Laryngeal Papillomatosis with High BMI

You are assessing a 33 year old morbidly obese woman in preparation for the laser ablation of severe laryngeal papillomatosis. How will you assess this patient?


Laryngeal papillomatosis

o Presence of stridor

o Exercise capacity

o Respiratory distress

o Previous treatments


Morbidy Obesity

o Presence of co-morbidities such as

§ OSA

§ DM

§ HTN

§ RLD/Asthma

PMH ,Meds/allergies, FH, AnesthHx, Previous airway management


Exam

o Airway

o CVS

o Resp


Imaging

§ CT

o Nasopharyngoscopy by surgeon

o Past anesthetic records


You discover that the patient has had laser ablation in the past and is a known difficult airway. Her airway has been previously captured with awake flexible bronchoscopy. She has mild stridor that becomes worse with activity. Her BMI is 50. The airway obstruction wasn’t critical on nasopharyngscopy. The surgeon informs you that the ablation can be performed with a laser-safe endotracheal tube. What are your anesthetic considerations?


Laryngeal papilomatosis

o Need for infection control (N95 mask)

Laser precautions

o Need for eye protection (patient and staff)

Shared airway

Known Difficult intubation

Morbid Obesity

o With potentially difficult BMV, Laryngeal mask placement and FONA

Stimulating procedure

o Need for deep anesthesia

o Need for paralysis

§ Short procedure


You proceed with an awake fiberoptic intubation. Despite great difficulty you manage to secure a laser safe endotracheal tube and administer an uneventful IV induction, paralysis and TIVA maintenance once the endotracheal tube position has been confirmed. The surgery continues as planned until a large amount flame and smoke are visualized in the endotracheal tube and airway. The surgeon confirms that they inadvertently penetrated the tube with the laser. The patient’s saturations rapidly decline to the high 60’s. How do you proceed?



CONFLICT: Known airway fire and need to remove the fuel (the endotracheal tube) in the presence of a potentially impossible airway.


Things to be done immediately and concurrently

o Call for help

o Call for the difficult airway cart

§ Especially for LMA, cric/trach equipment

§ Flex bronch

o Decrease FiO2

o Flood the field/tube with saline.


Although a difficult decision to make given the complicating factors listed below, the decision should be made to immediately remove the endotracheal tube as it would risk further damage to the airway. One would have to quickly provide ventilation through other means while actively attempting to re-intubate. After flooding the field one could consider an intubating conduit of some sort as well

o Features of difficult BMV

o Features of difficult Intubation

o Features of difficult surgical airway


Plans should be made to immediately assess the lower airway with bronchoscopy once a secure airway is achieved as well as some description of post op disposition (ICU with ETT in place)


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