1. Laser resistant tracheal tube a. The Norton tube: Reusable Stainless steel Flexible tube No cuff

2. Laser resistant tracheal tube b.The Laser Flex tube (Mallinckrodt laser tube): Airtight stainless steel tube Flexible Uncuffed or with two cuffs

3. Laser resistant tracheal tube c.The Laser-Shield II (Xomed-laser shield II tube): Silicone tube Inner aluminum wrap Outer Teflon coating

4. Laser resistant tracheal tube d. The Bivona Fome-Cuff laser tube: Designed to solve the perforated-cuff-deflation- problem. It consists of an aluminum wrapped silicone tube with unique self inflating foam sponge filled cuff which prevent deflation after puncture.

5. Reduction of the flammability of ETT: B.Wrapped standard tubes: Standard tracheal tubes (rubber, silicon, and PVC). Wrapped with laser resistant material (except the cuff). the wrapped material may be :  Aluminum or copper foil tape with adhesive back.  Merocel laser guard (merocel wrap).

6. Disadvantage of wrapping: No cuff protection. Add thickness to the tube. Not an FDA approved device. May reflect laser beam to non target tissue. Protection varies with the type of the metal foil used. Air way obstruction. Rough edges may cause damage to mucosal surface. Wrapped standard tubes

7. Mechanism of wrapping: Paint the tube with medical adhesive such as benzoin. Cut the end of the tape with scalpel to approximately 60 degree. Start wrapping from the junction of the tube and the proximal end of the cuff Wrapping in spiral with 30% to 50% overlap layer. Wrapping include the inflation tube of the cuff..

9. Wrapped standard tubes  Protection of the cuff:  Filling the cuff with saline colored with methylene blue.  Place the cuff distally in the trachea and covered visible cuff with moistened cotton pledgets.

10. Approaches to reduce the incidence of airway fire: 2.Removal of flammable material from air way: a) Jet ventilation : Use high pressure oxygen source directed at the glottis through small metal tube such as ventilating bronchoscope or 12 gauge blunt needle. it permit entrainment of oxygen enriched air during inspiration and escape of carbon dioxide and exhaust gases during expiration.

11. Removal of flammable material from air way Advantage:  Adequate ventilation without introducing flammable material.  No obstacle to the surgical field. Disadvantage:  Barotrauma  Pneumothorax  Restriction to only anesthetic intravenous agents  Gastric distention  Relative requirement for compliant lungs

12. Removal of flammable material from air way b)Intermittent extubation with or without apnea:  Intermittent extubation by the surgeon.  Combined with spontaneous ventilation or intermittent apnea.  General anesthesia provided by nasal insufflations of potent inhaled anesthetic or by use of intravenous anesthetic agent.

13. Approaches to reduce the incidence of airway fire: 3.Reduction of the available oxygen content:  Oxygen and nitrous are powerful oxidizer.  Reduce the inspired oxygen concentration to less then 0.40.  Avoiding diluting oxygen with nitrous.  Dilute with helium.

14. Airway fire protocol (Management of airway fire) 1.Communication and recognition. 2.Stop ventilation, remove ETT and disconnect breathing circuit from anesthesia machine to:  Remove flame  Remove the retained heat in the tube  Stop flow of enriched gas 3.Flood the surgical field with water. 4.Ventilate the patient with 100% oxygen via face mask.

15. Airway fire protocol (Management of airway fire) 5.Assess the damage:  Examine the patient face and oropharynx  Rigid bronchoscope.  Direct laryngoscope. 6.Monitor the patient with pulse oximetry, serial ABG and chest X ray. 7.Reintubate the patient or perform trachestomy as needed. 8.Use ventilatory support, steroid and antibiotic as needed.

16. Protective safety measure during laser surgery 1.Warning signs 2.Eye protection:  For the patient: eye should be taped closed and covered with opaque saline swabs or metal shield.  For the working personals: wear safety goggles or lens specific for the laser wave length in use. 3.For laser plume:  use efficient smoke evacuator at the surgical site.  Use special high efficiency mask.

17. Protective safety measure during laser surgery 4.Skin protection: The patient ‘skin, mucous membrane and teeth adjacent to operative field should be covered with saline soaked gauze. 5.Surgical drapes made of flame resistant or waterproof material. 6.Preventive measures against fire and explosion must be ready.

18. FINALLY Never are cooperation and communication between surgeon and anesthesiologist more important than during LASER surgery, it is the key to managing a crisis such as air way fire

20. High pressure oxygen source Venturi effect (entrainment of air). Active insipration Passive expiration