Crawley, Simon

Elhoweris, Azza

Flach, Susanne

Majumdar, Samit

Manickavasagam, Jaiganesh

English

University of Dundee Online Publications

                                                                    University of DundeeTransoral laser microsurgery using high‐flow nasal cannula oxygenationFlach, Susanne; Elhoweris, Azza; Majumdar, Samit; Crawley, Simon; Manickavasagam,JaiganeshPublished in:Clinical OtolaryngologyDOI:10.1111/coa.13398Publication date:2019Document VersionPeer reviewed versionLink to publication in Discovery Research PortalCitation for published version (APA):Flach, S., Elhoweris, A., Majumdar, S., Crawley, S., & Manickavasagam, J. (2019). Transoral laser microsurgeryusing high‐flow nasal cannula oxygenation: Our experience of 21 cases. Clinical Otolaryngology, 44(5), 871-874.https://doi.org/10.1111/coa.13398General rightsCopyright and moral rights for the publications made accessible in Discovery Research Portal are retained by the authors and/or othercopyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated withthese rights. • Users may download and print one copy of any publication from Discovery Research Portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain. • You may freely distribute the URL identifying the publication in the public portal.Take down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Download date: 17. Aug. 2023Accepted ArticleThis article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/coa.13398 This article is protected by copyright. All rights reserved. DR SUSANNE  FLACH (Orcid ID : 0000-0001-6196-3706)  Article type      : Our Experience  Transoral laser microsurgery using high-flow nasal cannula oxygenation: Our experience of 21 cases  Susanne Flach1,2, Azza Elhoweris1, Samit Majumdar1, Simon Crawley3, Jaiganesh Manickavasagam1  1Department of Otorhinolaryngology and Head & Neck Surgery and Tayside Medical Sciences Centre, Ninewells Hospital, Dundee, U.K. 2Department of Otolaryngology, Hospital of the Ludwig-Maximilians-University, Munich, Germany  3Department of Anaesthesia, Ninewells Hospital, Dundee, U.K.  Contact details: Susanne Flach Department of Otolaryngology  Hospital of the Ludwig-Maximilians-University Marchioninistrasse 15 81377 Munich Germany E-mail: susanne.flach@googlemail.com  Introduction Transoral laser microsurgery (TLM) using carbon dioxide lasers (CO2) has become a widely used technique for treatment of a variety of oropharyngeal and laryngeal conditions.1 The traditional method for providing oxygenation during TLM involves controlled mechanical ventilation via a laser safe endotracheal tube (ETT). However, access and visualisation of the upper airway can be challenging.2 Alternatively, methods of tubeless field anaesthesia include supraglottic, transglottic and transtracheal jet ventilation and low-flow oxygen delivery as part of a spontaneously ventilating technique.3 Although jet ventilation provides a tubeless surgical field and improved visibility, there is a risk of barotrauma from airway outflow obstruction,2 potential desiccation and trauma of the supraglottis from ventilation pulses with subsequent mucosal oedema.4 As for spontaneous ventilation, it offers an optimal view for the surgeon, however, worrying features are inhalation risks of laser fumes and a moving surgical field.2   Humidified oxygenation via high-flow nasal cannulae (HFNC) has been increasingly adopted in adult patients in the emergency department for respiratory failure and in the critical care environment. Its introduction into anaesthetic practice and airway management has revolutionised practice. HFNC systems can deliver oxygen at a flow rate of up to 70 l/min and a fraction of inspired oxygen reaching 100%. Heated and humidified oxygen delivery via HFNC improves patient tolerance compared to existing approaches such as biphasic positive airway pressure ventilation therapy, maintains mucociliary clearance and decreases ventilation-perfusion mismatching by Accepted ArticleThis article is protected by copyright. All rights reserved. recruiting atelactatic alveoli. HFNC have been suggested to be useful for airway management during respiratory or anaesthetic procedures due to improved oxygenation from positive airway pressure generation and the ability for uninterrupted oxygenation.5-7 Apnoeic oxygenation and ventilation, described as Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE), has been utilised for patients undergoing general anaesthesia for hypopharyngeal and laryngotracheal surgery.8  Airway fires are a feared complication. All three components of a “fire triad“ have to be present for an airway fire to occur: fuels including ETTs and sponges in the airway, oxidisers such as oxygen or anaesthetic gases, and ignition sources, e.g. lasers. All of these components could come into close proximity during TLM.9 Therefore uncertainty exists about fire risks of TLM in the presence of oxygen-rich environments such as during HFNC oxygenation. There was an initial keeness to explore the use of HFNC within this setting with some experts proposing its safety due to abscence of a fuel source in the form of ETTs. To our knowledge there have been no reports describing complications in patients who underwent TLM using HFNC as part of their airway management.  Here, we describe our initial experience with CO2 laser excision for treatment of a variety of oropharyngeal and laryngeal conditions in adult patients using the HFNC. It must be noted, this is not the current practice of our institution. Much like many other centres who may have introduced this practice, many have more recently limited its utility to purely diagnostic upper airway procedures whilst awaiting more evidence surrounding its use in airway laser surgery.  Materials and Methods We retrospectively reviewed medical records of 21 cases, who underwent elective transoral CO2 laser-aided treatment of oropharyngeal and laryngeal conditions with heated humified oxygen delivery via HFNC at the Department of Otolaryngology and Head & Neck Surgery, Ninewells Hospital, Dundee, U.K., between January 2015 and February 2018. We recorded the time of HFNC use from the operation notes. Our main outcome was safety. Secondary outcome measures included feasibility, complications, HFNC usage time and surgical access.  Ethical considerations This study was approved by the NHS Tayside Caldicott Guardian (ref. IGTCAL4718).  Technique This was a retrospective case note review and as such there was no standardised anaesthetic protocol. All patients had been anaesthetised by consultant anaesthetists who have regular exposure to laryngotracheal surgery, using standards of monitoring as dictated by the Association of Anaesthetists of Great Britain and Ireland.10 Pre-oxygenation was achieved with use of high flow nasal oxygen at flow rates of up to 50 l/min. All cases were anaesthetised using a total intravenous anaesthetic technique using target controlled infusions of propofol and remifentanil. Bispectral index monitoring was used in addition to other monitors to guide anaesthetic management. Following induction, the airway was maintained with maximal airway maneouvres to ensure airway patency. Laryngoscopy was performed and additional airway anaesthesia was achieved by application of 4 % Accepted ArticleThis article is protected by copyright. All rights reserved. lidocaine to the supraglottis, glottis and subglottis, if required, prior to suspension laryngoscopy. Oxygen flow rate was increased to 70 l/min. During the procedure only wet patties were used and no drapes or sponges were left within the oral cavity. Cases undergoing balloon dilatation of subglottic stenosis were anaesthetised using a spontaneous ventilation technique which has since been described by Booth et al.11 Other procedures, such as cordotomy, utilised an apnoeic technique throughout with cessation or reduction of oxygen flow during laser use. After surgery, in both patient types, a supraglottic airway device was inserted prior to cessation of anaesthetic infusion to allow emergence from anaesthesia.  Results Out of the 21 TLM cases presented here, where HFNC oxygenation was used for airway management, 48% had treatment for subglottic stenosis, 29% underwent cordectomy, 14% had excision of a laryngeal papilloma and 9% had a vocal cord lesion excised. A summary of the results is shown in Table 1. HFNC usage time ranged from 15 min to 95 min. For 20 cases no intra- or immediate post-operative complications were recorded. Adequate surgical access and completion of the planned procedure was achieved in all of the 21 cases. Importantly, no airway fires or similar adverse events such as flaring were mentioned. One patient (case 6) had a brief episode of low oxygen saturations during balloon dilatation for subglottic stenosis. The balloon was deflated at oxygen saturations of 90% and saturations fell to 84% secondary to transient upper airway obstruction. The patient recovered rapidly and had further CO2 laser treatment to a tracheal stenosis.   Discussion We recognise the small number of cases in this analysis but hope it can add to the evidence to the use of TLM. In our experience, HFNC provided a safe and efficient oxygenation system during transoral endoscopic surgery using CO2 lasers. Apart from one transient episode of desaturation there were no safety concerns or complications related to HFNC oxygenation. Adequate surgical access was achieved for all cases with a median HFNC usage time of 45 min. In this study, half of the patients who received high flow nasal oxygenation had treatment for subglottic stenosis. Securing a safe airway for both intra-operative oxygenation and for the surgical procedure is one of the most important aspects in the surgical management of this condition. The main advantage of HFNC is that it allows safe and effective oxygenation of the patient in addition to good surgical access and avoidance of potentially serious risks associated with other methods of airway management.3 One case study by Tam et al.12 described the use of OptiflowTM HFNC oxygenation for CO2 laser excision of supraglottic-pharyngeal stenosis. The group used a combination of pre-oxygenation and intra-operative apnoeic oxygenation for successful treatment of the stenosis without any complications. Even though a CO2 laser was used in an oxygen-rich ennvironment an airway fire was unlikely to happen unless a fuel source such as an inhaled gas, airway-sponges, or an ETT were introduced, and so completing the components of the fire triad. There is one case report by Onwochei et al.13 describing a brief ignition within the oral cavity during the use of monopolar diathermy and OptiflowTM THRIVE in a sedated patient having a hard palate biopsy. Contrary to the report by Tam et al.12, the fire triad was completed in this case with HFNC oxygenation, the needle diathermy shaft insulation providing fuel, and ignition caused by an arc discharge between the diathermy needle tip and titanium implant screws in the patient’s palate. A Pubmed search Accepted ArticleThis article is protected by copyright. All rights reserved. conducted by us did not identify any further published reports about airway fires resulting from use of HFNC and TLM.  HFNC oxygenation can allow for safe and effective tubeless field anaesthesia and the risk of airway fires is low if the correct safety precautions are implemented. These cases were untaken with a high level of vigilance in the early phases of introducing this technique to our practice as this was a new technique to us. Although our use of TLM and HFNC is currently on hold in concordance with manufacturer guidance, we feel that this cohort may add to the evidence base. Our experience, albeit in small numbers is positive if done by senior and experienced clinicians who can maintain that high standard of care and vigilance. Other centres who may have employed these techniques in the past may have similar experience. We also strongly believe that any potential reintroduction of this practice in future should be based on a larger evidence base and cases be carried out by experienced consultant surgeons and anaesthetists who are familiar with both airway laser surgery and tubeless field anaesthesia.    Keypoints  Optimal access and visualisation is crucial during TLM, however, airway management can be challenging.  Oxygenation via HFNC provides a safe and effective way for airway management during tubeless field anaesthesia in TLM.  HFNC oxygenation during TLM is well tolerated and avoids risks associated with other methods of tubeless field anaesthesia.  HFNC oxygenation during TLM should only be used in appropriate clinical situations for selected cases.  HFNC oxygenation during TLM should only be used  with a consultant level operator and consultant anaesthetist involvement, necessary safety precautions in place, while keeping the components of the fire triad in mind.  References  1. Holsinger FC, Ferris RL. Transoral Endoscopic Head and Neck Surgery and Its Role Within the Multidisciplinary Treatment Paradigm of Oropharynx Cancer: Robotics, Lasers, and Clinical Trials. J Clin Oncol. 2015 Oct 10;33(29):3285–92.  2. Jaquet Y, Monnier P, Van Melle G, Ravussin P, Spahn DR, Chollet-Rivier M. Complications of Different Ventilation Strategies in Endoscopic Laryngeal Surgery. Anesthesiology. 2006 Jan 1;104:52–9.  3. Pearson K, Crawley S, McGuire B. Oxygen delivery during endoscopic management of severe subglottic stenosis: A case series using high-flow nasal cannula [Internet]. 2015. pp. 1–2. Available from: https://www.epostersonline.com/wamm2015/node/1850?view=true 4. Stevens MS, Chang A, Simpson CB. Supraglottic Stenosis: Etiology and Treatment of a Rare Condition. Annals of Otology, Rhinology & Laryngology. 2013 Mar;122(3):205–9.  5. Parke R, McGuinness S, Eccleston M. Nasal high-flow therapy delivers low Accepted ArticleThis article is protected by copyright. All rights reserved. level positive airway pressure. British Journal of Anaesthesia. 2009 Dec;103(6):886–90.  6. Badiger S, John M, Fearnley RA, Ahmad I. Optimizing oxygenation and intubation conditions during awake fibre-optic intubation using a high-flow nasal oxygen-delivery system. British Journal of Anaesthesia. 2015 Oct;115(4):629–32.  7. Vella MA, Pascual-Lopez J, Kaplan LJ. High-Flow Nasal Cannula System. JAMA Surg. 2018 Jul 11;:1–2.  8. Patel A, Nouraei SAR. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. Wiley/Blackwell (10.1111); 2015 Jan 10;70(3):323–9.  9. Coughlan CA, Verma SP. Evaluating the Effects of a 532-nm Fiber-Based KTP Laser on Transoral Laser Surgery Supplies. Otolaryngol Head Neck Surg. 2013 Nov 4;149(5):739–44.  10. Checketts MR, Alladi R, Ferguson K, Gemmell L, Handy JM, Klein AA, et al. Recommendations for standards of monitoring during anaesthesia and recovery 2015 : Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. Wiley/Blackwell (10.1111); 2015 Nov 19;71(1):85–93.  11. Booth AWG, Vidhani K, Lee PK, Thomsett CM. SponTaneous Respiration using IntraVEnous anaesthesia and Hi-flow nasal oxygen (STRIVE Hi) maintains oxygenation and airway patency during management of the obstructed airway: an observational study. British Journal of Anaesthesia. 2017 Mar;118(3):444–51.  12. Tam K, Jeffery C, Sung CK. Surgical Management of Supraglottic Stenosis Using Intubationless Optiflow. Annals of Otology, Rhinology & Laryngology. 2017 Jul 18;126(9):669–72.  13. Onwochei D, El-Boghdadly K, Oakley R, Ahmad I. Intra-oral ignition of monopolar diathermy during transnasal humidified rapid-insufflation ventilatory exchange (THRIVE). Anaesthesia. 2017 Mar 20;72(6):781–3.      Accepted ArticleThis article is protected by copyright. All rights reserved. Table 1. Summary of TLM cases with HFNC airway management. M = Male, F = Female. Patients who had TLM twice are indicated with a superscript character (*, § or &).  Case Gender Age Type of operation HNFC time Complications 1 M 48 Laryngeal papilloma excision 50min None recorded 2 M 63 Vocal cord lesion excision 45min    None recorded 3 F 65 Dilatation of subglottic stenosis 60min None recorded 4* F 34 Dilatation of subglottic stenosis 60min None recorded 5 M 58 Cordectomy 45min None recorded 6 F 50 Dilatation of subglottic stenosis 15min Transient low sats during balloon dilatation 7 F 60 Cordectomy 30min None recorded 8 F 78 Cordectomy 45min None recorded 9 F 40 Dilatation of subglottic stenosis 75min None recorded 10§ M 65 Cordectomy 45min None recorded 11 F 38 Dilatation of subglottic stenosis 45min None recorded 12* F 35 Dilatation of subglottic stenosis 45min None recorded 13& M 24 Dilatation of subglottic stenosis 45min None recorded 14& M 24 Dilatation of subglottic stenosis 30min None recorded 15 F 28 Dilatation of subglottic stenosis 95min None recorded 16 F 63 Vocal cord lesion excision 45min None recorded 17 F 46 Cordectomy 45min None recorded 18 M 52 Laryngeal papilloma excision 36min None recorded 19 M 27 Dilatation of subglottic stenosis 75min None recorded Accepted ArticleThis article is protected by copyright. All rights reserved. 20§ M 66 Cordectomy 25min None recorded 21 F 60 Laryngeal papilloma excision 60min None recorded 

Transoral laser microsurgery using high‐flow nasal cannula oxygenation:Our experience of 21 cases

                                                                    University of DundeeTransoral laser microsurgery using highflow nasal cannula oxygenationFlach, Susanne; Elhoweris, Azza; Majumdar, Samit; Crawley, Simon; Manickavasagam,JaiganeshPublished in:Clinical OtolaryngologyDOI:10.1111/coa.13398Publication date:2019Document VersionPeer reviewed versionLink to publication in Discovery Research PortalCitation for published version (APA):Flach, S., Elhoweris, A., Majumdar, S., Crawley, S., & Manickavasagam, J. (2019). Transoral laser microsurgeryusing highflow nasal cannula oxygenation: Our experience of 21 cases. Clinical Otolaryngology, 44(5), 871-874.https://doi.org/10.1111/coa.13398General rightsCopyright and moral rights for the publications made accessible in Discovery Research Portal are retained by the authors and/or othercopyright owners and it is a condition of accessing publications that users recognise and abide by the legal requirements associated withthese rights. • Users may download and print one copy of any publication from Discovery Research Portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain. • You may freely distribute the URL identifying the publication in the public portal.Take down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Download date: 22. Jan. 2021Accepted ArticleThis article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/coa.13398 This article is protected by copyright. All rights reserved. DR SUSANNE  FLACH (Orcid ID : 0000-0001-6196-3706)  Article type      : Our Experience  Transoral laser microsurgery using high-flow nasal cannula oxygenation: Our experience of 21 cases  Susanne Flach1,2, Azza Elhoweris1, Samit Majumdar1, Simon Crawley3, Jaiganesh Manickavasagam1  1Department of Otorhinolaryngology and Head & Neck Surgery and Tayside Medical Sciences Centre, Ninewells Hospital, Dundee, U.K. 2Department of Otolaryngology, Hospital of the Ludwig-Maximilians-University, Munich, Germany  3Department of Anaesthesia, Ninewells Hospital, Dundee, U.K.  Contact details: Susanne Flach Department of Otolaryngology  Hospital of the Ludwig-Maximilians-University Marchioninistrasse 15 81377 Munich Germany E-mail: susanne.flach@googlemail.com  Introduction Transoral laser microsurgery (TLM) using carbon dioxide lasers (CO2) has become a widely used technique for treatment of a variety of oropharyngeal and laryngeal conditions.1 The traditional method for providing oxygenation during TLM involves controlled mechanical ventilation via a laser safe endotracheal tube (ETT). However, access and visualisation of the upper airway can be challenging.2 Alternatively, methods of tubeless field anaesthesia include supraglottic, transglottic and transtracheal jet ventilation and low-flow oxygen delivery as part of a spontaneously ventilating technique.3 Although jet ventilation provides a tubeless surgical field and improved visibility, there is a risk of barotrauma from airway outflow obstruction,2 potential desiccation and trauma of the supraglottis from ventilation pulses with subsequent mucosal oedema.4 As for spontaneous ventilation, it offers an optimal view for the surgeon, however, worrying features are inhalation risks of laser fumes and a moving surgical field.2   Humidified oxygenation via high-flow nasal cannulae (HFNC) has been increasingly adopted in adult patients in the emergency department for respiratory failure and in the critical care environment. Its introduction into anaesthetic practice and airway management has revolutionised practice. HFNC systems can deliver oxygen at a flow rate of up to 70 l/min and a fraction of inspired oxygen reaching 100%. Heated and humidified oxygen delivery via HFNC improves patient tolerance compared to existing approaches such as biphasic positive airway pressure ventilation therapy, maintains mucociliary clearance and decreases ventilation-perfusion mismatching by Accepted ArticleThis article is protected by copyright. All rights reserved. recruiting atelactatic alveoli. HFNC have been suggested to be useful for airway management during respiratory or anaesthetic procedures due to improved oxygenation from positive airway pressure generation and the ability for uninterrupted oxygenation.5-7 Apnoeic oxygenation and ventilation, described as Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE), has been utilised for patients undergoing general anaesthesia for hypopharyngeal and laryngotracheal surgery.8  Airway fires are a feared complication. All three components of a “fire triad“ have to be present for an airway fire to occur: fuels including ETTs and sponges in the airway, oxidisers such as oxygen or anaesthetic gases, and ignition sources, e.g. lasers. All of these components could come into close proximity during TLM.9 Therefore uncertainty exists about fire risks of TLM in the presence of oxygen-rich environments such as during HFNC oxygenation. There was an initial keeness to explore the use of HFNC within this setting with some experts proposing its safety due to abscence of a fuel source in the form of ETTs. To our knowledge there have been no reports describing complications in patients who underwent TLM using HFNC as part of their airway management.  Here, we describe our initial experience with CO2 laser excision for treatment of a variety of oropharyngeal and laryngeal conditions in adult patients using the HFNC. It must be noted, this is not the current practice of our institution. Much like many other centres who may have introduced this practice, many have more recently limited its utility to purely diagnostic upper airway procedures whilst awaiting more evidence surrounding its use in airway laser surgery.  Materials and Methods We retrospectively reviewed medical records of 21 cases, who underwent elective transoral CO2 laser-aided treatment of oropharyngeal and laryngeal conditions with heated humified oxygen delivery via HFNC at the Department of Otolaryngology and Head & Neck Surgery, Ninewells Hospital, Dundee, U.K., between January 2015 and February 2018. We recorded the time of HFNC use from the operation notes. Our main outcome was safety. Secondary outcome measures included feasibility, complications, HFNC usage time and surgical access.  Ethical considerations This study was approved by the NHS Tayside Caldicott Guardian (ref. IGTCAL4718).  Technique This was a retrospective case note review and as such there was no standardised anaesthetic protocol. All patients had been anaesthetised by consultant anaesthetists who have regular exposure to laryngotracheal surgery, using standards of monitoring as dictated by the Association of Anaesthetists of Great Britain and Ireland.10 Pre-oxygenation was achieved with use of high flow nasal oxygen at flow rates of up to 50 l/min. All cases were anaesthetised using a total intravenous anaesthetic technique using target controlled infusions of propofol and remifentanil. Bispectral index monitoring was used in addition to other monitors to guide anaesthetic management. Following induction, the airway was maintained with maximal airway maneouvres to ensure airway patency. Laryngoscopy was performed and additional airway anaesthesia was achieved by application of 4 % Accepted ArticleThis article is protected by copyright. All rights reserved. lidocaine to the supraglottis, glottis and subglottis, if required, prior to suspension laryngoscopy. Oxygen flow rate was increased to 70 l/min. During the procedure only wet patties were used and no drapes or sponges were left within the oral cavity. Cases undergoing balloon dilatation of subglottic stenosis were anaesthetised using a spontaneous ventilation technique which has since been described by Booth et al.11 Other procedures, such as cordotomy, utilised an apnoeic technique throughout with cessation or reduction of oxygen flow during laser use. After surgery, in both patient types, a supraglottic airway device was inserted prior to cessation of anaesthetic infusion to allow emergence from anaesthesia.  Results Out of the 21 TLM cases presented here, where HFNC oxygenation was used for airway management, 48% had treatment for subglottic stenosis, 29% underwent cordectomy, 14% had excision of a laryngeal papilloma and 9% had a vocal cord lesion excised. A summary of the results is shown in Table 1. HFNC usage time ranged from 15 min to 95 min. For 20 cases no intra- or immediate post-operative complications were recorded. Adequate surgical access and completion of the planned procedure was achieved in all of the 21 cases. Importantly, no airway fires or similar adverse events such as flaring were mentioned. One patient (case 6) had a brief episode of low oxygen saturations during balloon dilatation for subglottic stenosis. The balloon was deflated at oxygen saturations of 90% and saturations fell to 84% secondary to transient upper airway obstruction. The patient recovered rapidly and had further CO2 laser treatment to a tracheal stenosis.   Discussion We recognise the small number of cases in this analysis but hope it can add to the evidence to the use of TLM. In our experience, HFNC provided a safe and efficient oxygenation system during transoral endoscopic surgery using CO2 lasers. Apart from one transient episode of desaturation there were no safety concerns or complications related to HFNC oxygenation. Adequate surgical access was achieved for all cases with a median HFNC usage time of 45 min. In this study, half of the patients who received high flow nasal oxygenation had treatment for subglottic stenosis. Securing a safe airway for both intra-operative oxygenation and for the surgical procedure is one of the most important aspects in the surgical management of this condition. The main advantage of HFNC is that it allows safe and effective oxygenation of the patient in addition to good surgical access and avoidance of potentially serious risks associated with other methods of airway management.3 One case study by Tam et al.12 described the use of OptiflowTM HFNC oxygenation for CO2 laser excision of supraglottic-pharyngeal stenosis. The group used a combination of pre-oxygenation and intra-operative apnoeic oxygenation for successful treatment of the stenosis without any complications. Even though a CO2 laser was used in an oxygen-rich ennvironment an airway fire was unlikely to happen unless a fuel source such as an inhaled gas, airway-sponges, or an ETT were introduced, and so completing the components of the fire triad. There is one case report by Onwochei et al.13 describing a brief ignition within the oral cavity during the use of monopolar diathermy and OptiflowTM THRIVE in a sedated patient having a hard palate biopsy. Contrary to the report by Tam et al.12, the fire triad was completed in this case with HFNC oxygenation, the needle diathermy shaft insulation providing fuel, and ignition caused by an arc discharge between the diathermy needle tip and titanium implant screws in the patient’s palate. A Pubmed search Accepted ArticleThis article is protected by copyright. All rights reserved. conducted by us did not identify any further published reports about airway fires resulting from use of HFNC and TLM.  HFNC oxygenation can allow for safe and effective tubeless field anaesthesia and the risk of airway fires is low if the correct safety precautions are implemented. These cases were untaken with a high level of vigilance in the early phases of introducing this technique to our practice as this was a new technique to us. Although our use of TLM and HFNC is currently on hold in concordance with manufacturer guidance, we feel that this cohort may add to the evidence base. Our experience, albeit in small numbers is positive if done by senior and experienced clinicians who can maintain that high standard of care and vigilance. Other centres who may have employed these techniques in the past may have similar experience. We also strongly believe that any potential reintroduction of this practice in future should be based on a larger evidence base and cases be carried out by experienced consultant surgeons and anaesthetists who are familiar with both airway laser surgery and tubeless field anaesthesia.    Keypoints  Optimal access and visualisation is crucial during TLM, however, airway management can be challenging.  Oxygenation via HFNC provides a safe and effective way for airway management during tubeless field anaesthesia in TLM.  HFNC oxygenation during TLM is well tolerated and avoids risks associated with other methods of tubeless field anaesthesia.  HFNC oxygenation during TLM should only be used in appropriate clinical situations for selected cases.  HFNC oxygenation during TLM should only be used  with a consultant level operator and consultant anaesthetist involvement, necessary safety precautions in place, while keeping the components of the fire triad in mind.  References  1. Holsinger FC, Ferris RL. Transoral Endoscopic Head and Neck Surgery and Its Role Within the Multidisciplinary Treatment Paradigm of Oropharynx Cancer: Robotics, Lasers, and Clinical Trials. J Clin Oncol. 2015 Oct 10;33(29):3285–92.  2. Jaquet Y, Monnier P, Van Melle G, Ravussin P, Spahn DR, Chollet-Rivier M. Complications of Different Ventilation Strategies in Endoscopic Laryngeal Surgery. Anesthesiology. 2006 Jan 1;104:52–9.  3. Pearson K, Crawley S, McGuire B. Oxygen delivery during endoscopic management of severe subglottic stenosis: A case series using high-flow nasal cannula [Internet]. 2015. pp. 1–2. Available from: https://www.epostersonline.com/wamm2015/node/1850?view=true 4. Stevens MS, Chang A, Simpson CB. Supraglottic Stenosis: Etiology and Treatment of a Rare Condition. Annals of Otology, Rhinology & Laryngology. 2013 Mar;122(3):205–9.  5. Parke R, McGuinness S, Eccleston M. Nasal high-flow therapy delivers low Accepted ArticleThis article is protected by copyright. All rights reserved. level positive airway pressure. British Journal of Anaesthesia. 2009 Dec;103(6):886–90.  6. Badiger S, John M, Fearnley RA, Ahmad I. Optimizing oxygenation and intubation conditions during awake fibre-optic intubation using a high-flow nasal oxygen-delivery system. British Journal of Anaesthesia. 2015 Oct;115(4):629–32.  7. Vella MA, Pascual-Lopez J, Kaplan LJ. High-Flow Nasal Cannula System. JAMA Surg. 2018 Jul 11;:1–2.  8. Patel A, Nouraei SAR. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways. Anaesthesia. Wiley/Blackwell (10.1111); 2015 Jan 10;70(3):323–9.  9. Coughlan CA, Verma SP. Evaluating the Effects of a 532-nm Fiber-Based KTP Laser on Transoral Laser Surgery Supplies. Otolaryngol Head Neck Surg. 2013 Nov 4;149(5):739–44.  10. Checketts MR, Alladi R, Ferguson K, Gemmell L, Handy JM, Klein AA, et al. Recommendations for standards of monitoring during anaesthesia and recovery 2015 : Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. Wiley/Blackwell (10.1111); 2015 Nov 19;71(1):85–93.  11. Booth AWG, Vidhani K, Lee PK, Thomsett CM. SponTaneous Respiration using IntraVEnous anaesthesia and Hi-flow nasal oxygen (STRIVE Hi) maintains oxygenation and airway patency during management of the obstructed airway: an observational study. British Journal of Anaesthesia. 2017 Mar;118(3):444–51.  12. Tam K, Jeffery C, Sung CK. Surgical Management of Supraglottic Stenosis Using Intubationless Optiflow. Annals of Otology, Rhinology & Laryngology. 2017 Jul 18;126(9):669–72.  13. Onwochei D, El-Boghdadly K, Oakley R, Ahmad I. Intra-oral ignition of monopolar diathermy during transnasal humidified rapid-insufflation ventilatory exchange (THRIVE). Anaesthesia. 2017 Mar 20;72(6):781–3.      Accepted ArticleThis article is protected by copyright. All rights reserved. Table 1. Summary of TLM cases with HFNC airway management. M = Male, F = Female. Patients who had TLM twice are indicated with a superscript character (*, § or &).  Case Gender Age Type of operation HNFC time Complications 1 M 48 Laryngeal papilloma excision 50min None recorded 2 M 63 Vocal cord lesion excision 45min    None recorded 3 F 65 Dilatation of subglottic stenosis 60min None recorded 4* F 34 Dilatation of subglottic stenosis 60min None recorded 5 M 58 Cordectomy 45min None recorded 6 F 50 Dilatation of subglottic stenosis 15min Transient low sats during balloon dilatation 7 F 60 Cordectomy 30min None recorded 8 F 78 Cordectomy 45min None recorded 9 F 40 Dilatation of subglottic stenosis 75min None recorded 10§ M 65 Cordectomy 45min None recorded 11 F 38 Dilatation of subglottic stenosis 45min None recorded 12* F 35 Dilatation of subglottic stenosis 45min None recorded 13& M 24 Dilatation of subglottic stenosis 45min None recorded 14& M 24 Dilatation of subglottic stenosis 30min None recorded 15 F 28 Dilatation of subglottic stenosis 95min None recorded 16 F 63 Vocal cord lesion excision 45min None recorded 17 F 46 Cordectomy 45min None recorded 18 M 52 Laryngeal papilloma excision 36min None recorded 19 M 27 Dilatation of subglottic stenosis 75min None recorded Accepted ArticleThis article is protected by copyright. All rights reserved. 20§ M 66 Cordectomy 25min None recorded 21 F 60 Laryngeal papilloma excision 60min None recorded 

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Transoral laser microsurgery using high‐flow nasal cannula oxygenation:Our experience of 21 cases

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