YAG Laser Photoresection of Lesions Obstructing the Central Airways*

- ----

clinical clinical invesligalions investigations VAG Photoresection of Lesions YAG Laser Photoresection Lesions Obstructing Obstructing the Central Airways* PaulA Kvale, M.D., F.C.C.P.; Michael S. M.D., EC.C.P; F.C.C.P.; PaulA. Kuale, M.D., EC.C.l?; S . Eichenhorn, M.D., Jan F.C.C.P.; M.D. Jan R. R. Radke, M.D., M. D . , E C.C.l?; and Veronica Veronica Miks, M. D.

Some patients with with cancer and others with benign benign lesions lesions which obstruct the central airways airways (larynx, (larynx, trachea, major bronchi) with aa laser. laser. Ninety-nine patients bronchi) can be treated with were considered for treatment during the first 18 months of experience with a YAG YAC (yttrium aluminum garnet) garnet) laser laser at Henry Ford Hospital; 55 patients were treated 82 82 times. Results were satisfactory (surgery was avoided) in eight of ten patients patients with with benign lesions. Satisfactory results (doubling of airway size with relief of dyspnea/drainage dyspnealdrainage of obstuctive pneumonia) were obtained in 12 of 13 patients

139,000 new k n estimated 139,000 new cases cases of bronchogenic

A

States in carcinoma will develop in the United States 1984. 1984.'1 Traditional Traditional methods for treatment include surgical resection, radiation therapy, and chemotherapy. chemotherapy. Obstruction of the central airways, airways, either at the time of initial presentation, or more more commonly, as tumors recur after initial therapy, is a serious problem. When central airways dyspnea bebeairways obstruction is present, dyspnea comes the overpowering symptom; symptom; the patient will die photoresection of the by slow asphyxiation. Laser photoresection tumor through a bronchoscope is a new alternative to For editorial comment see page 277 open the airways, relieve dyspnea, and prolong life. life. airways, relieve When obstruction is so severe that that immediate improvement in the airways airways is needed, laser photoresection can also be offered as an initial form of treatment for patients with unresectable central central cancers, cancers. in conjunction with with radiation and/or andlor chemotherapy. Moreover, Moreover, some patients with benign obstructing leairways can be treated with a laser sions of the central airways as an alternative to standard surgical techniques. 18 months of experience This report details our first 18 patients with lesions lesions using a YAG laser to treat patients obstructing the central airways airways at Henry Ford Hospital. *From the Division of Pulmonary and Critical Care Medicine, Department of Medicine, Henry Ford Hospital, Detroit. Detroit. 8; revision accepted acce ted October 29. Manuscript received received June 8; Reprint requests: Dr. Kvale, Pulmonary and Critical requests: D1: Koale, a n s c r i t i c a l Care c a r e Medicine, Henry Ford Hospital, Detroit 48202

with bronchogenic bronchogenic carcinoma carcinomamanaged managedinitially initially with with thethe recurrent laser, and in 22 of 32 (69 (69 percent) patients with recurrent malignancies. There were five minor and seven major comcomincluding two deaths. We conclude that that laser plications, including treatment can can relieve central airways airways obstruction obstruction with withits its associated symptoms of dyspnea and infection. Avoidance of complications requires requires aaskillful skillfulapproach, approach, careful anescareful thetic management, and availability of back-up posttreatment intensive care.

MATERIALS AND MATERIALS A N D METHODS METHODS

Ninety-nine patients were referred for consideration ofYAG of YAG laser therapy for central obstructing obstructing lesions of the airways during the the first 18 1982 to April 28, 1984) that 18 months (Oct 29, 29,1982 28,1984) that this this form of treatment was available at Henry Ford Hospital. Hospital. Three groups of patients were evaluated as follows: follows: benign lesions obstructing the Nineteen patients in group 11 had benign subglottic larynx or the trachea. Laser Laserphotoresection photoresectionhad had been recommended by a thoracic surgeon surgeon or otorhinolaryngology otorhinolaryngology surgeon as an alternative to standard surgical techniques. Twenty-three patients patients in group 2 had bronchogenic bronchogenic carcinoma carcinoma which produced severe dyspnea and clinical evidence of severe produced severe airflow obstruction; none had received radiation radiation therapy before they were treated treated with the laser. laser. Their treatment treatment plan was laser therapy therapy to open the airway, followed immediately by radiation therapy, chemotherapy, or both. Fifty-seven patients in group 33 had recurrent carcinoma treated previously by radiation therapy and/or chemotherapy. The obstructed airway in groups 2 and 3 was a lobar or mainstem bronchus or the trachea. Obstruction of ofaa more peripheral peripheral bronchus was not judged to be sufficient for treatment with the YAG laser. Informed consent specifying the nature and risks oflaser therapy was was obtained from each patient before treatment started. Preliminary studies included a complete history and physical examination, posteroanterior posteroanterior and lateral chest roentgenograms, complete blood cell cell count, prothrombin prothrombin time, partial thromboplastin time, platelet count, spirometry and flow-volume loops, and arterial blood gas assessment with with a gas analysis. Endoscopic assessment flexible bronchoscope under local anesthesia usually preceded treatment with the YAG laser. Conventional linear tomograms tomograms of the airways were also obtained dUring the study. alsoobtained duringthe first eight months of ofthe study. Computed axial tomography (CAT (CAT scans) scans) with contrast infusion and rapid sequence imaging was employed to display the relationship between the involved bronchus and the surrounding structures, particularly the large intrathoracic blood vessels. As experience with CAT scans in this patient population population was gained and data were CHEST Ii 87 Ii 33 I i MARCH, MARCH. 1985

283 283

analyzed.'2 CAT scans were restricted to patients with lesions below analyzed. below the midtracheal was typed and cross-matched tnidtracheal level. Whole blood was before each treatment session. session. Patients received received glympyrrolate glycopyrrolate and narcotics as premedication. Treatment with the YAG YAC laser was performed for patients with suhglottic s~thglotticlaryngeal and high tracheal lesions using local anesthesia with 2 percent lidocaine lidtxaine (maximal (maximal dose was 600 mg). mg). A tracheostomy was performed prior to treatment with the laser to protect the airway in most patients with severe stenosis (054 ( 5 4 mm in diameter) of the suhglottic larynx or proximal trachea. Two patients with henign lesions and all patients with malignancies were treated under general anesthesia. anesthesia. The trachea was intubated with a plastic endotracheal tube (9.0 (9.0 mm internal internal diameter for females; females; 10.0 mm internal diameter for most males) and general anesthesia was maintained with isoflurane and aa 40:60 mixture of oxygen and atid helium. helium. Continuous muscle paralysis with pancuronium bromide 1)n)mide allowed the anesthesiologist to interrupt breathing while the laser was discharged at a stationary target. Continuous entire Continuo~ts ECG EC(; monitoring was utilized during the entire anesthetic pnxedure procedure and while the patients were recovered after afier treatment. A CO, analyzer was inserted in-line with the anesthetic tubing when general anesthesia was employed. tubitigwhen employed. Patients judged to be at especially high risk because of poor general condition, condition. ventilator dependency or severe hypoxemia before before laser photoresection. photoresection, were mntinuously continuously monitored with a pulse oximeter oximeter and/or had an arterial cannula inserted to facilitate intermittent blood gas analysis intraoperatively. Less severely ill patients had one or more intraoperative single single puncture arterial blood samples obtained. obtained, if judged judged to be necessary necessary by the anesthesiology team. All treatments in this study were weredone through a f1exihle flexihle Ilberoptic fiberoptic bronchosmpe 191)). A YAG (Molectron (hlolectron bronchoscope (Olympus (Olympus ITR 1TR or Pentax Pentaw 19D). Medical model modelBOOO) 8000) laser was used. used. During the Ilrst first few months of the study. W with pulse durations stud!; higher power settings of70 to 90 O\t' durations of 1. 0 second were generally chosen. after 1.0 chosen. In the later months and after discussion discttssion with other users of the YAG laser. laser, lower power settings of 25 to 35 Wand durations of 0.5 M' and shorter pulse durations 0 . 5 second were more commonly employed. employed. Most patients were treated in a single session until an adequate airway was was established; with established; occasional cxcasional patients with vt'ry largt' tumors were treated over over several very largc tltmors seb~eralsessions in order to completely complrtely debulk the tumor within the airway. Irrigation with saline solution and manual debridement with forceps was an integral part of the pl'lx.'edure. charring of tissue was procedure, particularly when charring

evident. The majority of laser treatment sessions sessiotis took ttmk 60 to 90 minutes to perform; rarely. the procedure lasted for three to four hours. Most our blost of the longer cases occurred very early during our experience. experience. Initially. laser Initially, all patients were hospitalized hospitalized the day before a laser treatment session. and the patient was session. If If therapy was uneventful and stable. stable, the patient was discharged home the day following laser treatment. Severely ill patients who had respiratory insuffiCiency insufficiency or who were hemodynamically hernodynamically unstable were managed in a medical intensive care unit after after treatment. As we gained experience with laser treatments. treatments, some patients in hetter better general health were treated treated on an ambulatory basis, basis. even when general anesthesia anesthesia was used. used. After laser treatment. treatment, all patients were asked to return for followfollou,up pulmonary assesspulmotiary function studies and posttreatment endoscopic etidoscopicassessment at one week and monthly monthly thereafter. Additional treatment sessions were performed when tumor tumor growth again compromised the airway and for benign lesions when staged treatment was planned. For benign lesions, lesions. results were mnsidered considered satisfactory if surgery could be avoided. resection was avoided, and unsatisfactory if surgical resection eventually needed to correct the prohleni. problem. For malignancies. malignancies, satisdefined factory results were dell ned as a doubling doubling of the diameter of the obstructed airway mupled dyspnea coupled with subjective improvement of ofdyspnea or drainage drainage of pus behind the obstructed airway. airwa): One patient with malignancy was treated with the YAG bleeding; as YAC laser to mntrol control 1)leeding: c1assilled as bleeding was controlled, this treatment was also alsoclassified as satisfactory. Any outt'Ome outcome which did not accomplish ac~omplishthese goals was judged unsatisfactory. unsatisfactory, Mean hfean length of survival suwival (:t ( ? oone n e standard deviation) was analyzed statistically statistically for patients with satisfactory vs unsatisfactory outmmes outcomes in groups 2 and 3, using the log rank test. Complications of treatment were carefully oftreatment carefi~llyidentilled identified and and c1assilled classified as laser-related, laser-related, major and minor, and death. We calculated survival suwival days after the for all treated patients with malignancies in number of ofdays initial laser laser treatment session. session. Data were tallied through Aug 3, 1984. 1984, for patients still alive. alive. RESULTS RESL~LTS

During the first year, 99 patients with known or suspected lesions obstructing the central airways were therapy. Fifty-five patients considered for YAG laser therapy. were treated aa total of82 times (Table 1);44 patients did (Table 1); not receive laser therapy (Table 2). (Table 2).

Table I-Patients I-PatientsTreated Treated with YAC ¥AG Laser· her* -

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Average size size~of airway in mm ~ n t n(Range) (Range)

Mean hlean I1 SD SI) Survival (Days) (Days)

n

No. Rx Kx (Range) (Range)

4 2

1.5 (1-2) 4.5 (3-6)

3.6 (3-4) 5 (2-B)

7.B (6-9)

NA NA

4 0

1.3 (1-2)

1.5 (0-4)

9.6 (B-IO)

NA

Group (Malignancies; laser laser treatment Ilrst) first) Croup 2 (Malignancies; 12 Satisfactory Unsatisfactory I1 Llnsatisfactory

1.5 (1-3) I

1.9 (0-9) 4

9.3 (5-14) 8

>210 :t 140} 7

p
Group Croup 3. (Malignancies; (Malignancies; chemochernotherapy and/or radiation therapy preceded laser) laser) Satisfactory Unsatisfactory

1.4 (1-4) 1.3 (1-2)

2.B (0-6)

B.2 (6-10)

7.4 (4-10)

>142:t142} 56:t 92

p
3.5 (0-6)

Group I1 (Benign disorders) disorders) Stenosis Satisfactory Unsatisfactory Other Satisfactory Unsatisfactory

22 10

Before After

Alter

7.2 (6-10)

*NA is not applicable; an apparent cardiac arrhythmia four weeks alter applicable: all patients still alive except one who died died of ofan after laser treatment (see (see text). text).

284 284

VAG Laser YAG Laser Photoresection 01 of Central Central Airways Lesions (Kvale el et aI) al)

2-Patients Evaluated, But Not Treated Table 2-Patients Reason Not Treated

n

Tumor too extensive Extrinsic compression Adequate airway size Malignant 4 Benign 2 Died before treatment CT C T findings (proximity (proximity of blood vessels) mitigated against treatment Other Technical: could not accurately aim laser laser Another medical problem precluded treatment Responded to chemotherapy Incorrect diagnosis by referring physician Bleeding too distal Chose permanent tracheostomy

13 9 6

Total

44

Two other patients required intensive care unit observation after laser treatment because of doubtful respiratory reserve. Mean Mean (± ( 5 one standard deviation) survival in group 2 patients with with satisfactory results is >210 statistically different >210 days ±+ 140 days and is statistically (p115 >115 days. days. Satisfactory results were obtained in 22 patients (69 (69 percent), percent), and mean survival (± ( + one standard deviation) was >142 >I42 ±+ 142 142 days. days. One patient with with unsatisfactory result was lost to follow-up; follow-up; and in the remaining nine, mean survival (± ( +- one standard deviation) was 56 ± +- 92 days. Survival was statistically better among patients in group 33 with satisfactory results when compared with those in whom results results were classified asas unsatisfactory unsatisfactory (p
3 2 3 2 2 2

Treated Patients Group 1, Disorders: Nine patients patientswith with 1, Benign Disorders: benign disorders causing obstruction of of the subglottic larynx, proximal or midtrachea were treated 19 19 times. Four had a single treatment session; all had satisfactory with benign disorders who who results. In five patients with required more more than one laser treatment, results appeared to to bbee satisfactory at first. However, the late first. However, results were unsatisfactory in two. The YAG laser was also used to fracture a broncholith to facilitate its removal in another patient. ~ a t i e n3 t . ~ Spirometric values improved in five five of the six patients in whom measurements could be obtained before and after treatment (mean (mean A ~ FVC = = 183 183 ml; mean ~A FEVl.O FEV, ,= = 358 358 ml) (Fig (Fig 1). 1). Group 2, Malignancies, Malignancies, Laser Treatment First: Twelve of the 13 13 patients in this group had satisfactory results. The large bulk of endobronchial tumor necessitated multiple treatment sessions in five five patients in this group. group. One patient required ventilatory support for ten days until he h e was able to to breathe breathespontaneously. Or_I

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FIGURE 1. FIGURE 1. Group 11(benign disorders), disorders), group 2 (malignancies; (malignancies;laser lasertreatment first); first); group 3 (recurrent malignancies, radiation radiation therapy, and/or chemotherapy first). first).

CHEST CHEST /I 87 /I 33/ I MARCH, MARCH. 1985

285

3-Complications oofYAG Laser Table 3-Complicatiom f YAG h e r Treatment

Minor fires Flash fires Bleeding (125 (125 ml) Bleeding pain Neck pain extubation Premature extubation Major Near tracheoesophageal fistula Pneumonia Pneumonia Hemophilus influenzae, injluenzae, recovered recovered Hernophilus Staphylococcus aureus, au reus, died Pulmonary edema Cardiac arrhythmia, arrhythmia, died

n

Laser Related Related Laser

3 1 1 1 1 1

Yes Yes Yes No

1 1 2

Yes

1 11

2 11

Yes Yes No No

Complications Twelve complications occurred during the 82 laser treatment sessions (Table (Table 3). 3). All complications occurred during during the first six months we used the YAG laser-related complications complications occurred five laser. Minor laser-related five times. Three flash fires occurred at the tip of the quartz fiber which had had not been cleared completely of blood or mucus mucus when when the laser was discharged; discharged; each fire lasted for less than one second and extinguished spontaneously. Although Although there was no thermal injury to the patient, operator, or to the bronchoscope, the tip of the quartz quartz fiber was damaged in each case and could not be re-used until it had been polished and repaired. One modest (125 occurred (125 ml) ml) episode of bleeding occurred from a left lower lower lobe lesion, but it was controlled by tamponade and suctioning. suctioning. One patient complained of neck pain for 24 hours after after his benign tracheal stenosis had been treated under local anesthesia. anesthesia.

Major laser-related complications occurred in three patients. In a patient with benign tracheal stenosis, stenosis, the operator failed toto differentiate invaginating invaginating membranous (posterior) (posterior)trachea tracheafrom the web-like stenosis. stenosis. If laser treatment had been continued, continued, a tracheoIf esophageal fistula would have been created. created. This complication was managed conservatively, and healing was essentially complete when an autopsy was performed four weeks later. later. The autopsy disclosed extenextensive coronary artery disease with sive with extensive extensive old myocardial infarction and cardiac arrhythmia was the the presumptive cause of death. death. Two Two patients with malignancies developed pneumonia pneumonia following following laser treatment; ment; one died from from overwhelming sepsis. sepsis. Four complications complications were anesthesia-related. anesthesia-related. One patient was prematurely extubated, extubated, and re-intubation with ventiltory support was required for for two two more hours. Two developedpulmonary pulmonary edema Two patients developed because fluids had been too vigorously infused inintraoperatively; however, however, each responded within hours to diuresis ventilatory support. diuresis and mechanical ventilatory support. One patient with pre-existent coronary artery disease disease dedeveloped a fatal fatal cardiac arrhythmia during laser therapy 288

anesthesia. He had been been ventilatorunder general anesthesia. dependent for two weeks, and he had already received maximum radiation therapy for his malignancy. Laser in an attempt to relieve airway treatment was offered in obstruction toto allow him to be weaned from the ventilator. Evaluated But But Not Not Treated Patients Evaluated During our first 18 months, 44 patients were considered for YAG laser therapy but were not treated (Table (Table 2). The extent of of airway obstruction was judged judged to to be 2). extensive for successful successful laser treatment in 13 too extensive 13 patients and not severe enough to warrant laser treatInnine ninepatients, patients, the ment in another six patients. In airways were compressed extrinsically by malignancy malignancy with little or no intraluminal tumor suitable for laser resection. Three patients with malignancies malignancies died before treatment was feasible. The findings on CAT scan feasible. assessment mitigated against against safe treatment in two because of the proximity of patients, because of the adjacent blood vessels. vessels. Eleven patients were were not treated for other reasons (Table (Table 2). 2). DISCUSSION

Lasers are increasingly important tools in the treatment of various medical disorders. The following following three for treatment of lesions types of lasers are available for which obstruct the central airways: airways: (1) (1)The argon dye laser emits red light light with with aa wave length of 635 nm. nm. It It can be used in conjunction with hematoporphyrin derivative to treat small central lung cancers, when when surgery or radiation therapy are inadvisable due to proximity to the trachea or poor cardiopulmonary reserve. 4·7 reserve.4-' (2) (2) The CO CO,2 laser emits light in the far infrared spectrum with a wave length oflO,600 of 10,600 nm. nm. This laser is an excellent cutting tool, but at present, it must be delivered with mirrors through through a rigid bronchoscope. b r o n c h o s ~ o p8,9e . ~ ~ ~ (3) The YAG laser emits light energy with a wave length (3) of 1,060 1,060 nm which can be delivered by a quartz fiber and a fiberoptic bronchoscope for coagulating and vaporizing tissue to open obstructed airways. airways. Because the YAG laser light light can can be delivered through a flexible flexible quartz fiber and either a rigid or a flexible flexible bronchoscope, bronchoscope, the axial axial extent of airways which can be reached is greatly increased. increased. Physicians in France have been using the YAG laser to treat treat patients with obstructing lesions of the cental airways 10,11 McDougall and Cortese for l2 refor several several years. year^.'^^" CorteseU reported the first American experience with YAG laser treatment of recurrent airway malignancies. malignancies. We treated patients with recurrent malignancies for for palliation of symptomatic central airways airways obstruction, but we also offered offered laser treatment before radiation thertherapy to some some patients patients with bronchogenic carcinoma. carcinoma. All of our patients with bronchogenic carcinoma treated initially with the YAG laser had non-small cell types. types. VAG aI) YAG Laser Laser Pholoresection Photoresection of of Central Central Airways Ailways lesions Lesions (Kvale (Kvale et eta/)

Whereas patients with small cell carcinoma might also be treated initially with a YAG laser, we believe that that with small cell carcinoma carcinoma respond most patients with quickly toto chemotherapy and/or radiation therapy. therapy. Moreover, small cell carcinomas often involve aa considerable axial length of the airways. For these reasons, YAG laser therapy often may not be necessary for carcinoma. We were also patients with small cell carcinoma. prepared to apply the YAG laser to control bleeding from central malignancies. However, only two such patients presented during during the first 18 months of our experience. One was successfully treated; the other was site in the right was bleeding from a more peripheral site upper lobe and bronchial artery embolization was chosen as a preferred alternative. Our experience includes patients patients with benign obpatients with structing lesions. lesions. Eight of ten treated patients benign disorders had satisfactory results with the YAG laser and surgical intervention was avoided. avoided. Two patients with tracheal tracheal or subglottic laryngeal laryngeal stenosis stenosis failed laser treatment and and required additional surgery; surgery; longer than those in whom treattheir lesions were longer l1 reported similar ment was successful. successful. Dumon et e t al all1 results with YAG laser treatment of tracheal stenosis. stenosis. All four patients with benign lesions other than stenosis (two (two granulomata, granulomata, one amyloid, one broncholith) were successfully managed with the YAG laser. Laser treatment was offered before radiation therapy to patients with with bronchogenic bronchogenic carcinoma, provided provided they had severe dyspnea at the time of diagnosis coupled with endoscopic and clinical evidence of severe airways obstruction. We also reasoned that opening the airways immediately with the laser in patients with bronchogenic carcinoma would relieve orthopnea and make itit easier for them to tolerate tolerate radiation therapy. Theoretically, Theoretically, radiation therapy might be more effective after laser laser debulking of a tumor because the tumor load would be reduced or a smaller radiation portal would be permitted. Twelve of 13 patients with malignancies 13 malignancies managed managed initially with the laser did well. Patients with recurrent malignancies who had failed other treatment treatment modalities comprised our group 3. 3. Although these patients were were generally sicker sicker and therefore at higher risk, the results of treatment were satisfactory in 22 22 of 32 32 (69 (69 percent). Although most patients stated that that dyspnea dyspnea was improved after after YAG laser therapy, objective objective improvement in air flow was not always seen in those patients where data could be obtained both before and after treatment. On the theother hand, endoscopic assessment showed enlargement of the obstructed airway in in all patients. Two patients were were treated to to drain drain pus behind a completely obstructed bronchus. In each, the clinical picture mimicked an an abscess; abscess; immediate draining of 400 ml and 250 ml of

pus after obliterating the tumor improved the clinical state. Complications were, in part, a function of the learning curve. curve. Operator error in the early part of the series was responsible fur one instance of near for the one tracheoesophageal fistula. fistula. Three flash fires fires which occurred during treatment of the first 15 15 patients were caused by blood and mucus adherent to the quartz fiber tip. As recommended by Brutinel et al,)3 a1,'"hethe oxygen concentration was kept :540 540 percent. Fortunately, none of the fires caused damage. The flash flash fires fires were not due to accidental discharge of the laser at the plastic endotracheal tubes or at the flexible 6beropfiberoptic bronchoscope. No additional flash fires occurred after we recognized the importance of keeping the tip of the quartz fiber meticulously clean. clean. We decided to to utilize rapid sequence imaging via CAT scans after contrast infusion because McDougall 12 reported a fatal hemorrhage from laser and Cortese CorteseU perforation into a pulmonary artery during YAG laser treatment. Vascular anatomy is often altered by the growing malignancy or by atelectasis caused caused by by obstruction of the airway. airway. The image provided by the CAT scans was useful if the lesion obstructed the distal trachea or a more peripheral airway but not when obstruction was higher in the trachea or the larynx. l a r y n 2~ . ~ Pneumonia complicated laser treatment twice. In both patients, incomplete treatment was followed by tissue edema and necrosis. More complete removal of the tumor may have helped us to avoid postoperative pneumonia in these two patients. However, because potential the risk of pulmonary infection is a major potential problem after laser treatment, it may be appropriate to to use perioperative prophylactic prophylactic antibiotics antibiotics in patients who have leukopenia, poor respiratory reserve, or in whom excessive secretions or bleeding are are present during laser treatment. treatment. Although we we used only aa flexible fiberoptic bronchoscope dUring during the first 18 18 months that we used the YAG laser, we intend to use a rigid rigid bronchoscope for some patients patients we we treat treat in the future. future. This may shorten operative time, and it will clearly be advantageous to control bleeding complications, should they occur. occur. We agree with Dumon et alB that there are many arguallVhat ments for using a rigid bronchoscope when operating We believe the complications we with the YAG laser. We are reporting are related more to our inexperience, since they all occurred during the first six months we were using the YAG laser rather than to our decision to use a flexible instead of a rigid bronchoscope. Anesthetic complications included a fatal cardiac overload and prearrhythmia, two episodes of fluid overload mature extubation. Patients Patients undergoing laser treatment of pulmonary obstructing lesions are at high risk and require skillful anesthetic management, usually with a general anesthetic agent. agent.13-l5 )3-)5

CHEST CHEST I 87 I 33 I MARCH. MARCH. 1985 1985

287 287

Not all patients referred for YAG laser photoresection merit treatment. We evaluated but did not treat 44 patients during the first year. Three patients died before treatment could be accomplished. accomplished. Other patients were were not treated because because their malignancies were too extensive or because the airways were compressed extrinsically. extrinsically. Our experience supports the 12 that patients selected view of McDougall and Cortese Corteseu selected for YAG laser treatment ideally should have an endoin bronchial component of the tumor less than 4 cm in length. In addition, CAT scan assessment of large length. In vessels adjacent to the planned treatment site may help to avoid fatal bleeding complications when laser treatment is performed, particularly if treatment is with a flexible fiberoptic bronchoscope. bronchoscope. We conclude from an initial I8-month 18-month experience with YAG laser therapy for obstructing lesions of the central airways that successful treatment relieves dyspnea, drains infected areas of the lung, improves ventilatory function in some but not all patients, and may prolong life. Complications of this treatment modality are potentially severe and occur more often as one is learning the technique. Avoidance requires a skilled, experienced operator operator of the laser, careful careful anesthetic management, and and availability of back-up posttreatposttreatment intensive care. care. As we see YAG laser treatment of central obstructing lesions of the airways taken into the community hospital with less less experienced operators, minimal help, and less of a team approach, approach, there will likely be inadequate resections and a higher rate rate of complications. ACKNOWLEDGMENTS: The authors are grateful for the support. and critical comments from Doctors Kent Chrisencouragement. encouragement, and topher. topher, Patricia Cornett. Cornett, Philip Dellinger. Dellinger, Thomas Killip, and Thomas Neff. We are also indebted to Ms. Ms. Mary hlary Klebans for typing the manuscript.

288

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VAG Laser (Kvale et aI) YAG Laser Photorasection Photoresection of of Central Central Airways Lesions (Kvale a/)