Anaesthetic management of a patient with carcinoma larynx for laryngectomy

1. 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.inanaesthesia.co.in@gmail.com

2. Identify • Clinical presentation • investigation-IL • airway evaluation • essential monitoring • anaesthetic concerns • unexpected problems- after extubation in MLS - during laryngectomy spot

3. 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

4. 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)

5. 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.

6. 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

7. Major← Plan →MLS or D/L Short case long case Short case Long case

8. 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

9. 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 weeks immune function and drug metabolism normalize 8-12 weeks ↓overall PO morbidity

10. Preoperative preparation • Cessation of alcohol effect on liver, gastric irritation, CVS, therefore pre-medication with antacids and metachlorpromide Effects Acute Chronic inhalational agents, ↓ need ↑MAC barbi+benzo+opioids more sensitive cross-tolerance suxamethonium - ↑effect relaxants: rely on hepatic clearance drug of choice: atracurium

11. 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,

12. 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

13. 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

14. 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)

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

23. 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

24. Patient’s limitations • Swimming • Cannot call aloud • Climbing up the stairs, • Strenuous work • High altitude

25. D/L BIOPSY or MLS Day care surgery Goals COMPLAINTS 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

26. How to proceed ? • Airway concerns • Anaesthetic concern

27. 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

28. LA • Topical, oral lignocaine lozenges • Oral 4 % lignocaine gargles, spray • Nerve block (SLN and glossopharyngeal) • Nebulization with 4% xylocaine

29. landmarks SLNB (ext)

30. 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

31. 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

32. 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

33. Methods for ventilation (Manual and automated) • Ventilation with ETT • Venturi jet ventilation (supraglotic) • Intermittent apnea technique • HFPPV

34. 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

35. 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

36. 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

38. 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

39. 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

40. 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)

41. 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

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

43. 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

44. 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)

45. LASER • Advantages Disadvantages No bleeding Lack of pathology specimen No oedema, scarring Damage 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

46. 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

47. 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

48. 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

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

50. GOOD LUCK www.anaesthesia.co.inanaesthesia.co.in@gmail.com