Flooding With Carbon Dioxide Prevents Airway Fire Induced by Diathermy During Open Tracheostomy

Background: The standard tracheostomy involves open standard dissection technique, established more than a hundred years ago. Alternative procedures like percutaneous tracheostomy (PCT) have evolved recently due to advance in technology and interest in minimally invasive procedures. A systematic randomized comparative cohort study was done with the aim to compare standard open tracheostomy with percutaneous tracheostomy techniques, namely serial guide wire dilating forceps (GWDF) and PercuTwist. Methods: This study was carried out in the Department of ENT and head and neck surgery in a tertiary referral medical center of Indian Army. The patients were followed up for one year post-decannulation or till their death due to medical morbidities. 45 adult patients in ICU, intubated and on prolonged mechanical ventilation, needing elective tracheostomy were included in the study. Pediatric cases, patients with distorted neck anatomy and those requiring emergency tracheostomy were excluded. 15 patients underwent standard open surgical tracheostomy. Amongst the other 30 cases, 15 percutaneous tracheostomy were done by guide wire dilating forceps technique and remaining 15 by PercuTwist. Results: Although the indications were limited and another surgeon was required to keep a watch through bronchoscope, it was observed that PCT was easier and quicker than open standard tracheostomy. It involved small incision and no dissection, less tissue trauma and better cosmetic result. Comparatively, the complication rate was also less. Conclusion: It can be concluded that training of surgeons and proper case selection makes percutaneous tracheostomy as good and safe as open technique.

The aim of this study was to examine the training methods and needs of Otolaryngology-Head and Neck Surgery (OTO-HNS) residents to independently perform open tracheostomy (OT). An anonymous 26-items questionnaire pertaining to OT teaching aspects was distributed to all 93 IsraeliOTO-HNS residents during March-June 2016. Residents were categorized as 'juniors,' if they were in their post-graduate year (PGY)-1 and PGY-2; 'mid-residency' (PGY-3 and PGY-4); or 'seniors' (PGY-5 and PGY-6). Response rate was 74% (n=69). There were 25 'juniors' (36%), 24 'mid-residency' (35%) and 20 'seniors' (29%). Overall, the responses of the 3 groups were similar. Forty-seven (68%) residents estimated that there are≥50 tracheostomies/year in their hospital, which roughly corresponds to an exposure of~8 tracheostomies/year/resident. There was an inconsistency between the number of teaching hours given and the number of hours requested for OT training (23% received≥5h, but 82% declared they needed≥5h). Eighty-two percentage reported that their main training was conducted during surgery with peer residents or senior physicians. Forty-five (65%) feel competent to perform OT, including juniors. Due to the need to perform OT in urgent scenarios, the competency of OTO-HNS resident is crucial. Training for OT in IsraeliOTO-HNS residency programs is not well structured. Yet, residents reported they feel confident to perform OT, already in the beginning of their residency. Planned educational programs to improve OT training should be done in the beginning of the residency and may include designated 'hands-on' platforms; objective periodic surgical competence assessments; and specialist's feedback, using structured assessment forms.

At the center of the COVID-19 pandemic: Lessons learned for otolaryngology-head and neck surgery in China.

Tracheostomy is a common procedure for intensive care patients requiring prolonged mechanical ventilation. In this case report, we describe a 78-year-old female patient admitted for an aneurysm of the cerebral anterior communicating artery. Following immediate endovascular coiling, she remained ventilated and was transferred to the neurological intensive care unit. On postoperative day ten, a percutaneous tracheostomy (PCT) was requested; however, a large ulcer or possible tracheoesophageal fistula was identified on the posterior tracheal wall following bronchoscopic assessment of the trachea. Therefore, the requested PCT procedure was aborted. An open tracheostomy in the operating room was completed; however, due to the position and depth of the ulcer, a reinforced endotracheal tube (ETT) was placed via the tracheostomy. Four days later, the reinforced ETT was replaced with a Shiley distal extended tracheostomy tube to bypass the ulceration. Careful inspection and evaluation of the tracheostomy site before PCT prevented a potentially life-threatening issue in our patient.

The information available to the author indicates that the only fatalities attributable to laser emissions (beams) have resulted from medical laser procedures and that the most prevalent cause of death and serious injury during laser surgery is airway fires. The airway fire reported in this paper is the second such case for which the author has served as an expert witness. The first case was presented at ILSC-2003 [1] and in that paper the question, “When will laser-induced airway fires cease?”, was posed. As the case herein described was settled out of court in 2006 and as other airway fires have occurred since 2003, it is most appropriate to ask this question again. Both the immediate and root causes for this particular airway fire and for such fires in general will be presented. This paper closes with a protocol, which if followed consistently during CO2 laser airway surgery, should significantly minimizing, if not eliminating, the likelihood of such fires.

Tracheostomy is one of the most common procedures performed in trauma patients in the intensive care unit (ICU). Few studies have evaluated the incidence of surgical site infections (SSIs) specifically in a trauma population. Our objective was to compare the incidence of SSI after open versus percutaneous tracheostomy and to discern whether there were any differences in outcome. A prospective single-institution study was conducted on 640 patients admitted to the ICU over eight years who underwent tracheostomy. Age, gender, race, admission Injury Severity Score (ISS) and Acute Physiology and Chronic Health Evaluation (APACHE) II score, and mechanism of injury were obtained. The majority of patients were male (56.1%) and white (62.5%) with a mean age of 43.2 ± 20.2 years, ISS of 30.7 ± 13.2 points, and APACHE score of 13.3 ± 6.3 points. The majority of patients were admitted for blunt trauma (85.1%). The outcome was measured by hospital (HLOS) and ICU (ILOS) lengths of stay, duration of mechanical ventilation, infection rate, and mortality rate. A total of 330 open and 310 percutaneous tracheostomies were performed. A total of 36 SSIs (5.3%) were found. Patients who underwent percutaneous tracheostomy had a statistically significantly lower rate of SSI (3.4%) than the open surgery group (7%) (p=0.04). There was no difference in HLOS, ILOS, ventilator days, or mortality rate. To our knowledge, this is the largest study of the benefit of percutaneous tracheostomy in a critically injured trauma population. The risk of SSI is significantly lower after percutaneous than open tracheostomy.

Tracheotomy is one of the most common surgical procedures performed in the ICU setting. Traditionally tracheotomy has been performed by otolaryngologists as well as general surgeons. While percutaneous tracheotomy (PT) has been available for some time, it has only recently gained widespread acceptance with the advent of convenient and safe kits. Over the past decade, there has been increased utilization of this technique. However, there is a relative reluctance of certain surgical specialties to perform and train residents in PT; a previous study identified that only 29% of otolaryngology head and neck surgery (OTO-HNS) departments in the USA perform PT. In this study we aim to investigate the trends of PT usage in general surgery training programs and compare them to those previously described in otolaryngology programs. The study design is multi-institution physician survey and the study method was a survey of 250 general surgery program directors. This survey was identical to a published survey of OTO-HNS and a head-to-head comparison of results was performed. The response rate was 53% (133 programs). 89% of general surgery programs performed open tracheotomy on a regular basis. 75% performed percutaneous tracheotomy on a regular basis. 79% use the Ciaglia Blue Rhino method. Simultaneous video bronchoscopy was used by 67%. 83% of general surgery residency programs train their residents in PT. 61% felt that PT was either safer than or equal to open tracheotomy. PT is performed in a majority of general surgery residency programs and taught to their trainees. This is in contrast to otolaryngology residency programs, which have been shown to prefer open tracheotomies in both practice and teaching. This trend may severely impact the skills of the next generation of otolaryngologists.

Practice Advisory for the Prevention and Management of Operating Room Fires: An Updated Report by the American Society of Anesthesiologists Task Force on Operating Room Fires Jeffrey Apfelbaum;Robert Caplan;Steven Barker;Richard Connis;Charles Cowles;Jan Ehrenwerth;David Nickinovich;Donna Pritchard;David Roberson;Robert Caplan;Steven Barker;Richard Connis;Charles Cowles;Albert de Richemond;Jan Ehrenwerth;David Nickinovich;Donna Pritchard;David Roberson;Gerald Wolf; Anesthesiology

To the Editor Under the current situation of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, evidence on patient management has been published in real-time, changing according to new experiences and release of clinical research that cover the comprehensive care of patients with coronavirus disease 2019 (COVID-19). The study by Bassi et al1 is very appropriate, mainly the algorithm on the correct choice of the tracheostomy technique in agreement with the characteristics and conditions of the patients. After reading the article, we present the following considerations: Patients with COVID-19 show a decrease in viral load from day 14 of the onset of symptoms. Therefore, the risk of transmission, even by aerosols, is significantly reduced by this time. Thus, there are no advantages between percutaneous and open tracheostomy,2 as mentioned in the article. Furthermore, there is evidence showing no difference in infection rate between personnel performing these approaches.3 The average time required to perform percutaneous tracheostomy is lower than the time needed for the conventional technique.3 We believe the reduction in the duration of the procedure may be an advantage, as patients are often critically ill with poor tolerance to hypoxia. Given the necessity to incise the trachea under direct vision, the use of energy devices, such as bipolar cautery or harmonic scalpel, to control bleeding during an open tracheostomy may lead to an increased risk of aerosolization. Moreover, the use of a bronchoscope as a guide in tracheostomy might increase aerosol production, due to the requirement to intermittently open the circuit under positive pressure ventilation. Thus, a sealing port is used, and ventilation is paused for insertion and extraction of the bronchoscope.4 Perioperative complications are less common using the percutaneous approach when compared to the open tracheostomy. These complications include accidental decannulation, air leak from de fistula, major bleeding, surgical site infection, and tracheal stenosis.5 The election of an approach (percutaneous or open tracheostomy) depends on different factors like availability of resources, surgeon experience, and characteristics of patients. Open tracheostomy may require the patient to be transferred to the operating room, with the consequent circuits’ disconnection. In our institution, percutaneous tracheostomies are the election technique in patients with COVID-19. We have performed around 100 percutaneous tracheostomies in our hospital, all carried out in the intensive care unit (ICU). We believe the best approach is whatever the surgical team feels more comfortable with and the one they have the most experience. Oswaldo Amaya, MDEnrique Arango, MDStefanie Pabón, MDSara Mejía, MDMaría C. Montoya, MDGuillermo Madrid, MDDepartment of AnesthesiaFundación Santa Fe de BogotáBogotá D.C., Colombia[email protected]

Safe Use of High-Flow Oxygenation During Transoral Laser Microsurgery Without Airway Fire: A Review of 369 Consecutive Cases.

Studying airflow structures in periodic cylindrical hills of human tracheal cartilaginous rings

Associate Professor of Anesthesia and Critical Care (Faure)Assistant Professor of Anesthesia and Critical Care (Cook)Department of Anesthesia and Critical Care; University of Chicago; Chicago, Illinois; eaf3@midway.uchicago.edu (Miles)To the Editor: - Venous air embolism has been reported during neurologic and cardiothoracic procedures, but only one report describes it during arthroscopy. [1]We report an additional case that occurred during shoulder arthroscopy.A 40-yr-old healthy woman was scheduled for arthroscopy of the left shoulder. There was no history of allergy or reactive airway disease. She was administered general anesthesia with sevoflurane/nitric oxide/oxygen after placement of an interscaline block. Ventilation was controlled. The patient was placed in the beach-chair position. After the skin incision was made, the surgeon injected 60 ml air into the joint, after which the arthroscope was inserted. This was followed by the infusion of saline into the joint. Within 3 min after the insertion of the arthroscope, the end-tidal carbon dioxide (ETCO2) decreased to less than 10 mmHg. The oxygen saturation by pulse oximetry (SpO2) decreased to less than 90% before the signal acquisition was lost. Blood pressure measurement was unobtainable. The electrocardiogram showed a sinus rhythm at 90 beats/min. Anesthetics were discontinued, manual ventilation with 100% oxygen was begun, surgery was discontinued, and the patient was placed in the supine position. No pulse was felt in the groin or the neck, and closed chest massage was begun. At the same time, 1 mg intravenous epinephrine was administered. After approximately 3 min, spontaneous pulses were palpated. A radial artery catheter was placed, revealing a pressure of 160/100 mmHg. Oxygen saturation remained below 90%, but the capnogram returned to normal height with an end-expiratory value of 34 mmHg. The oxygen saturation gradually rose to the low 90% range. An arterial blood gas sample showed a pH of 7.25, a PO2of 64 mm Hg, a PCO2of 48 mmHg, and a base deficit of -6. The patient was transferred to the intensive care unit. Serial cardiac enzymes did not reveal myocardial infarction. Subsequent chest radiography was consistent with mild pulmonary edema and elevated right hemidiaphragm, but not pneumothorax. The patient was extubated the next day and discharged from hospital in good condition on the second postoperative day.When cardiopulmonary resuscitation was begun, we were not aware of the insufflation of air because it was used for the first time by this surgeon. Later, we learned that 60 ml air had been injected followed by a jet stream of crystalloid solution.The Australian Incident Monitoring Study (AIMS) reported the overall incidence of detectable venous air embolism in 2000 incidents to be 1%. [2]The surgical field was the entry field in 63% of cases, 47% occurred during head and neck surgery. The incidence of venous air embolism is increased to 15% when the patient is in the sitting position, as in neurosurgical procedures and forceful insufflation [3]of air into the operating field. Slow infusion of air or small amounts of air might be undetected in the anesthetized patient and may occur more often than reported. By control, the rapid changes seen in our patient suggested the injection of air over a short period. In our patient, the disappearance of the end expired carbon dioxide wave was most useful, not only for early detection, but also for confirmation of the diagnosis. Although the incident of venous air embolism during arthroscopy is rare, the possibility has to be kept in mind.Eveline A. M. Faure, M.D.Associate Professor of Anesthesia and Critical CareRichard I. Cook, M.D.Assistant Professor of Anesthesia and Critical CareDavid Miles, C.R.N.A.Department of Anesthesia and Critical Care; University of Chicago; Chicago, Illinois; eaf3@midway.uchicago.edu(Accepted for publication May 12, 1998.)

Lasers emit very high-intensity light with a narrow focus. With proper use, lasers allow surgeons to operate on small areas in a confined space, with reduced blood loss, decreased postoperative discomfort, and better wound healing. The most popular laser in otolaryngeal procedures is carbon dioxide (CO2) laser, which typically requires general anesthesia. Airway pathologies often pose potential challenges to airway management for anesthesiologists. A detailed history and physical exam combined with imaging studies are essential for airway evaluation and management. Preoperative smoking cessation is strongly advised. One of the most devastating complications of airway laser surgeries is airway fire. Close communication among OR personnel is essential for prevention of airway fire. Minimizing the oxygen concentration and using laser-resistant endotracheal tubes are among the commonly used strategies to prevent airway fire. The American Society of Anesthesiologists (ASA) Task Force on Operating Room (OR) Fires has developed guidelines and an algorithm to manage OR fires. Anesthesiologists should also be familiar with other hazards associated with laser procedures and how to prevent or minimize them. Two main strategies have been developed for laser surgeries in the airway: endotracheal intubation with intermittent apnea phases, and jet ventilation. Each strategy has its unique advantages and disadvantages. Total intravenous anesthesia technique is commonly used for these procedures in order to maintain a steady state of anesthesia that would not be attainable with inhalational techniques using intermittent ventilation. Other potential complications associated with laser surgery of the airway include dental injuries, postoperative airway edema, barotrauma, pneumothorax and subcutaneous emphysema, etc. Close communication with surgeons and other OR personnel is the key component to ensure safe anesthesia care for patients undergoing airway laser surgeries.

In carbon dioxide (CO2) laser surgery of the larynx, the potentially dangerous combination of laser-induced heat in an oxygen-enriched atmosphere typically occurs when jet ventilation is used or due to an insufficiently blocked endotracheal tube. Until now, no limitations for safe oxygen concentrations or laser intervals have been established. The aim of this study was to investigate and quantify the factors that may contribute to an airway fire in laryngeal laser surgery. Fat, muscle and cartilage were irradiated with a CO2 laser at 2, 4, 6 and 8 W in five different oxygen concentrations with and without smoke exhaustion. The time to ignition was recorded for each different experimental setup. Fat burnt fastest, followed by cartilage and muscle. The elevation of laser energy or oxygen concentration reduced the time to inflammation of any tissue. The elevation of oxygen by 10 % increases the risk of inflammation more than the elevation of laser power by 2 W. Under smoke exhaustion, inflammation and burning occurred delayed or were even inhibited at lower oxygen concentrations. Lasing in more than 50 % oxygen is comparatively dangerous and can cause airway fire in less than 5 s, especially when laser energies of more than 5 W are applied. In equal or lower than 50 % oxygen, an irradiation interval of 5 s can be considered a comparatively safe time limit to prevent inflammation in laryngeal laser surgery. Smoke exhaustion should always be applied.

Background: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-associated viral infection (coronavirus disease 2019, COVID-19) is a virulent, contagious viral pandemic that is affecting populations worldwide. As with any airborne viral respiratory infection, surgical and non-surgical patients may be affected. Methods: Review and synthesis of pertinent English-language literature pertaining to COVID-19 infection among adult patients. Results: COVID-19 disease that requires hospitalization results in critical illness approximately 25% of the time and requires mechanical ventilation with positive airway pressure. Acute kidney injury, a marked hypercoagulable state, and sometimes myocarditis can be features of COVID-19 in addition to the characteristic severe acute lung injury. Even if not among the most seriously afflicted, older patients with medical comorbidities are both predisposed to infection and risk increased morbidity and mortality, however, all persons presenting for surgical intervention should be suspected of infection (and thus transmissibility) even if asymptomatic. Although most elective surgery has been curtailed by administrative or governmental fiat, patients will still need urgent or emergency operative intervention for time-sensitive disease processes such as malignant neoplasia or for true emergencies such as perforated viscus or traumatic injury. It is possible to provide safe surgical care for SARS-CoV-2-positive patients and minimize nosocomial transmission to healthcare workers. Conclusions: This guidance will facilitate appropriate protection of patients and staff, and maintenance of infection control measures to assist surgical personnel and facilities to prepare for COVID-19-infected adult patients requiring urgent or emergent operative intervention and to provide optimal patient care.