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Anesth Analg 2004;99:1882
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000140810.31194.26

LETTERS TO THE EDITOR

Should CO2 Laser Jet Ventilation Be Abandoned?

Mitchel B. Sosis, MD, PhD

Lafayette Hill, PA, mitchelsosis@hotmail.com

To the Editor:

I read with interest the recent case report by Leemann et al. on the use of a Teflon catheter for high-frequency jet ventilation during carbon dioxide (CO2) laser laryngeal surgery employing a jetting pressure of 2.3 atm (1). The authors noted the occurrence of subcutaneous emphysema to the neck and thorax, bilateral pneumothoraces, and a mediastinal shift to the left. The case was terminated before the tumor was completely removed, but the patient underwent a second procedure using a jetting pressure of 0.5 atm for removal of the residual tumor on the next day. However, the subcutaneous emphysema recurred after only a few seconds. Surgery was then successfully continued employing a Mallinckrodt Laser-FlexTM endotracheal tube. It was later determined that the Teflon catheter had been damaged by the laser.

Several points are in order in a discussion of this case:

  1. The original pressure employed for the jet ventilation was 2.3 atm. This pressure is equivalent to 2,367 cm of water and can easily cause the kinds of problems encountered in the case (2).
  2. Teflon was already known to be vulnerable to the CO2. For example, the Teflon wrapping on the Xomed Laser Shield II endotracheal tube was shown to be rapidly vaporized by this laser (3).
  3. The occurrence of the kinds of barotrauma noted after the first operation indicates the occurrence of a mucosal rent or passageway for the jetting pressure. Thus, once these complications have occurred, the technique should not be used again on the next day.
  4. Cases of this type can be handled successfully employing laser-resistant endotracheal tubes, thus avoiding the severe risks of high-frequency jet ventilation.

References

  1. Leemann B, Heidegger T, Grossenbacher R, et al. A severe complication after laser-induced damage to a transtracheal catheter during endoscopic laryngeal surgery. Anesth Analg 2004; 98: 1807–8.[Abstract/Free Full Text]
  2. Sosis MB. Anesthesia for laser surgery. Problems in Anesthesia 1993; 7: 239–46.
  3. Sosis MB. Anesthesia for laser surgery. Problems in Anesthesia 1993; 7: 233–4.
 

Response

Bettina Leemann, MD*, Thomas Heidegger, MD*, Rudolf Grossenbacher, MD{dagger}, Thomas Schnider, MD*, and Hans J. Gerig, MD*

Departments of *Anesthesiology and {dagger}Ear, Nose, Throat, Head, and Neck Surgery, St. Gallen Cantonal Hospital, St. Gallen, Switzerland, bettina.leemann@kssg.ch

In Response:

We would like to thank Dr. Sosis for his interest in our case report. The operating pressure for high-frequency jet ventilation through a transtracheal catheter is between 2.8 to 4.0 atm (2800–4000 cm H2O, respectively) in order to overcome the high resistance of the 13-gauge catheter. To prevent barotraumas under these conditions the pressure in the trachea is automatically controlled and our ventilator stops, if pressure is higher than 50 cm H2O. Even though we have been using laser resistant tubes over more then 10 years (1), our surgeons prefer percutaneous transtracheal catheters because they give perfect surgical conditions (2,3). Retrospectively, it can surely be discussed whether the primary use of a laser resistant tube for the second operation would have been the better choice.

References

  1. Gerig H, Heidegger T, Ulrich B, et al. Fiberoptically guided insertion of transtracheal catheters Anesth Analg 2001; 93: 663–6.[Abstract/Free Full Text]
  2. Monnier PH, Ravussin P, Savary M, Freeman J. Percutaneous transtracheal ventilation for laser endoscopic treatment of laryngeal and subglottic lesions. Clin Otolaryngol 1988; 13: 209–17.[ISI][Medline]
  3. Bourgain JL, Desruennes E, Fischler M, Ravussin P. Transtracheal high frequency jet ventilation for endoscopic airway surgery: a multicentre study. Br J Anaesth 2001; 87: 870–5.[Abstract/Free Full Text]




This Article
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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press