Asian Cardiovasc Thorac Ann 2008;16:e49-e51
© 2008 Asia Publishing EXchange Ltd
Endotracheal Tube Ignition During the Intratracheal Laser Treatment
Teruya Komatsu, MD,
Reiko Kaji, MD1,
Shun Okazaki, MD2,
Ikuko Miyawaki, MD2,
Kyousuke Ishihara, MD1,
Yutaka Takahashi, MD
Department of Thoracic Surgery
1 Department of Respiratory Medicine
2 Department of Anesthesiology and Intensive Care Medicine, Kobe City Medical Center General Hospital, Hyogo Prefecture, Japan
For reprint information contact: Teruya Komatsu, MD, Tel: 81 783 024 321, Fax: 81 783 027 537, Email: tokushucross{at}hotmail.com, Department of Thoracic Surgery, Kobe City Medical Center General Hospital, 4-6 Minatojima-nakamachi, Chuoku, Kobe City, Hyogo Prefecture, 650-0046, Japan.
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ABSTRACT
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We experienced the combustion of the endotracheal tube during a bronchoscopic potassium titanyl phosphate laser resection of an intratracheal metastatic tumor. Some preventive precautions have been reported, however, none of them are absolutely perfect. We report the rare occurrence of tracheal tube ignition, preventive measures and treatment strategies for the resultant airway burn.
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INTRODUCTION
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Bronchoscopic laser resection of an intratracheal tumor is achieved safely under tracheal intubation. However, it carries the very low risk of tube ignition, which could lead to lethal tracheal burn. We herein report a case of tracheal tube ignition during tracheobronchial laser treatment.
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CASE REPORT
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A 76-year-old female with a history of uterine cancer, complained of dyspnea. She had undergone total hysterectomy 2 years before. The dyspnea had worsened and tracheal intubation was performed. On bronchoscopy, the tracheal bifurcation was about 90% stenotic due to the intratracheal metastasis which was about 20 mm in length and well localized to the bifurcation. For airway salvation, a potassium titanyl phosphate laser debulking of the tumor in a continuous mode was tried with inhaled sevoflurane and intravenous vecuronium. The tube ignition occurred about 60 mins after the beginning of the procedure. The tracheal tube [siliconized, size: 7.5 I.D. (Mallinckrodt Company, Chih., Mexico)] was stained black along its entire length (Figure 1
). At that moment, the FiO2 was about 40% and the inhaled sevoflurane was 1.5%. The ignited tracheal tube was replaced with a new one immediately. The resulting soot clung to almost the entire tracheobronchial mucosa which suggested severe airway burn (Figure 2). After respiratory support with mechanical ventilation, the patient recovered (Figure 3) and was transferred to the palliative care unit.
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Figure 3. Bronchoscopy: tracheal bifurcation after the stent insertion showing well healed bronchial mucosa.
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DISCUSSION
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Tube ignition is a potential life-threatening complication of laser treatment for intratracheal lesions. Of 20,000 laryngeal laser-surgical procedures, Sesterhenn and colleagues. reported 15 cases (0.075%) of tube fires.1 The mechanism of combustion is the initial penetration of the endotracheal tube by the laser and then the ignition of the tube. This is facilitated by the heat produced by the laser, the flow of oxygen, inflammable anesthetic agents or combustible materials (flexible bronchoscope, endotracheal tube, fragments of desiccated tissues and laser fiber).1–4 Sesterhenn and colleagues. reported the use of cuff area protection and of specially designed tracheal tubes as a preventive measure. In the same report it was revealed that 6 of the 15 cases of tube fire occurred despite the use of specially designed laser-resistant tubes.1,5 Therefore, there is no consensus concerning the safest laser-resistant endotracheal tube so far. In our case, the FiO2 was 40% and 1.5% sevoflurane was being administered when the combustion occurred. Considering the recent reports which suggest the correlation between high levels of inspired oxygen and tube combustion, jet ventilation could have reduced the FiO2.6 Unfortunately, this instrument was not available at our institution. Sevoflurane seemed to have been contraindicated in this case due to its flammability. However, the anesthesiologist put more emphasis on administering balanced anesthesia rather than on the extremely low possibility of tube ignition. So far there have been no studies comparing the incidence of tube ignition between recent-available laser types (for example, CO2 laser, Argon Plasma Coagulator, and KTP/Nd-YAG laser), however, Martin and colleagues. suggested a lower possibility of tube fire with cryotherapy.7 A rigid bronchoscope might have reduced the possibility of tube ignition due to the absence of the tracheal tube and the ease of maneuverability of the laser probe. However, technically, we were not familiar with rigid bronchoscopes. In our case, an inadvertent hit to the flammable siliconized tracheal tube by the laser probe and remaining fragments of desiccated tissues were thought to be the most likely causes for the ignition.
Once the tube ignition occurs, the ignited tube should be replaced with a new one, and the degree of burn injury should be assessed with a bronchoscope. In order to predict the mortality and treatment, Chou and co-workers classified the inhalation burn injury of the respiratory tract into 3 groups (G1, G2, and G3) according to the depth of mucosal damage. According to their classification, our case could be classified as G3 (ulcerations, necrosis, absence of both cough reflex and bronchial secretions, mortality rate: 62%). They suggested 3 important principles: (1) Ventilatory support, (2) Fluid resuscitation support, (3) Intensive pulmonary toilet.3,8 Prophylactic steroids as anti-inflammatory agents or intravenous antibiotics were controversial. In our case, ventilatory assistance with pressure support ventilation and pulmonary toileting were successful without steroids and antibiotics.
In conclusion, during laser procedures through the tracheal tube, the risk of tube combustion still exists, irrespective of the observance of well-reported preventive measures, and once the tube ignition occurs, prompt re-intubation, followed by the appropriate ventilatory support and pulmonary hygiene are paramount.
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REFERENCES
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- Sesterhenn AM, Dunne AA, Braulke D, Lippert BM, Folz BJ, Werner JA. Value of endotracheal tube safety in laryngeal laser surgery. Lasers Surg Med 2003;32:384–90.[Medline]
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- Ishihara H, Takahira Y, Muraoka M, Hashimoto H, Matsuki A, Hasegawa Y, et al. [Does a high inspired oxygen concentration consistently play a key role in developing combustion in the airway during fiberoptic bronchoscopy guided laser treatment?—A case of firing in the airway under total intravenous anesthesia]. Masui 2002;51:1359–62.[Medline]
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ABSTRACT
INTRODUCTION
