Spontaneous respiration anesthesia for respiratory papillomatosis

Strategies for CO2 Laser Use in Laryngeal Microsurgery: A Systematic Review

OBJECTIVE

We aim to systematically review the literature addressing perioperative practices for optimal use of the CO2 laser in laryngeal transoral laser microsurgery (TOLMS), with a focus on safety.

DATA SOURCES

A systematic review of publications indexed in Medline, Embase, and EBM reviews-Cochrane Central Register of Controlled Trials which evaluated perioperative strategies for the use of CO2 laser in laryngeal TOLMS was conducted.

REVIEW METHODS

Records obtained from the search strategy were assessed for eligibility in a 2-step process by 2 independent researchers using the Covidence software.

RESULTS

Among 2143 identified records, 103 were included in this study. The majority of studies (n = 25) focused on the use of the CO2 laser in oncologic resection, while 20 addressed the treatment of vocal cord paralysis, 16 discussed the treatment of pediatric or congenital pathologies, 11 detailed the management of benign lesions, and 31 studies tackled other surgical indications. Strategies for safe CO2 TOLMS were highly heterogeneous across studies and included preoperative measures (ie, related to the environment, staff preparation, patient protection, and ventilation), intraoperative precautions (ie, protection of nontarget structures, technical considerations, topical and systemic medications), and postoperative strategies (ie, related to airway protection, oral intake, vocal rest, hospitalization duration, drug regimen, and consultant follow-up).

CONCLUSION

The results provided in this study can be used as a framework to guide the creation of laser safety protocols across institutions, guide quality improvement initiatives, the development of simulation training activities, and as a tool to facilitate resident teaching and skill assessment.

Pediatric airway surgery under spontaneous respiration using high-flow nasal oxygen

OBJECTIVES

In pediatric airway surgery, SponTaneous Respiration using IntraVEnous anesthesia and Hi-flow nasal oxygen (STRIVE Hi) has not been well explored. Here, we report our experience of using STRIVE Hi in endoscopic evaluations and surgeries of the pediatric airway.

METHODS

This retrospective review was based on 45 airway procedures conducted under STRIVE Hi, performed by a single surgeon at a single institute from May 2017 to September 2018. After induction of anesthesia, continuous infusion with propofol and remifentanil was provided to ensure an adequate level of anesthesia and supply of humidified oxygen via a nasal cannula. Monitoring was conducted using a transcutaneous CO₂ sensor and a pulse oximeter, and the oxygen reserve and bispectral indexes were measured. No muscle relaxant was administered.

RESULTS

The median age of the patients was 16.0 months (range: 1-215 months) and the median weight was 10.2 kg (range: 2.4-38.5 kg). The median duration of spontaneous respiration was min 40 (range: 10-140 min). The airway procedures included diagnostic microlaryngoscopy, tracheocutaneous fistula excision, balloon dilation, supraglottoplasty, laryngeal cleft repair, injection laryngoplasty, papilloma excision, and subglottic cyst removal. During these procedures, STRIVE Hi facilitated evaluation of dynamic obstruction of the airway and the immediate outcome of surgical treatment and provided a good surgical view. Intubation and the termination of spontaneous respiration were required in only five patients.

CONCLUSIONS

STRIVE Hi is an effective and feasible anesthesia option in pediatric airway surgery. It provides unobstructed surgical access and is applicable to a wide range of procedures.

Safety of paediatric day-stay laryngeal surgery for recurrent respiratory papillomatosis

OBJECTIVES

Safety assessment of day-stay laryngeal surgery in a cohort of children with recurrent respiratory papillomatosis (RRP). Recurrent respiratory papillomatosis is a chronic debilitating disease which usually requires multiple recurrent interventions under general anaesthesia. Day-stay surgery is an attractive option as it allows avoiding the inconvenience and costs of routine overnight admissions while recovering in the safe environment of the family home. This is the first study to assess the safety of day-stay laryngeal surgery in this cohort of patients.

METHODS

Retrospective cohort study of all consecutive RRP procedures performed between December 1998 and May 2015 in a single paediatric tertiary-level hospital.

RESULTS

A total of 465 surgical procedures were performed in 20 patients. Average age on diagnosis was 4.5 years. 415 (89.25%) of the procedures were done as day cases without overnight admission. Average number of procedures per patient was 20 and 25 for Children positive to HPV6 and HPV11, respectively. Only one patient after one single procedure (presenting 0.21% of total procedures, 0.24% of day-stay procedures) represented after discharge.

CONCLUSIONS

Day-stay surgery for children with RRP has a favourable safety profile in selected cases.

The use of a double-lumen central venous catheter for airway management in pediatric patients undergoing laryngeal papillomatosis surgery

PURPOSE

To evaluate the efficacy and safety of a spontaneous ventilation anesthesia technique with insufflation of oxygen and volatile agent through a double-lumen central venous catheter (DLCVC) in pediatric patients undergoing suspension laryngoscopic surgery for laryngeal papillomatosis.

METHODS

Thirty-six pediatric patients with laryngeal papillomatosis undergoing suspension laryngoscopic surgery were anesthetized with oxygen and volatile anesthetic insufflation while spontaneously breathing. Anesthesia was induced by inhalation of 8% sevoflurane in oxygen by mask. Atropine, dexamethasone, lidocaine, and midazolam were administered intravenously. The tip of a 7Fr DLCVC was inserted below the glottis after placement of the laryngoscope and establishing suspension. Anesthesia was maintained with insufflation of 4-6% sevoflurane and oxygen with a total fresh gas flow of 6 l·min(-1) through the 14G (larger lumen) of the DLCVC. Endtidal carbon dioxide tension (PetCO2) was monitored using the other lumen of the DLCVC, which was connected to the CO2 sampling line. Duration of the procedure as well as total anesthesia time was recorded. Electrocardiography (ECG), heart rate (HR), mean arterial pressure (MAP), oxygen saturation (SpO2), and PetCO2 were also monitored. Arterial blood was sampled for blood gas analysis including pH, PaO2 , PaCO2 , and actual base excess (ABE). Complications, including intraoperative patient movement, hypoxemia (SpO2 < 95% during oxygen insufflation), nausea, vomiting, bronchospasm, and arrhythmias, were recorded.

RESULTS

There was a significant increase in PetCO2 and PaCO2 (P values <0.05) as well as a decrease in ABE, pH, and PaO2 (P values <0.05) in samples collected before and after surgery. MAP, HR, and SpO2 after surgery were not significantly different from after induction values (P values >0.05). During surgery, SpO2 < 95% in three cases and body movements in three cases were observed. No patient had any other of the complications previously described. Furthermore, no postsurgical endotracheal intubation was needed in any patient.

CONCLUSION

After establishing an adequate depth of anesthesia, a spontaneous ventilation anesthesia technique with insufflation of oxygen and volatile agent through a DLCVC is feasible in pediatric patients undergoing suspension laryngoscopic surgery for laryngeal papillomatosis.

Airway management in pediatric patients undergoing suspension laryngoscopic surgery for severe laryngeal obstruction caused by papillomatosis

OBJECTIVES

To review perioperative airway management and ventilation strategy during the surgical removal of papilloma under suspension laryngoscopy in pediatric patients with severe airway obstruction.

METHODS

Seventy pediatric patients with degree III and IV laryngeal obstruction who underwent suspension laryngoscopy to remove laryngeal papillomatosis, between July 2005 and March 2009, were included in the study. All patients were intubated initially to secure the airway. Controlled ventilation through an endotracheal (ET) tube was used during the papilloma debulking near the glottis vera. Spontaneous ventilation or apneic technique was adopted based on the stage of the surgical procedure and the location of the remaining tumor. Hemodynamic parameters, pulse oxygen saturation (SpO(2)), and CO(2) were closely monitored, and adverse events were recorded.

RESULTS

The duration of the surgical operation and the duration of the extubation period were 5-35 min and 5-20 min, respectively. Thirty cases with degree III and twenty cases with degree IV laryngeal obstruction received inhalation induction. Sixteen cases with degree III laryngeal obstruction were given an intravenous induction. Four patients admitted with a comatose status were emergently intubated without any anesthetics. The ET tube size was determined by assessing the opening through the tumor mass or glottic aperture under direct laryngoscopy. SpO(2) was maintained above 97% after the airway was secured and sufficient ventilation established. Controlled ventilation was used in all children during the bulk removal of tumor. Spontaneous respiration and apneic technique were adopted for the removal of the remaining tumor in the hypolarynx or trachea in 16 and 28 cases, respectively. Three patients had to be re-intubated postoperatively because of persistent desaturation or laryngospasm.

CONCLUSION

Key points of perioperative airway management in pediatric patients with papillomatosis-induced severe laryngeal obstruction include careful preoperative airway evaluation; the proper choice of induction methods, and ET tube size; maintenance of an adequate depth of anesthesia; and flexible ventilation strategy, continuous and close monitoring during the extubation and postextubation period; and prompt management of adverse events.

Anesthesia for pediatric airway surgery: recommendations and review from a pediatric referral center

Pediatric airway surgery presents many significant challenges to the anesthesia provider. The clinical experience of the Massachusetts Eye and Ear Infirmary serves as a guide in this review to describe the clinical reasoning and perioperative management of the pediatric patient needing airway surgery, with specific emphasis on diagnostic procedures, trauma, laryngotracheal reconstruction, juvenile recurrent respiratory papillomatosis, and adenotonsillectomy.

Comparison of intravenous general anaesthesia vs endotracheal intubation in the surgical management of juvenile onset recurrent respiratory papillomatosis

CONCLUSIONS

Both intravenous general anaesthesia (IVGA) and general anaesthesia with endotracheal intubation (GA with ET) are applicable for the procedure of juvenile onset recurrent respiratory papillomatosis (JO-RRP). GA with ET was found to be better for JO-RRP patients with dyspnoea, as it provided better stabilization of the vital signs with fewer postoperative complications.

OBJECTIVES

To evaluate the safety and efficacy of two different anaesthetic techniques in the removal of JO-RRP.

METHODS

A total of 52 JO-RRP patients with mild dyspnoea were included in the study. Each case underwent two procedures, one by IVGA and the other by GA with ET. A total of 104 procedures were performed. The effectiveness and safety of the two anaesthetic techniques were pairwise compared.

RESULTS

There were no significant differences in anaesthetic recovery time, operative time or postoperative voice quality between the two anaesthetic groups. However, significant differences in heart rate, oxygen saturation and carbon dioxide saturation were observed. Some patients who underwent IVGA developed apnoea (28.8%) and laryngeal spasm (19.2%). These complications were not observed in the GA with ET group.

The role of HPV type in Recurrent Respiratory Papillomatosis

OBJECTIVE

Human Papillomavirus (HPV) 6 and 11 are the aetiological agents responsible for Recurrent Respiratory Papillomatosis (RRP). There is general consensus that HPV11 results in more aggressive disease compared to HPV6.

METHOD

Pubmed was searched using the terms respiratory papillomatosis, HPV 6 and HPV11. Comparisons were made in the outcomes of HPV6 versus HPV11 positive RRP disease.

RESULTS

There are numerous sub-types or variants of both HPV6 and HPV11. These sub-types have different activities at least in-vitro. The numbers of different HPV types within RRP tissue may be more extensive than initially appeared. This depends specifically upon the HPV types tested for.

CONCLUSION

The clinical differences between HPV6 and HPV11 disease may not be accurately predictable as these viruses exist in numerous sub-types. Also, RRP tissue may contain more than one subtype or even be co-infected with other viruses that may influence outcome. In-vitro studies upon cell lines are a reasonable starting point for evaluation of these differences.

Anesthesia for laser surgery of the airway in children

Anesthesia for laser surgery in children carries a number of particular challenges and pitfalls. The anesthetist must be aware not only of the problems of anesthetizing a patient with a potentially compromised airway but also of how to maintain homeostasis when surgery is taking place, as procedures may make a bad situation temporarily worse. Personnel must also be very aware of the benefits and dangers of medical lasers, and what safety precautions must be taken to ensure their proper use. This section will deal with the properties of lasers, how and why they are used, and a description of how these procedures are carried out in our own institution.

Juvenile recurrent respiratory papillomatosis: still a mystery disease with difficult management

Juvenile recurrent respiratory papillomatosis (RRP) is the most common benign neoplastic disease of the larynx in children and adolescents and has a significant impact on patients and the health care system with a cost ranging from $60,000 to $470,000 per patient. The aim of this paper is to review the current literature on RRP and summarize the recent advances. RRP is caused by human papillomavirus (HPV; mainly by types 6 and 11). Patients suffer from wart-like growths in the aerodigestive tract. The course of the disease is unpredictable. Although spontaneous remission is possible, pulmonary spread and malignant transformation have been reported. Surgical excision, including new methods like the microdebrider, aims to secure an adequate airway and improve and maintain an acceptable voice. Repeated recurrences are common and thus overenthusiastic attempts to eradicate the disease may cause serious complications. When papillomas recur, old and new adjuvant methods may be tried. In addition, recent advances in immune system research may allow us to improve our treatment modalities and prevention strategies. A new vaccine is under trial to prevent HPV infection in women; the strongest risk factor for juvenile RRP is a maternal history of genital warts (transmitted from mother to child during delivery). Better understanding of the etiology of the disease and the knowledge of all available therapies is crucial for the best management of the affected patients.

Overview of recurrent respiratory papillomatosis

PURPOSE OF REVIEW

The purpose of this article is to review recent literature regarding pediatric recurrent respiratory papillomatosis (RRP) published within the last year. By reviewing and assessing these articles, a more clear understanding regarding the etiology and management of pediatric RRP can be obtained, allowing physicians to better care for their pediatric RRP patients.

RECENT FINDINGS

Pediatric RRP continues to be an extremely difficult management problem for otolaryngologists. This disease process continues to be a significant burden on the health care system and is a significant cause of morbidity in affected patients and their families. The incidence of RRP continues to be approximately 3.96 per 100,000 in the pediatric population. It has been noted recently that approximately 7 of every 1000 children born to mothers with vaginal condyloma develop pediatric RRP. Although the mainstay of surgical management has traditionally been the CO2 laser, newer surgical techniques have demonstrated efficacy in the management of pediatric RRP patients, including powered instrumentation and the pulse-dye laser. The traditional adjuvant medical therapies used for pediatric RRP continue to be commonly used, including interferon-alpha2a, retinoic acid, and indol-3-carbinol/diindolylmethane (I3C/DIM). Recently cidofovir has demonstrated efficacy in selected patients. In addition, current research regarding vaccine therapy for pediatric RRP has shown promise. Basic science research in the field of immunology has demonstrated multiple defects in cell-mediated immunity, which has shed further light on the etiology of pediatric RRP.

SUMMARY

Pediatric RRP continues to be a highly morbid disease process. New surgical and medical therapies offer hope for better control of this disease in affected patients. Recent advances in immunologic research offer the hope of immune system modulation and augmentation as potential future treatment modalities to better control this disease process.

Propofol Decreases Waste Anesthetic Gas Exposure During Pediatric Bronchoscopy

OBJECTIVE

This study compared the anesthetic gas exposure and operating conditions during insufflation anesthesia with halothane-alone versus halothane-propofol in children undergoing direct laryngobronchoscopy.

STUDY DESIGN

Forty-six children were enrolled in this randomized prospective study, with institutional review board approval and informed consent.

METHODS

All children were anesthetized by halothane mask induction and anesthesia was maintained using spontaneous ventilation with insufflation. No muscle relaxants or opioids were used. In the halothane group, halothane was titrated as needed. In the propofol group, halothane was decreased to 1% inspired concentration and the propofol was titrated as needed to maintain spontaneous ventilation and a still patient. Trace anesthetic gases, hemodynamic stability, and operating conditions were measured.

RESULTS

The groups were similar in age, weight, and bronchoscopy time. There was significantly less gas exposure in the propofol group (25 +/- 33 parts per million) versus the halothane group (66 +/- 97 ppm; P <.02). There was a trend toward earlier emergence in the halothane group (33 +/- 13 minutes) versus the propofol group (41 +/- 17 minutes). Postoperative stridor was common, occurring in 30% of children.

CONCLUSIONS

Insufflation anesthesia with spontaneous respiration provides excellent surgical conditions for laryngobronchoscopy. The addition of propofol resulted in fewer airway complications (P =.047). Although the addition of propofol significantly decreased anesthetic gas exposure in the operating room, both techniques resulted in operating room pollution that exceeded the maximum levels of 2 ppm per hour recommended by the US National Institute for Occupational Safety and Health (NIOSH).

Recurrent respiratory papillomatosis

A 6-year-review of patients who presented with recurrent respiratory papillomatosis (RRP) to our hospital from January 1996 to December 2001 was carried out. Ten cases were identified, of which six were juvenile-onset RRP. Hoarseness was the most common symptom, noted in nine (90%) patients. Other clinical presentations included cough, stridor and aphonia. All patients had glottic papillomas; two had multiple sites of involvement. One patient underwent a tracheostomy that revealed papillomas over the trachea, bronchus and lung parenchyma. Half of the patients were Chinese. Of the six cases of juvenile-onset RRP, three patients were Malay, two Chinese and one Indian. Three Chinese and one German patient had adult-onset RRP. Among the juvenile-onset RRP cases, the mean age at presentation was 2 years, while for adult-onset RRP, it was 42 years. Juvenile-onset RRP was more common in females. There were more papillomas over more sites in patients with juvenile-onset RRP than with adult-onset disease. Subglottic involvement was noted in the juvenile-onset RRP cases. All patients were treated with CO2 laser therapy, but there was complete remission of the papillomas in only two cases.