Evaluation of the safety of carbon dioxide laser and transnasal humidified rapid insufflation ventilatory exchange in laryngeal surgery

Background: The use of transnasal humidified rapid insufflation ventilatory exchange (THRIVE) for laryngeal surgery is gathering increasing interest due to improved surgical access in the absence of an airway device. However, the use of higher levels of oxygen concentration compared to other techniques, has given rise to concerns over airway fires with this technique. This study aims to investigate the safety of carbon dioxide laser when combined with THRIVE in laryngeal surgery. Methods: A retrospective cohort review of patient medical records over the age of 18 who underwent carbon dioxide laser laryngeal surgery with THRIVE at three Geelong (Victoria, Australia) hospitals between January 2016 and December 2021 was undertake. Factors including surgical indication, ventilation parameters, laser settings, lowest oxygen saturation, highest carbon dioxide level, the use of adjunct airway devices and perioperative complications including airway fires were collected. Results: The medical records of 54 individual patients undergoing 106 procedures were identified. No airway fires were recorded. Three complications were recorded including charring of the nasal prong tubing, post operative atrial fibrillation, and stridor. Twenty-one patients required either intubation with an endotracheal tube or placement of a laryngeal mask airway during their procedure for hypoxia or hypercapnia. Three cases were converted to low frequency intermittent supraglottic jet ventilation. Conclusions: Carbon dioxide laser and THRIVE in laryngeal surgery can be safely performed without experiencing airway fires. Surgeons should nonetheless remain aware of the potential for fires in all laser cases and take precaution to minimize risks. Surgical teams should also be aware of the need for other airway devices during cases and the role hypercapnia may play in perioperative complications.