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Intratracheal Fire Ignited by a Gallium-Arsenide-Aluminum Diode Laser During Treatment of Airway Obstruction With Lung Cancer

Hasegawa, Yukihiro MD; Takanashi, Shingo MD; Okudera, Koichi MD; Kumagai, Mika MD; Hayashi, Akihito MD; Muraoka, Masatoshi MD; Ishihara, Hironori MD; Okumura, Ken MD

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Fire hazard with the use of the diode laser has not been reported. We recently experienced a case of intratracheal fire ignited by laser surgery for airway obstruction from lung cancer. We used a gallium-arsenide-aluminium (Ga-As-Al) diode laser for the laser surgery under total intravenous anesthesia with 60% oxygen supplement. It is well known that ignition can occur if the laser beam or its reflection impacts on the endotracheal tube. However, the tissue exposed to the laser also can be the ignition site. Therefore, it is not possible to completely eliminate the risk of fire. It is necessary to investigate the mechanism and prevention of fire hazard in laser surgery.

From the Second Department of Internal Medicine, (Drs. Hasegawa, Takanashi, Okudera, Kumagai, Hayashi, and Okumura), and the Department of Anesthesiology, (Drs. Muraoka and Ishihara), Hirosaki University School of Medicine, 5-Zaifu-cho, Hirosaki, Japan.

Reprints: Yukihiro Hasegawa, MD, The Second Department of Internal Medicine, Hirosaki University School of Medicine, 5-Zaifu-cho, Hirosaki, 036-8562 Japan (e-mail: hasegawa@cc.hirosaki-u.jp).

Laser photoresection with a CO2 laser and Nd-YAG (neodymiumyttrium aluminium garnet) laser has been used for palliative treatment of airway obstruction in lung cancer. 1,2 A newly developed high-power semiconductor diode laser with a compact, lightweight body has been introduced. The optical properties of this laser system are comparable with those of Nd-YAG laser. 3 Recently, a fire accident in the airway occurred in our laser surgery unit. This occurred while using the diode laser for treatment of airway obstruction with lung cancer. A fire accident in the airway is a well-recognized hazard of the surgical use of the CO2 laser and Nd-YAG laser. 4–6 We report a case of intratracheal fire during diode laser surgery.

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CASE REPORT

A 58-year-old man was admitted to our hospital for the treatment of non-small-cell lung cancer. The patient reported progressive dyspnea and a chest radiograph revealed complete right lung atelectasis. Videobronchoscopy showed obstruction of the right mainstem bronchus. He had severe hypoxemia and required supplemental oxygen therapy. Laser surgery was applied to the endobronchial lesion under general anesthesia and mechanical ventilation because of his psychologic problem. General anesthesia was induced and maintained by total intravenous anesthesia combined with propofol, fentanyl, and ketamine. The patient was intubated with a conventional polyvinylchloride (PVC) plastic tube (internal diameter, 8.0 mm; Portex, UK) and was delivered 15 breaths per minute with a tidal volume of 600 mL and a fraction of inspired oxygen (FIO2) of 0.6 during the laser surgery. The gallium-arsenide-aluminium (Ga-As-Al) diode laser (UDL-60, Olympus Optical Co., Tokyo, Japan) was used in non-contact and pulsed modes. A Teflon-sheathed quart laser fiber was passed through a channel of a flexible videobronchoscope (BF type P200, Olympus Optical Co.). In the first procedure of laser surgery, a total of 4131 J of laser output with 0.5-second pulses of 30 W was delivered to the tumor tissue for about 15 minutes (Fig. 1). During the second procedure, the operator saw an emission of light on the video monitor. He immediately removed the videoscope and the laser fiber that was visibly burned. At the same time, he heard a pop and saw a spark and black smoke around the endotracheal tube. The anesthesiologist quickly removed the endotracheal tube that was also burned, and the patient was reintubated. The videoscope revealed extensive carbonization of the airway distal to the end of the endotracheal tube. The patient was cared for according to the airway fire protocol including: 1) the combustible endobronchial materials were immediately removed; 2) ventilation with 100% oxygen was performed and anesthesia was continued; 3) gentle bronchial lavage was instituted; and 4) steroids and antibiotics were administered. 6 An examination of the airways revealed charred mucosa in the distal trachea and left mainstem bronchus (Fig. 2). The inflammation (Fig. 2) caused by the fire disappeared approximately 2 weeks later, whereas bronchial obstructive tumor enlarged gradually. The patient died 2 months later as a result of tumor progression.

FIGURE 1.

FIGURE 1.

FIGURE 2.

FIGURE 2.

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DISCUSSION

The largest published series of CO2 laser airway procedures documented 6 airway fires in 4416 cases (0.14% incidence). 7 Nd-YAG laser also has been reported to have a risk of causing endobronchial ignition. 5,6 It is well known that ignition can occur when the laser beam or its reflection impacts on the tube. This seems to be because the endotracheal tube or the laser fiber is flammable. In addition, flaming tissue on the tube can also ignite. 4 However, in this case, the irradiation point was apart from the tracheal tube. Therefore, another ignition mechanism could exist.

We performed the laser surgery under an oxygen concentration of 60%. It has been emphasized that the oxygen concentration during laser surgery is the major factor in ignition accidents. Brutinel et al. recommended that the oxygen concentration should be kept ≤40% during Nd-YAG laser surgery. 8 Therefore, most clinicians recommend FIO2 <40–50% or the minimum concentration consistent with the patient's oxygenation needs. 9 There is no doubt that a high concentration of oxygen increases the risk of ignition. However, there are many cases that show supplemental oxygen is needed during treatment. Furthermore, endobronchial ignition has been reported to occur even at an oxygen concentration of 40%. 5,6,10 Our basic experiments showed that fire occurred when oxygen concentration was >30%. 11 On the other hand, Jackson reported that no attempt was made to limit the FIO2 during Nd-YAG laser surgery because the immediate risk of intraoperative hypoxia was considered to outweigh the minimal risk of intratracheal fire or explosion. 12

In the present accident, we intubated the patient with a conventional PVC plastic tube. The tube was removed quickly when the ignition occurred. All common endotracheal tubes are potentially flammable, and so the risks of the various types of construction material have been well studied. A reusable red rubber tube and clear PVC plastic tube are resistant to laser irradiation in vitro. However, a thin coating of mucus or blood in vivo will absorb energy and cause ignition. 9 Silicone tubing is the most resistant to ignition. Furthermore, application of a protective metal foil wrap to the endotracheal tube and cuff has been recommended for the prevention of intratracheal fire. 9 However, it has also been reported that endobronchial fire resulting in endobronchial burn during Nd-YAG laser surgery occurred even when the tracheal tube was wrapped with metal tape. 6 Maximum possible distance should be maintained between the endotracheal tube and the surgical field. 6Figure 1 shows that the tracheal tube in the fire accident was kept at a sufficient distance from the surgical field. This accident indicates that ignition can occur from laser irradiation without direct impact to the tube. 5

There are other strategies to limit airway fire risk during laser surgery: Excessive pulse energy applications should be avoided and, to dissipate with adequate time spacing between repeated pulses, laser resection should be performed intermittently. 6 Furthermore, we recently discussed that the tissue exposed to the laser also can be the ignition site, and that increasing airway flow through the laser fiber was an effective technique to prevent airway fire. 11 Fire hazard in laser surgery could become rare. 1 However, it is not possible to completely eliminate the risk of fire. Prevention of fire hazard in laser surgery is still of utmost importance.

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REFERENCES

1. Cavaliere S, Venuta F, Foccoli P, et al. Endoscopic treatment of malignant airway obstructions in 2,008 patients. Chest. 1996; 110:1536–1542.
2. Dumon JF, Shapshay S, Bourcereau J, et al. Principles for safety in application of neodymium-YAG laser in bronchology. Chest. 1984; 86:163–168.
3. Nagatani T, Saito K, Yoshida J. Experimental use of semiconductor diode laser for neuroendoscopic surgery. Minim Invasive Neurosurg. 1997; 40:98–100.
4. Hirshman CA, Smith J. Indirect ignition of the endotracheal tube during carbon dioxide laser surgery. Arch Otolaryngol. 1980; 106:639–641.
5. Casey KR, Fairfax WR, Smith SJ, et al. Intratracheal fire ignited by the Nd-YAG laser during treatment of tracheal stenosis. Chest. 1983; 84:295–296.
6. Krawtz S, Mehta AC, Wiedemann HP, et al. Nd-YAG laser-induced endobronchial burn. Management and long-term follow-up. Chest. 1989; 95:916–918.
7. Healy GB, Strong MS, Shapshay S, et al. Complications of CO2 laser surgery of the aerodigestive tract: experience of 4416 cases. Otolaryngol Head Neck Surg. 1984; 92:13–18.
8. Brutinel WM, McDougall JC, Cortese DA. Bronchoscopic therapy with neodymium-yttrium-aluminum-garnet laser during intravenous anesthesia. Effect on arterial blood gas levels, pH, hemoglobin saturation, and production of abnormal hemoglobin. Chest. 1983; 84:518–521.
9. Rampil IJ. Anesthesia for laser surgery. In: Miller DR, ed. Anesthesia, 5th ed. Philadelphia: Churchill Livingstone, 2000:2199–212.
10. Kvale PA, Eichenhorn MS, Radke JR, et al. YAG laser photoresection of lesions obstructing the central airways. Chest. 1985; 87:283–288.
11. Takanashi S, Hasegawa Y, Ito A, et al. Airflow through the auxiliary line of the laser fiber prevents ignition of intra-airway fire during endoscopic laser surgery. Lasers Surg Med. 2002; 31:211–215.
12. Jackson KA, Morland MH. Anaesthesia for resection of lesions of the trachea and main bronchi using the neodymium yttrium aluminium garnet (Nd YAG) laser. A report of 75 treatments in 52 patients. Anaesth Intensive Care. 1990; 18:69–75.
Keywords:

ignition; laser surgery; diode laser; lung cancer

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