October 2025 POCUS Case of the Month: Lung Ultrasound

Anesthesia for suspension laryngoscopy and laser excision of laryngeal tumors can be quite complex due to the risk of airway fire, need for adequate visualization and manipulation of instruments, and the inability to adequately administer inhaled anesthetic agents. Fires are possible with the presence of an oxygen-rich environment, an ignition source (electrocautery, lasers), and a fuel source (tracheal tubes, drapes, preparatory agents, and gowns). Both intubation and non-intubation techniques can be used for Nd:YAG laser excision of a laryngeal tumor. Non-intubation techniques include apneic oxygenation, spontaneous ventilation, and jet ventilation. The major advantages of jet ventilation are the decreased risk of airway fire, improved visibility of the surgical field, and atraumatic airway manipulation in the case of a large tumor. Since there is no endotracheal tube in the airway, no fuel source is present for an airway fire to start. The major disadvantage of jet ventilation is that the ventilation is difficult to control and hypoventilation is common. Other disadvantages are the inability to monitor oxygenation and ventilation, increased aspiration risk, risk of gastric distension or barotrauma with a malpositioned ventilation jet, and the need for paralysis. While endotracheal intubation provides a secure airway and ability to control ventilation, the endotracheal tube may obstruct the surgeon’s view of the tumor or limit surgical manipulation. Even with the use of low inspired oxygen concentrations and reinforced tracheal tubes, airway fires can still occur due to the presence of a fuel source in the airway, which is increased if an endotracheal tube with a cuff is used.