Tubeless GA

airway management general anaesthetic safety shared airway Jul 08, 2024

🌟 What and why? 🌟
A tubeless general anaesthetic may be required to improve access to the larynx or in situations where an endotracheal tube is not possible (subglottic stenosis). A common indication for tubeless GA is for subglottic dilation to treat subglottic stenosis. This technique has been made safer by high-flow nasal oxygen devices that provide apnoeic oxygenation without the need for jet ventilation or transtracheal oxygenation.

🔍 Intraoperative considerations: 🔍
📍 Position: Supine with ideal intubating position
⏱️ Duration: 20-90 mins
🌬️ Airway plan:

  • Spontaneously ventilating
    High-flow nasal oxygen with titrated propofol TIVA +/- opioid to keep the patient breathing. Local anaesthetic spray to improve tolerance of instrumentation. Preserves the option to abandon and wake patient. Risk of laryngospasm & coughing.
  • Apnoeic/paralysed
    High-flow nasal oxygen at 50-70 L/min. Propofol/remifentanil + paralysis. Relies on adequate apnoeic oxygenation via nasal oxygen. Optimal surgical conditions (no coughing, movement, or laryngospasm).

💡 Expert tips:
A size 4.0mm microlaryngoscopy tube should be available as a rescue device and can be placed by an ENT surgeon or the anaesthetist. Remember to use the Vortex Approach and consider all lifelines in the setting of airway rescue!

🌟 Postoperative considerations: 🌟
💥 Pain: Usually minimal, occasional anxiety relating to tracheal irritation.
❗ Airway risks: Bleeding/tracheal injury/laryngospasm.

🔄 Other:
This is a good case to request assistance from a senior colleague if you haven’t seen many!

✅ Build knowledge
✅ Improve safety

Ref: KL Pearson, BE McGuire, Anaesthesia for laryngo-tracheal surgery, including tubeless field techniques, BJA Education, Volume 17, Issue 7, July 2017, Pages 242–248, https://doi.org/10.1093/bjaed/mkx004.

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