obscures surgical view but allows for standard equipment
    • Jet ventilation + GA—unobstructed view but risk barotrauma

  6. Lasers—risk of airway fire. Use minimal inspired oxygen concentration to maintain oxygenation and use specialized laser airway endotracheal tubes

  7. TIVA useful to maintain anesthesia and/or reduce pollution

History
  • Location, size, and symptoms of airway abnormality (dyspnea, hoarseness, dysarthria, aspiration, coughing)
  • Tumors—medications, radiation, surgery?
  • Foreign body? Often pediatric patients
  • Comorbid cardiopulmonary disease
  • Other—cigarette smoking, alcohol use
Physical Exam
  • Vital signs
  • Airway exam—stridor? Neck ROM, MP score
  • Features of difficult mask ventilation—obesity, beard, or no teeth
  • Cardiopulmonary exam
Lab Tests/Imaging
  • Airway—imaging, bronchoscopy results, fiberoptic assessment
Consults
Conflict(s)
  • Weigh pros and cons of various ventilation modes for given patient and surgical requirements
Optimize
  • Positioning—protect neck, teeth, eyes
  • Anesthesia—often TIVA—ensure adequate IV access
Options
  • MAC/local anesthesia
  • General anesthesia—spontaneous ventilation, jet ventilation, or with ETT or LMA as required
Preop:
  • Premed
  • Blood
  • ICU/stepdown bed
Room Setup (Special Drugs/Monitors)
  • Consider arterial line for hemodynamic monitoring or blood gases as required
Induction
  • Depending on assessment:
    • surgical airway
    • AFOI
    • induce but maintain spontaneous ventilation
    • induce, muscle relaxants, and PPV
Maintenance
  • TIVA or balanced technique ± muscle relaxants
  • Short-acting agents often preferred
  • Dexamethasone 10 mg IV—to reduce airway edema
  • Laser surgery—protective eye equipment for patient and staff
Emergence
  • Assess airway—edema or bleeding may limit ability to extubate
Disposition/Pain
  • Assess re: airway edema, obstruction
  • Stridor: nebulized epinephrine, heliox
  • Emergency airway equipment available
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References

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Moorthy SS, Gupta S, Laurent B. Management of airway in patients with laryngeal tumors. J Clin Anesth. 2005;17:604-609.
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English J, Norris A, Bedforth N. Anaesthesia for airway surgery. Continuing education in Anaesthesia. Critical Care and Pain. 2006; 6(1):28-31.

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Considerations

  1. Anesthetics with adequate recovery profile

  2. Major complications (MI, stroke, PE, respiratory failure) are rare

  3. Minor complications (pain, PONV, sore throat, somnolence, hypotension, hypertension, and bleeding) are common

  4. Ease of transfer in case of unplanned admission? Know your surroundings—office-based procedure, freestanding ambulatory surgery center, or hospital

  5. Predictors 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 anesthesia

  6. Unanticipated admission causes:

    • Medication—complications from preexisting disease
    • Surgical—direct complication, pain, bleeding
    • Anesthesia—aspiration, PONV, somnolence
    • Social—no escort, long distance from home

  7. Controversial patients for ambulatory surgery—elderly, morbid obesity, severe OSA, significant COPD or asthma, and infants (risk of apnea if postconceptual age <60 weeks)

  8. ENT, urology, and generally surgery—higher rates of unanticipated admission

History
  • Planned procedure and symptoms
  • Active upper respiratory tract ...

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