Tracheostomy, laser surgery and jet ventilation
Stem
A 52-year-old man, 80 kg, with recurrent respiratory papillomatosis is scheduled for suspension microlaryngoscopy and CO2 laser excision of papillomas on both vocal folds and the anterior commissure. He has had four previous excisions, a normal mouth opening and neck, no lung disease, and an SpO2 of 98% on room air. The surgeon asks for a field without a tracheal tube.
Question
How will you oxygenate and ventilate him, and how will you keep him safe while the laser is in use?
Ideal answer
HeadlineShared airway, laser: supraglottic jet ventilation through the suspension laryngoscope, no combustible tube in the field.
- Agree the plan, including rescue, with the surgeon before induction, for oxygenation, a motionless field, and no fire or barotrauma.
- Total intravenous anesthesia: propofol, remifentanil, neuromuscular blockade, because volatile agents cannot be delivered through a jet and he must not cough or move;1 I preoxygenate and mask ventilate, handing over once the scope is suspended and aligned.
- Glottis open, chest rise and fall watched, because exhalation is passive; ventilator with airway pressure monitoring and an automatic cutoff.1
- Arterial line for blood gases, because end-tidal CO2 is unreliable; accepting moderate hypercapnia if he stays stable.1
- Minimum oxygen before every laser burst, and wait.2 Rescue: a laser-resistant tube, its cuff filled with saline tinted with methylene blue.2
Watch for: Falling saturation, rising pressure, chest distension and neck crepitus.
Breaking down the answer
- Changes if the glottis is blocked — a tight stenosis or a mass over the glottis changes the technique; a shared airway fails when anesthesia and surgery improvise separately.
- Two jet modes — low-frequency jet runs at 10–30 breaths per minute by hand; high-frequency jet at 60–600 per minute with tidal volumes smaller than dead space.1
- Laser tube when jetting is unsafe — a laser-resistant tube suited to the laser in use, with a saline-filled and dyed cuff, is the alternative when jetting is unsafe.2
- Egress is everything — upper airway obstruction above 50%, morbid obesity, severe COPD and restrictive disease are relative contraindications to jetting, because gas gets in but cannot get out.1
- Barotrauma is the serious complication — pneumothorax, pneumomediastinum and subcutaneous emphysema; driving pressure is usually between 0.3 and 3 bar, with pressure alarms that stop inspiration when the limit is reached.3
- CO2 management — I raise driving pressure, or lower frequency to lengthen expiration; PaCO2 of 45–60 mmHg with pH above 7.20 is usually tolerated, and I check a gas every 30 minutes if CO2 is rising.1
- Tracheostomy is a fire case too — the surgeon should not enter the trachea with electrosurgery, and must warn me so I can lower the oxygen first.2
Follow-up question
Twenty minutes into jetting, the saturation falls to 86%, the pressure alarm keeps cutting off the jet, the chest looks hyperinflated, and the surgeon feels crepitus in the neck. Blood pressure is 78/40. What do you do?
Follow-up answer
HeadlineBreath stacking with barotrauma, possibly a tension pneumothorax. I stop the jet and have the laryngoscope taken out of suspension so the glottis opens.
Gas can now escape. I call for help, ventilate by mask or intubate with a standard tube at 100% oxygen now that the laser is off, and listen and scan both sides of the chest. A silent side with hypotension gets needle decompression, then a chest tube. Fluid and a vasopressor treat the pressure. Once he is stable, I reassess: a chest radiograph, a blood gas, and a look at the surgical airway for an obstructing lesion. Further laser work proceeds with a laser-resistant tube, not the jet.
Pitfalls that cost points
- Filling the laser tube cuff with air.
- Planning sevoflurane maintenance with a jet.
Rapid-fire
Q: Why does the jet deliver more volume than the gas that leaves the injector? A: The high-velocity jet entrains room air by the Venturi effect, which increases the delivered volume.1
Q: Why is methylene blue added to the cuff saline? A: It marks cuff puncture by the laser.2
Q: Is transtracheal jet ventilation still a good rescue for "cannot intubate, cannot oxygenate"? A: Its use has declined because of barotrauma risk and the availability of supraglottic devices; I go to a scalpel cricothyrotomy.1
Q: How do you improve oxygenation during jetting? A: Raise FiO2, driving pressure or inspiratory time.1
Q: What happens if the catheter slips into the esophagus? A: The stomach distends and can rupture.1
Numbers to know
| Item | Value |
|---|---|
| Low-frequency jet | 10–30 breaths/min1 |
| High-frequency jet | 60–600 breaths/min1 |
| Driving pressure | 0.3–3 bar3 |
| Obstruction that contraindicates jetting | >50%1 |
| Tolerated hypercapnia | PaCO2 45–60 mmHg, pH >7.201 |
| Blood gas when hypercapnic | Every 30 min1 |
Links
- Airway fire, Electrical safety, electrocautery and lasers, Cannot intubate, cannot oxygenate, Pneumothorax and tension pneumothorax, Anticipated difficult airway and the ASA algorithm
- ASA Practice Advisory for the Prevention and Management of Operating Room Fires (2013)
Sources
- 1.Jet Ventilation · OpenAnesthesia (IARS), 2025 · openanesthesia.orgLast updated 12/09/2025; LFJV vs HFJV, contraindications, monitoring, complications.
- 2.Practice Advisory for the Prevention and Management of Operating Room Fires · ASA, 2013 · asahq.orgAnesthesiology 2013;118(2); laser tube, saline and methylene blue cuff, tracheostomy and ignition-source recommendations.
- 3.Jet Ventilation during Rigid Bronchoscopy in Adults: A Focused Review · BioMed Research International, 2016 · ebi.ac.ukFull text via Europe PMC (PMC5101361); driving pressure range and complications.
Facts on this page were checked against these sources on Oct 16, 2026. Guidelines change; confirm doses against current institutional protocols.