Good relationship with surgeon paramount. Usually they will specify type of ETT and position.
ETTs can become displaced, compressed and kinked easily. Vigilance is necessary. Reinforced ETTs are commonly used.
Nasal ETTs are commonly required for procedures involving the jaw and oral cavity.
Flexible reinforced LMAs are being increasingly used for short procedures that are not expected to bleed. This must be a measured informed decision taking into account increased risk of displacement and surgical access restriction.
Throat packs may be inserted by the surgeon or anaesthetist. Local policy must be followed with regard to safety and avoidance of retention.
Verbal declaration of insertion and removal
Visual cue on the patient themselves (e.g. sticker or part of pack)
Written on board in theatre
Part of swab count
Recorded in anaesthetic chart
Eyes should be kept closed with appropriate tape and padded as necessary, ensuring pressure from equipment is prevented.
Range from the young and fit to elderly and with many comorbidities.
Head and neck cancer patients are often smokers with co-existant cardiorespiratory disease and all the associated complications.
Previous neck irradiation is common and may cause problems during airway management due to immobility of neck, poor mouth opening and lack of saliva.
Maxillofacial/Dental Surgery: Surgical extraction of impacted/buried teeth; maxillary/mandibular osteotomy; fixation of zygomatic fracures; ORIF fractured mandible; major head and neck reconstructions and free flap surgery (see separate section)
May occur intra-operatively or post-operatively. Can occur into the airway which could become threatened. Primary haemorrhage usually requires rapid re-intubation and surgical exploration.
Operations such as radical neck dissection and laryngectomy have potential for major haemorrhage due to proximity of major vessels and IV access should be planned accordingly.
The nature of the operation and the patient population lends itself to high rate of laryngospasm.
Awake extubation or deep extubation (especially in children) to avoid this.
Awake extubation in ALL patients with a difficult airway.
Deep extubation in adults should only be done by an experienced anaesthetist in this area. It is best suited to SV.
At the end of surgery, increase volatile agent concentration, discontinue NO. After careful suction, insert guedel airway, turn patient left lateral/head down, check respiration is regular then extubate. Keep patient in this position until airway reflexes return.
Intense opioid action of remifentanil and its rapid recovery profile makes it ideal for many ENT/MaxFax procedures.
Facilitates controlled arterial hypotension to reduce bleeding in middle ear surgery/major head and neck resections.
In procedures where facial nerve monitoring occurs (e.g. parotidectomy), remifentanil facilitates IPPV without relaxant.
Attenuates hypertensive response during prolonged laryngoscopy/pharyngoscopy.
Superior antiemetic properties. Attenuates post operative airway swelling. Morphine-sparing.
End of procedure laryngoscopy
Removal of coroner’s clot (blood accumulation in nasopharynx which can be aspirated following extubation with fatal results)
Suction under direct vision, especially around vocal cords: vigilance with this can avoid post operative complications e.g. laryngospasm
Impaired Ventilation: hypoxia; hypercapnia; airway soiling by debris/secretions
The important and inter-related variables are: rate/frequency f; driving pressure DP; inspiratory time I-time (%ventilatory cycle); inspired oxygen fraction FI02.
A typical parameter set for HFJV via a subglottic catheter is DP 2 atm; f 150 per min; FI02 1.0 (can be decreased to 0.25 if using LASER); I-time 50%
Low Frequency Jet Ventilation: hand held apparatus e.g. Sander’s injector/Manujet. Used for short procedures.
Hand held jet apparatus used supraglottically and attached to a rigid bronchoscope
Attached to high-pressure wall piped O2 at 4 bar. Passed through pressure reducing valves and can be further adjusted via a regulator near the handset to a pressure that produces desired chest wall movement
Frequency of 8-10 per minute allows adequate time for exhalation via passive recoil and prevents air trapping.
Effective FI02 in trachea is 0.8-0.9 because of entrainment of ambient air
TIVA must be used
Muscle relaxant usually used, but some centres use alternative methods such as strong short acting opioid (e.g. remifentanil); local anaesthetic to cords to facilitate passage of small diameter tube
LASER (Light Amplified by Stimulated Emission of Radiation)
TIVA if high frequency ventilator, manual jet ventilation or THRIVE used.
If specific LASER ETT used normal ventilation with volatile agents should be possible but be wary of surgical compression/high airway pressures.
Inspired O2 should be decreased to 25% or less when LASER is in use.
Air/O2 mixtures only. No nitrous oxide.
Equipment: LASER endotracheal tubes
Silicone rubber tubes with metal links incorporated into the tube wall with either a sponge cuff or a double cuff. If the cuff bursts the sponge will maintain a sealed airway. If one cuff bursts in the double cuff option, the second cuff can be used.
Foil wrapped tubes with outer Teflon coat with cuff filled with methylene blue crystals so that if the laser bursts the cuff it is detected quickly by the surgeon.
Cuffs should be inflated with saline and not air.
Patient: Eye protection with moist pads
Patient: Other nearby tissues should be protected with wet swabs. Beware of drying out of swabs and pledgets inserted into airway by surgical team.
Staff: Protective LASER goggles
LPS (laser protection supervisor) should be named for every clinical area in which a laser is used.
Non reflective black-matt surgical instruments to minimise reflection
SWITCH OFF LASER
FLOOD OPERATION SITE WITH SALINE
DISCONNECT ANAESTHETIC CIRCUIT AND REMOVE ETT IF FEASIBLE
VENTILATE PATIENT with AIR using bag/valve/mask
After fire has been extinguished, the surgeon should inspect the airway with a rigid bronchoscope. Consider keeping patient intubated and transfer to ICU in case of developing airway oedema.