Anaesthetic management of a patient with carcinoma larynx for laryngectomy
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Dr Poonam Bhadoria Professor Department of anaesthesia and intensive care Maulana Azad Medical College & Lok Nayak hospital New Delhi-110002. Anaesthetic management of a patient with carcinoma larynx for laryngectomy. www.anaesthesia.co.in [email protected] Identify

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Anaesthetic management of a patient with carcinoma larynx for laryngectomy

Dr Poonam Bhadoria

Professor

Department of anaesthesia and intensive care

Maulana Azad Medical College &

Lok Nayak hospital

New Delhi-110002

Anaesthetic management of a patient with carcinoma larynx for laryngectomy

[email protected]


Anaesthetic management of a patient with carcinoma larynx for laryngectomy

  • Identify

  • Clinical presentation

  • investigation-IL

  • airway evaluation

  • essential monitoring

  • anaesthetic concerns

  • unexpected problems- after extubation in MLS

    - during laryngectomy

spot


History

History

  • Age, Sex: 60 years male

  • Present history c/o

    hoarseness, dyspnoea, stridor, cough, haemoptysis, dysphagia, referred pain to ear anorexia, mass in neck

  • Treatment history

    • Radiation - glottic oedema

      trismus

      fibrosis

      stiff larynx + epiglottis

    • Chemotherapy

    • Surgery - scarring


Anaesthetic management of a patient with carcinoma larynx for laryngectomy

  • Past history

    • Medical (COPD, CVS – aspirin)

    • Surgical (previous interventions)

  • Personal history – smoke, alcoholic

  • Dietary history

  • Occupational history; industrial and textile worker (air pollution and chronic inflammation of larynx)


Examination

Examination

  • GPE

    • Built / nutritional status

    • Vitals

    • Oral cavity

    • Jugular venous pressure

  • Respiratory system –wheeze

  • Airway examination: distorted upper airway and obstructed, because of friable growth with or without tracheostomy.


Investigations

Investigations

  • Routine

    • Haemogram , blood glucose, KFT, LFT, SE

    • Urine routine,

    • ECG

  • Specific: to assess extent, invasion, destruction

    • Chest X–ray PA

    • X–ray neck – AP / Lateral

    • Indirect laryngoscopy

    • PFT (COPD)

    • Laryngogram filling defect:

    • CT scan, barium swallow

    • MRI


Anaesthetic management of a patient with carcinoma larynx for laryngectomy

Major← Plan →MLS or D/L

Short case long case

Short case

Long case


Anaesthetic management of a patient with carcinoma larynx for laryngectomy

Preoperative preparation

  • Optimize lung functions:

    antibiotics, bronchodilators, corticosteroids, chest physiotherapy including breathing exercises

  • Care of nutrition, hydration

  • Removal of bad teeth

  • Indirect laryngoscopy - review again

  • Treatment of associated medical disorders and age related problems

  • Counseling-post operative speaking

  • Care of tracheostomy


Preoperative preparation

Preoperative preparation

  • Cessation of smoking

    Time course beneficial effects

    12-24 hours ↓CO and nicotine levels

    48-72 hours↓COHb levels normalizes and bronchociliary functions improve

    1-2 weeks sputum production

    4-6 weeks PFT improves

    6-8 weeksimmune function and drug metabolism normalize

    8-12 weeks ↓overall PO morbidity


Anaesthetic management of a patient with carcinoma larynx for laryngectomy

Preoperative preparation

  • Cessation of alcohol

    effect on liver, gastric irritation, CVS, therefore pre-medication with antacids and metachlorpromide

    EffectsAcute Chronic

    inhalational agents,↓ need ↑MAC

    barbi+benzo+opioidsmore sensitive cross-tolerance

    suxamethonium - ↑effect

    relaxants: rely on hepatic clearance

    drug of choice: atracurium


Anaesthetic management of a patient with carcinoma larynx for laryngectomy

Preoperative advice

  • NPO, continue bronchodilators + morning dose of drugs, arrange blood, consent

  • Pre-medication – Glycopyrrolate 0.2 – 0.3 mg i/m, nasal drops ± FOB, ± IL, sedatives ±

  • If with tracheostomy: steam, nebulisation, encourage cough, suction,


Surgical plan

Surgical plan

  • Direct laryngoscopy and biopsy (day care)

  • Major surgery

    • Partial / total laryngectomy

    • Laryngo-pharyngectomy

    • RND

    • Flap surgery

  • Besides normal routine check for Int.

    • Stylet , MLS tube

    • Tracheostomy set

    • Local: 2%, 4%, 10% for awake intubation

    • Availability of defibrillator

    • Other type and size of laryngoscope

    • check the equipment like FOB

    • Ready ENT surgeon


Major surgery

Major surgery

  • Preoperatively arrange

    • Blood, Ryle’s tube CVP line, Foley’s catheter

  • If already tracheostomised

    • Care of tracheostomy tube

    • Montendo tube / Montgomery T – tube

  • I/V access

  • Premedication ±

  • Preoxygenation

  • Induction

    • Propofol / Thiopentone

    • Suxamethonium after mask ventilation

  • Maintenance on O2, N2O , Halothane or Isoflurane


Monitoring

Monitoring

  • Routine

    • HR, ECG

    • SpO2, EtCO2

    • NIBP

    • Temperature (rectal + axillary probes)

  • In addition

    • CVP (towards higher side)

    • Urine output

    • Blood loss

    • Arterial line for serial estimation of blood gas and hematocrit

    • Airway pressures

  • Positioning – head up tilt (15 to 20 degree)


Intra operative problems

Intra-operative problems

  • Bleeding (hematocrit 0.25 to .0.27)

    • ↓by positioning of patient (pillow under knees, reversed Trendelenburgh position), 2 mmHg fall in BP for each 2-5 cm rise in head position above the heart level.

    • Induced hypotension – inhalational, i/v (NTG, SNP etc).

    • Early, accurate assessment of blood loss: Timely replacement with blood / colloid.

  • Compromised cerebral circulation

    • carotid artery infiltration →↓cerebral arterial pressure

    • jugular vein infiltration →↑cerebral venous pressure

    • rotation of neck →↓carotid blood flow

      Contd


Anaesthetic management of a patient with carcinoma larynx for laryngectomy

Induced hypotension

Inhalational

Isoflurane

dose dependent hyotensive effect by vasodilatation

up to 40mmHg in 6 minutes, little change in CO

Halothane/enflurane

↓ BP, CO, Stroke volume →↑right heart filling pressure

IV agents

fentanyl 1-3mcg/kg

propofol 100mcg/kg/minute

NTG 0.5-3mcg/kg (BP 80-90mmHg)

SNP 3mcg/kg/minute, ↓es dias. by 30 to 40%

Contd


Anaesthetic management of a patient with carcinoma larynx for laryngectomy

During opening of neck veins

  • Rapid fall in EtCO2, BP → Air embolism

  • ECG: inverted T, tall P, RBBB, RHS→VF

  • Treatment

    • Stoppage of surgery

    • Flood with saline/fluid

    • 100 % O2 , stop N2O- why?

    • Durhant’s position

    • Aspiration of air through CVP catheter

    • PPV

      Contd


Anaesthetic management of a patient with carcinoma larynx for laryngectomy

  • Carotid sinus stimulation → cardiac dysrhythmias, bradycardia, Hypotension

  • Denervation of carotid sinus body→ hypertension and loss of hypoxic derive.

  • Ablation of rt sympathetic ganglion-↑QT interval and malignant arrhythmias → cardiac arrest

    Treatment – LA infiltration of carotid bulb / vagolytic agents

    cessation of pressure

  • Hypotension

  • Hypothermia Contd


  • Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    • Intra-operative maintain adequate analgesia

    • When trachea is transected, tube is replaced by non kinkable tube (confirmed by capnography and auscultation)

    • ↑ airway pressure: malpositon of tube, bronchspasm, debris

    • Loss of airway at induction, midway, extubation, postoperative


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    In microvascular flap reconstruction

    • avoid vasoconstrictor

    • Avoid induced hypotension techniques

    • Maintain hematocrit 0.30

    • No diuresis

    • Avoid hypothermia

      • forced air warming blankets

      • IV warm fluids

      • Inspired anaesthetic gasses warm and humidified


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    • Postoperative problems

      • Prolonged recovery – ICU care preferably

      • Ventilation care - pneumothorax, subcutaneous emphysema

      • Speaking

    • Postoperative care

      • Monitoring of vital signs

      • Care of tracheostomy

      • Chest physiotherapy, suctioning ,

      • head up 30° to help venous drainage

      • Chest X – ray, within 6 hours

      • No tight bandage– airway impingement

      • Bronchodilation, nebulisation

      • Oxygen and analgesia


    Rehabilitation

    Rehabilitation

    Vocal

    • Oesophageal speech

    • Artificial larynx (electro-larynx and trans-oral pneumatic device)

    • Tracheo–oesophageal speech (Blom-singer and Panje prosthesis)

      Other rehabilitation procedure

    • Social

    • Psychological

    • Vocational


    Patient s limitations

    Patient’s limitations

    • Swimming

    • Cannot call aloud

    • Climbing up the stairs,

    • Strenuous work

    • High altitude


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    D/L BIOPSY or MLS

    Day care surgery

    GoalsCOMPLAINTS

    Clear view Hoarseness,

    Immobile field stridor

    Sufficient space to work haemoptysis

    CVS stability

    Etiology

    • Benign growth

    • Vocal cord dysfunction

    • Foreign body aspiration

    • Obstructed tumour

    • Papillomatosis


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    How to proceed ?

    • Airway concerns

    • Anaesthetic concern


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    Airway concerns

    Mask ventilation?

    Intubation with laryngoscopy ?

    Any doubt - secure airway before induction by FOB or by tracheostomy ↓ LA

    -airway evaluation for type of lesion

    (95% ant. & 5% post.)

    -i/l & d/l (laryngeal inlet), CT, MRI

    -discuss with surgeon for size of tumor


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    • LA

      • Topical, oral lignocaine lozenges

      • Oral 4 % lignocaine gargles, spray

      • Nerve block (SLN and glossopharyngeal)

      • Nebulization with 4% xylocaine


    Landmarks slnb ext

    landmarks SLNB (ext)


    Nebulisation

    Nebulisation

    • 4-6 ml 4 % lignocaine

    • Particle size >100 microns-oral

      60-100 microns-trachea

      30-60 microns-larger bronchi

      10-30 microns-small bronchi

      <5 microns-alveoli

    • >50 % loss during spont resp


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    Anaesthetic concerns (MLS)

    What are they ?

    • Rapid awakening & return of protective airway reflexes

    • Minimize secretions and reflexes

    • Protection to trachea

    • Ensure good ventilation & oxygenation

      -Review on table

      -Pre-oxygenation

      -Glycopyrrolate 0.2-0.3mg IM

      -no premed. If any s/o UAO


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    Intubation depending on spread of growth

    • Small – routine paralysis, tracheal intubation

    • Mod. Large – awake intubation / tracheostomy ↓ LA as airway obstruction may worsen after anaesthesia. -If ventilation- yes – intubation ↓ VA and S/R -If ventilation- no - intubation awake + block + IV sedation

      -limited pre-medication

    • Large, impinging on upper airway – stridor at rest preoperative tracheostomy, no pre-medication

    • No BNI if friable lesion


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    • Methods for ventilation

      (Manual and automated)

    • Ventilation with ETT

    • Venturi jet ventilation (supraglotic)

    • Intermittent apnea technique

    • HFPPV


    Ventilation oxygenation

    Ventilation & oxygenation

    A). ETT – 5mm ID, long with standard cuff (Micro laryngeal tube) low pressure high volume tube

    • Control ventilation-:

      advantages

      - prevent aspiration

      - maintain inhalation anaesthesia

      - monitor ETCo2

      disadvantages

      - limited access to surgeons

      - possible distortion of tissue during intubation


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    Alternatives techniques (post. commi. lesion)

    (balanced technique-injector below vocal folds/lx)

    B). Jet ventilation

    • ETT not required

    • Unobstructed view (profound messeter relax)

    • Alignment of laryngoscope & tracheal axis. (pneumatic knife)

    • Full relaxation of V.C.

    • Free egress of gas

    • Monitor chest wall motion

      contd


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    • Ventilatory rate – 6-7 bpm at 30-50 PSI I/E 1.5:6 sec (Saunder’s jet injector)

    • Cuffed Carden tube.

    • Contraindicated in children, obese & bullous emphysema.

    • Risks -barotrauma, stomach dilatation, forcing of blood & tumour in lungs, pneumothorax, hypotension.

      C). Intermittent intubation and apneic period.

      D). HFPPV, less risk of barotrauma. (80-300/min)

      - 2-3 ml/kg  T.V


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    Reflex responses:-HT, tachycardia, arrhythmia

    -Use : topical lignocaine,

    or I/V (1-1.5mg/kg)

    -I/V fentanyl, esmolol (200- 400mcg/minute)

    Anaesthesia :-Propofol (2mg/kg), fentanyl (1-2mcg/kg)

    -topical anaesthesia of larynx

    -appropriate muscle relaxation

    -suxamethonium, intermediate acting

    -Ensure adequate depth

    -remifentanyl -potent rapid recovery profile

    -thorough suction before extubation

    Remember if difficult intu then difficult extubation


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    • Monitoring: ECG-essential as sym stimulation ++,

      BP, Oximetry, ETCo2

    • Post op risk: -MI or Ischemia 1.5-4%

      -laryngospasm,

      -laryngeal edema

      -strider

      -restlessness (hypoxia, pain)

    • barotrauma and pneumothorax

    • Aspiration / seeding of polyp into trachea

    Laryngospasm


    Laryngospasm

    Laryngospasm

    • Reflex closure of upper airway from spasm of glottic

      musculature

    • Mechanism

      • False cords and epiglottic body come together

      • Extrinsic muscles of larynx create ball valve mechanism

      • Reflex apnea d/t stimulation of SLN

    • Etiology

      • Stimulation by blood, vomitus , secretions

      • Light planes of anaesthesia

      • Chemical irritation of laryngeal , pharyngeal mucosa

      • Can persist even after irritation ceases

      • Visceral pain reflex

      • Negative pressure pulmonary edema (as a result)


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    • Treatment

      • Removal of stimulus

      • 100 % oxygen

      • Lifting the mandible up and maintain sniffing position

      • Sustained positive pressure → bulge in pyriform fossa

      • Low dose Suxa (10 – 20 mg i/v)

      • If fails , 100 mg Suxa and intubate

      • i/v lidocane

      • Propofol and ketamine → inhibit the N-methyl-D aspartate receptor


    Our role

    Our role

    “Pro active approach to prevent or terminate the laryngospasm and thus preventing hypoxemia is the mark of a seasoned anaesthesiologist ”


    Stridor

    Stridor

    Immediate attention, establish cause, intubation ±, assess severity situation and clinical details

    Treatment

    • Heliox helium 70% + 30% O2

    • Full monitoring + head end of bed up by 45 to 90 degree

    • Nebulize epinephrine

    • Dexamethasone 4-8mg/8-12 hourly if oedema is the casue


    Laser surgery

    Laser surgery

    • Light amplification by stimulated emission of radiation: useful tool in modern surgery

    • CO2 laser :-

      • Invisible infra red light

      • Absorbed by tissue water

      • is used for treatment of early carcinoma of larynx

      • Beam focused to small spot-precise controlled coagulation.

      • Incision or vaporization of tissue, suitable for vocal cord & laryngeal surgery (10 W power with 0.1 sec pulses & a small spot)


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    LASER

    • AdvantagesDisadvantages

      No bleeding Lack of pathology specimen

      No oedema, scarringDamage to surrounding tissue

      Rapid healing Risk to eyes

      ETT damage and Intratracheal fire

      Hazards

      • To staff, patient and theatre

      • Eyes are vulnerable

      • Fire & explosion (thermal effect)

      • Noxious fumes

      • Ignition of inflammable materials


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    Safety considerations

    • OT warning signs for laser use.

    • Restrict entry into OT

    • Wear protective eye glasses (wave length specific).

    • Avoid flammable materials (drapes, plastic tubes etc.).

    • Patient's eyes – taped closed & cover with wet pads

    • Wet towels to drape.

    • Competent personnel for equipment use

    • Avoid misdirection of beam

    • Avoid ETT in short procedures use venturi

    • Ready bucket of clean water for dipping the tube

    • Smoke evacuators at surgical site


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    Metal endotracheal tube

    • Norton’s stainless steel spiral coil without cuff

      (Walls not air tight)

    • Laser flextube air tight stainless steel spiral with two distal cuffs

    • Bivona foam cuff aluminum spiral tube with outer silicone Coat and self inflating foam sponge filled cuff


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    Airway fire (0.1%) protocol

    • Fatal due to

      Thermal injury, Chemical burn – brochospam & edema, melting & burning ETT lead to obstruction

    • Management

      -use of special tubes

      -stop O2, remove ETT, flood with saline

      -bag & mask/venturi ventilation

      -if difficult airway, remove ETT on guide wire

      -check bronchoscopy

      -post operative: sitting position, X-ray chest , antibiotics, humidified O2, steroids


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    “careful thought ahead of time by anaesthetist can prevent such complications”


    Anaesthetic management of a patient with carcinoma larynx for laryngectomy

    GOOD LUCK

    [email protected]


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