The Open Anesthesia Journal


Formerly: The Open Anesthesiology Journal

ISSN: 2589-6458 ― Volume 13, 2019
LETTER

Inhalation Insufflation Technique with Local Anaesthetic Spray without Intubation and Opioids for Paediatric Upper Airway Surgery - Observational Case Series Study



Vasanth Rao Kadam*
Department of Anaesthesia, The Queen Elizabeth Hospital, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia

Abstract

Background:

Anaesthetic management of upper airway surgery in paediatric is challenging. Total intravenous anaesthesia with opioid or inhalation technique with spontaneous respiration has been used but studies are limited on inhalation technique. This study aimed to use tubeless inhalation insufflation technique without opioids at a tertiary centre.

Methods:

All paediatric patients coming for elective upper airway surgery to the centre, were included. Mask induction was with 5-8% sevoflurane in O2 and maintenance with 2-3%, via a nasopharyngeally placed Endotracheal Tube (ETT) or catheter on spontaneous ventilation with flow between 8-10 l/min. Lidocaine up to 5 mg/kg was then sprayed to the mucosa of larynx and trachea. Once adequate depth was attained, suspension laryngoscope was placed by a surgeon for surgery. Some complications were observed i.e inadequate anaesthesia requiring rescue drugs like opioids or propofol, intubation, desaturation events from laryngospasm and delayed recovery. Surgical technique involved was diagnostic and therapeutic for the upper airway lesions.

Results:

Fifteen paediatric patients (2 months to 7 yrs) were included in the study with tubeless anaesthesia. None of them required intubation during the procedure. The mean time from induction of anaesthesia to unconsciousness was 15 ± 3 s and attainment of necessary anaesthetic depth for surgery was 4.7 ± 0.90 min. None had desaturation events or required opioids. However, propofol was required in one and delayed anaesthetic recovery was observed in one patient.

Conclusion:

This study on tubeless anaesthesia with Local Anaesthetic (LA) spray with spontaneous inhalation insufflation technique provided an opioid-free, interference-free operative field without airway compromise, not requiring intubation, therefore, further studies are required.

Keywords: Anaesthetic technique, Inhalational, Airway management, Suspension laryngoscopy, Upper airway, Opioid.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 13
First Page: 44
Last Page: 46
Publisher Id: TOATJ-13-44
DOI: 10.2174/2589645801913010044

Article History:

Received Date: 11/02/2019
Revision Received Date: 20/05/2019
Acceptance Date: 22/05/2019
Electronic publication date: 30/06/2019
Collection year: 2019

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© 2019 Vasanth Rao Kadam.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Anaesthesia, The Queen Elizabeth Hospital, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia; Tel: +61882226000; Fax: +61882227065;
E-mail: vasanth.rao@sa.gov.au





1. INTRODUCTION

Anaesthetic management of upper airway surgery in paediatric is challenging, requiring a high level of skill and cooperation between surgeon and anaesthetist. There are various anaesthetic techniques used in managing upper airway surgery. The number of different methods reported are: tubeless inhalation anaesthesia with tube at the nasal airway or bronchoscope, Total Intravenous Anaesthesia (TIVA) technique spontaneous or with IPPV after paralysis or using jet ventilation [1Spargo PM, Neilsen MS, Carruth JAS. Use of carbon dioxide laser for treatment of recurrent laryngeal papillomatosis in small children. Lasers Med Sci 1986; 1: 211-5.
[http://dx.doi.org/10.1007/BF02040241]
-5Rontal E, Rontal M, Wenokur ME. Jet insufflation anesthesia for endolaryngeal laser surgery: a review of 318 consecutive cases. Laryngoscope 1985; 95(8): 990-2.
[http://dx.doi.org/10.1288/00005537-198508000-00022] [PMID: 4021694]
]. Inhalation technique with spontaneous respiration has been used effectively but there are limited studies [6Xu J, Yao Z, Li S, Chen L. A non-tracheal intubation (tubeless) anesthetic technique with spontaneous respiration for upper airway surgery. Clin Invest Med 2013; 36(3): E151-7.
[http://dx.doi.org/10.25011/cim.v36i3.19726] [PMID: 23739669]
-10Talmage EA. Safe combined general and topical anesthesia for laryngoscopy and bronchoscopy. South Med J 1973; 66(4): 455-9.
[http://dx.doi.org/10.1097/00007611-197304000-00015] [PMID: 4575235]
]. The aim of this study was to use tubeless inhalation insufflation technique without opioids at the tertiary centre in the paediatric age in patients coming for elective upper airway surgery.

2. METHODS

In this observational study, all the paediatric patients coming for elective upper airway surgery to the tertiary centre were included after the institutional permission. Patients without parental consent and incomplete record were excluded. Premedication was with oral midazolam 0.5 mg/kg and atropine 0.02 mg/kg in orange juice to make it 5 ml. Mask induction was up to 5-8% sevoflurane in O2 with high flow rates (8-10 l/min). The maintenance anaesthesia with sevoflurane was 2-3% with low O2 flow rates, via nasopharyngeally placed Endotracheal Tube (ETT) size 4 or suction catheter connected to Jackson Rees circuit on spontaneous ventilation. The scavenging system was in use, with the possibility of gas leaking around the tube. Lidocaine up to 5mg/kg was then sprayed to the mucosa of larynx and trachea. Once adequate depth was attained with sevoflurane (minimum alveolar of concentration >1), suspension laryngoscope was placed by a surgeon for surgery. A stethoscope was placed on the chest to monitor breath sounds (end-tidal monitoring not available). Time of induction to unconsciousness and time from unconsciousness to the insertion of suspenfion laryngoscope, which is the time for adequate deep anaesthesia were measured by the parameters. Some complications were observed such as inadequate anaesthesia requiring rescue drugs like opioids or Propofol, intubation, desaturation events from laryngospasm and delayed recovery. When oxygenation was compromised and intubation was necessary, the prior discussion was made with the surgeon to make way for it. Diagnostic and therapeutic surgical techniques were involved like a laser for the upper airway lesions. They were assessed for surgical conditions, being satisfactory or not.

Table 1
Patient characteristics.


3. RESULTS

The demographics of the basic clinical profile is summarised in Table 1. Except for one patient, all the remaining patients were successful in utilising insufflation technique for anaesthesia. Propofol was used in only one patient which was a single bolus dose to increase the depth of anaesthesia. None of them required any opioids. The mean time from induction of anaesthesia to unconsciousness was 15 ± 3 s and attainment of necessary anaesthetic depth for surgery was 4.7 ± 0.90 min. None had desaturation events or showed local anaesthetic toxicity signs during the intraoperative and recovery period. None of the surgeons expressed unsatisfactory conditions. Though routine observations were not studied, none of them deviated from the normal range. There was no morbidity related to the cardiovascular changes in the postoperative period and they fulfilled the recovery discharge criteria.

4. DISCUSSION

Our study with tubeless anaesthesia with Local Anaesthetic (LA) spray on spontaneous inhalation insufflation technique provided opioid-free anaesthesia. Local anaesthesia applied to airway has decreased anaesthetic needs like opioids sparing and maintained cardiovascular stability. These results were similar to the study of Richards and Jing Xu Zheng Yao [2Richards SD, Kaushik V, Rothera MP, Walker R. A tubeless anaesthetic technique for paediatric laryngeal laser surgery. Int J Pediatr Otorhinolaryngol 2005; 69(4): 513-6.
[http://dx.doi.org/10.1016/j.ijporl.2004.11.018] [PMID: 15763290]
, 6Xu J, Yao Z, Li S, Chen L. A non-tracheal intubation (tubeless) anesthetic technique with spontaneous respiration for upper airway surgery. Clin Invest Med 2013; 36(3): E151-7.
[http://dx.doi.org/10.25011/cim.v36i3.19726] [PMID: 23739669]
].

Justifying inhalation anaesthesia as better than TIVA propofol is a subject of major debate and beyond the reach of this manuscript. Though there are few studies TIVA reported to be effective, there may be an issue with increased depth of anaesthesia requiring intubation and reduced depth having airway issues like desaturation and hypoxia. Such events were reported in a study by Lin et al. [11Bo L, Wang B, Shu SY. Anesthesia management in pediatric patients with laryngeal papillomatosis undergoing suspension laryngoscopic surgery and a review of the literature. Int J Pediatr Otorhinolaryngol 2011; 75(11): 1442-5.
[http://dx.doi.org/10.1016/j.ijporl.2011.08.012] [PMID: 21907420]
]. Inhalation technique was first used in children by Spargo et al. [1Spargo PM, Neilsen MS, Carruth JAS. Use of carbon dioxide laser for treatment of recurrent laryngeal papillomatosis in small children. Lasers Med Sci 1986; 1: 211-5.
[http://dx.doi.org/10.1007/BF02040241]
]. It can have satisfactory conditions provided that a high enough vapour concentration is utilised to guarantee adequate depth of anaesthesia. An advantage is that with stimulation, the respiratory rate increases and the increase in the depth of anaesthesia results in self-regulation. However, to achieve adequate depth of anaesthesia before surgery begins, shared airway, tube migration into the surgical field, high fresh gas flowrequired (up to 10 l/min) to decrease the effect of dilution of inspired gases and difficulty to scavenge anaesthetic gases are assessed. If a child is too sensitive, at the induction time, any coughing can cause laryngospasm and complicate desaturation. This can be avoided by increasing the depth of anaesthesia with sevoflurane. If desaturation or apnoea occurs during the maintenance period, this may be treated by gentle CPAP. We inserted either ETT or nasopharyngeal catheter placed above the glottis. Other innovative methods used were, a central venous catheter inserted below the glottis and S.Q. Li et al. used muscle relaxant to insert ETT and when part of the procedure was performed, the ETT was pulled to the laryngopharynx to facilitate remaining surgery with few complications [9Zhu ZR, Hu ZY, Jiang YL, Xu LL, McQuillan PM. The use of a double-lumen central venous catheter for airway management in pediatric patients undergoing laryngeal papillomatosis surgery. Paediatr Anaesth 2014; 24(2): 157-63.
[http://dx.doi.org/10.1111/pan.12253] [PMID: 24033557]
, 12Li SQ, Chen JL, Fu HB, Xu J, Chen LH. Airway management in pediatric patients undergoing suspension laryngoscopic surgery for severe laryngeal obstruction caused by papillomatosis. Paediatr Anaesth 2010; 20(12): 1084-91.
[http://dx.doi.org/10.1111/j.1460-9592.2010.03447.x] [PMID: 21199117]
]. Limitations of the study are that this is a non-randomised study and there exists the possibility of biases. We did not have the facility of high flow O2 devices, as facilities are limited in third world countries. Therefore, this technique is still useful. We did not use any specific surgeon satisfaction scale, which could be one of the limitations. If this was used in the form of Likert score then that could have been a better tool of assessment. The main emphasis of the study is the effective use of lidocaine by sparing the use of opioid and its side effects. The possible opioid side effects may be sedation, nausea/vomiting, respiratory depression and, delayed discharge from post anaesthesia care unit.

CONCLUSION

This study on tubeless anaesthesia with Local Anaesthetic (LA) spray with spontaneous inhalation insufflation technique provided an opioid-free, interference-free operative field without airway compromise, not requiring intubation, therefore, further studies are required.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The study was done after obtaining institutional permission at the Department of Anaesthesia Al Nahdha hospital, Ministry of Health, Muscat Oman.

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION

All paediatric patients were included after institutional permission and parental consent.

FUNDING

None.

CONFLICT OF INTEREST

The author declares no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

The author acknowledges the encouragement and support provided by Dr. Shanta Kishore, Former Head of Anaesthesia, Alnahda Hospital, Muscat.

REFERENCES

[1] Spargo PM, Neilsen MS, Carruth JAS. Use of carbon dioxide laser for treatment of recurrent laryngeal papillomatosis in small children. Lasers Med Sci 1986; 1: 211-5.
[http://dx.doi.org/10.1007/BF02040241]
[2] Richards SD, Kaushik V, Rothera MP, Walker R. A tubeless anaesthetic technique for paediatric laryngeal laser surgery. Int J Pediatr Otorhinolaryngol 2005; 69(4): 513-6.
[http://dx.doi.org/10.1016/j.ijporl.2004.11.018] [PMID: 15763290]
[3] Scamman FL, McCabe BF. Supraglottic jet ventilation for laser surgery of the larynx in children. Ann Otol Rhinol Laryngol 1986; 95(2 Pt 1): 142-5.
[http://dx.doi.org/10.1177/000348948609500206] [PMID: 3083752]
[4] Giunta F, Chiaranda M, Manani G, Giron GP. Clinical uses of high frequency jet ventilation in anaesthesia. Br J Anaesth 1989; 63(7)(Suppl. 1): 102S-6S.
[http://dx.doi.org/10.1093/bja/63.7.102] [PMID: 2611078]
[5] Rontal E, Rontal M, Wenokur ME. Jet insufflation anesthesia for endolaryngeal laser surgery: a review of 318 consecutive cases. Laryngoscope 1985; 95(8): 990-2.
[http://dx.doi.org/10.1288/00005537-198508000-00022] [PMID: 4021694]
[6] Xu J, Yao Z, Li S, Chen L. A non-tracheal intubation (tubeless) anesthetic technique with spontaneous respiration for upper airway surgery. Clin Invest Med 2013; 36(3): E151-7.
[http://dx.doi.org/10.25011/cim.v36i3.19726] [PMID: 23739669]
[7] Aun CST, Houghton IT, So HY, Van Hasselt CA, Oh TE. Tubeless anesthesia for microlaryngeal surgery. Anesth Intensive Care 1990; 18(4): 497-503.
[8] Williams SR, van Hasselt CA, Aun CST, Tong MCF, Carruth JA. Tubeless anesthetic technique for optimal carbon dioxide laser surgery of the larynx. Am J Otolaryngol 1993; 14(4): 271-4.
[http://dx.doi.org/10.1016/0196-0709(93)90074-H] [PMID: 8214322]
[9] Zhu ZR, Hu ZY, Jiang YL, Xu LL, McQuillan PM. The use of a double-lumen central venous catheter for airway management in pediatric patients undergoing laryngeal papillomatosis surgery. Paediatr Anaesth 2014; 24(2): 157-63.
[http://dx.doi.org/10.1111/pan.12253] [PMID: 24033557]
[10] Talmage EA. Safe combined general and topical anesthesia for laryngoscopy and bronchoscopy. South Med J 1973; 66(4): 455-9.
[http://dx.doi.org/10.1097/00007611-197304000-00015] [PMID: 4575235]
[11] Bo L, Wang B, Shu SY. Anesthesia management in pediatric patients with laryngeal papillomatosis undergoing suspension laryngoscopic surgery and a review of the literature. Int J Pediatr Otorhinolaryngol 2011; 75(11): 1442-5.
[http://dx.doi.org/10.1016/j.ijporl.2011.08.012] [PMID: 21907420]
[12] Li SQ, Chen JL, Fu HB, Xu J, Chen LH. Airway management in pediatric patients undergoing suspension laryngoscopic surgery for severe laryngeal obstruction caused by papillomatosis. Paediatr Anaesth 2010; 20(12): 1084-91.
[http://dx.doi.org/10.1111/j.1460-9592.2010.03447.x] [PMID: 21199117]

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