Exposure and Technique

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Adequate exposure is extremely important to avoid complications from the use of the CO2 laser. We recommend the use of a "subglottic laryngoscope" with an attached Venturi Jet ventilation system when using a micromanipulator to deliver the CO2 laser energy. Ventilation is usually maintained with a Venturi apparatus and anesthesia is provided using intravenous compounds with muscle relaxation techniques. Since the use of intravenous anesthesia and muscle relaxation can severely compromise the patient's ventilation, spontaneous respiration with topical anesthesia is not recommended for cases with airway obstruction, until an adequate airway is established.

A tracheoscope is preferred to the long standard ventilating bronchoscope when dealing with lesions of the subglottis or upper trachea. Ventilating bronchoscopes are awkward to use in the upper airway and

Table 37-2 Choice of Laser for Various Conditions

Airway Lesions

Choice of Laser

Vascular Lesions Subglottic hemangioma Venous malformation

Benign Tumors

Vocal Cord Lesions Laryngeal papillomas Chondroma Tracheal papillomas

Metabolic/Idiopathic Sarcoid Amyloidosis

Locally Invasive Tumors Thyroid

Metastatic Tumors Breast, Colon, Kidney

Primary Malignant Tumors Squamous cell Carcinoid Adenoid cystic Lymphoma Melanoma

CO2 laser Nd:YAG

CO2 laser

CO2 laser or PDL 585 nm

Nd:YAG

Nd:YAG or KTP

Larynx: CO2 laser; Trachea: Nd:YAG Larynx: CO2 laser; Trachea: Nd:YAG

Nd:YAG

Nd:YAG

Larynx: CO2 laser; Trachea: Nd:YAG

Nd:YAG

Nd:YAG

Nd:YAG

Nd:YAG

have the disadvantage of allowing loss of ventilation through the ventilating openings at the glottis. On the other hand, for lesions involving the distal trachea, main bronchi, and bronchus intermedius, ventilating bronchoscopes are the preferred method for laser application. We prefer to use a ventilating Storz tracheoscope (Karl Storz Endoscopy, Culver City, CA) with telescopic imaging through the video (Figure 37-1). This bronchoscope incorporates an internal light source system, which offers the possibility of use without a telescope, thus allowing the use of larger instruments for tumor removal. Air leakage from the open end of the bronchoscope does not constitute a problem since most lesions are treated using a Venturi jet ventilation technique. Rigid bronchoscopy should always be performed in an operating room, with all necessary precautions to guarantee safe use of lasers.

The average laser power used with the Nd:YAG laser varies with the pathology. Vascular tumors with good laser absorption and respiratory papillomas with good vascular flow require 20 to 30 W, whereas for malignant tumors, in which the goal is to obtain good coagulation, 30 to 40 W are normally used. When delivering the laser energy, it is critical to maintain both adequate visualization and a clean and dry surgical field. For this purpose, we use a 0° telescope with one or two semiflexible suctions to remove steam caused by vaporization and simultaneously keep the field free of blood. The fiber can be guided with a steering device or an optical bridge but we prefer free use through an open system for ease of application and rapid removal of secretions, blood, or tumor fragments.

figure 37-1 A, Storz rigid bronchoscope. B, Distal end of the bronchoscope.

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