KTP laser safety by Dr. Sunil Verma

Otolaryngology http://oto.sagepub.com/
-- Head and Neck Surgery
Evaluating the Effects of a 532-nm Fiber-Based KTP Laser on Transoral Laser Surgery Supplies
Carolyn A. Coughlan and Sunil P. Verma
Otolaryngology -- Head and Neck Surgery 2013 149: 739 originally published online 20 September 2013
DOI: 10.1177/0194599813505423
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Original Research—Laryngology and Neurolaryngology
Evaluating the Effects of a 532-nm
Fiber-Based KTP Laser on Transoral
Laser Surgery Supplies
Otolaryngology–
Head and Neck Surgery
149(5) 739–744
Ó American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2013
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599813505423
http://otojournal.org
Carolyn A. Coughlan, MD1, and Sunil P. Verma, MD1
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Abstract
Objective. The KTP laser has become commonplace in transoral head and neck surgery. The interactions of this laser
with commonly used supplies in transoral surgery have not
been formally examined. This study evaluates the effects of
the KTP laser on surgical supplies.
Study Design. Experimental study.
Setting. The study was conducted in an empty operating
room at a university-affiliated medical center.
Methods. An Aura XP 532-nm KTP laser with a 600-nm
fiber was used in pulsed and continuous modes. The beam
was focused at the shaft and balloon of 3 ‘‘laser-safe’’ endotracheal tubes (ETTs), a polyvinyl chloride (PVC) ETT, and a
Codman surgical patty. Time to penetrate was recorded.
Results. The KTP laser beam was unable to penetrate any of
the laser-resistant ETTs. It did react with the black number
markings on the PVC ETT by producing sparks but was
unable to penetrate the shaft of the ETT. The KTP laser was
nonreactive with all ETT cuffs except in 1 of 3 trials with the
outer balloon cuff of a Rusch Lasertubus ETT when the laser
was used in a continuous mode. The KTP laser caused the
production of a flame upon contact with the blue radiopaque
strip of the surgical patty, even when the patty was wet.
Conclusion. This study demonstrates that a number of safe
ETT options may be used during transoral laser microsurgery with a KTP laser. In addition, Codman surgical patties
are shown to be a significant fire risk in KTP laser surgery.
1
Keywords
transoral laser surgery, KTP laser, laser safety
Received May 22, 2013; revised August 1, 2013; accepted August 27,
2013.
T
tissue within the pharynx, larynx, and trachea. Unfortunately,
it was soon realized that the risks of using lasers could be
devastating and deadly, particularly in the case of an airway
fire. For an airway fire to occur, all 3 components of the ‘‘fire
triad’’ must be present: an oxidizer, an ignition source, and
fuel. In transoral laser surgery, the oxidizer can include
oxygen and anesthetic gases, the laser itself supplies the ignition source, and fuels include endotracheal tubes (ETTs) and
sponges in the airway. Airway fires are a more distinct risk
during surgeries of the oral cavity and larynx due to the
proximity of these 3 components. To avoid this feared
complication, laser-resistant ETTs and special ventilation
techniques have been developed.1-4 Materials such as
Codman surgical patties (#80-1407; Codman & Shurtleff,
Raynham, Massachusetts) are commonly used to protect a
specialized laser-safe endotracheal tube and the larynx and
subglottis from aberrant laser energy beam during transoral
laser surgery. In addition, new protocols have been initiated
to raise awareness of laser and fire safety during the mandatory timeout at the start of every procedure.5,6 Although these
laser-resistant tubes have assisted in the prevention of airway
fires, they do add considerable cost to the patient in comparison to standard polyvinyl chloride (PVC) ETTs.
The safety of the carbon dioxide laser has been extensively studied in the literature ever since it was first introduced into practice in 1972.7 Multiple case reports of
airway fires have been detailed.8-14 In addition, controlled
studies have been performed to test the safety of lasers on
ETTs in head and neck surgery.7,15-22 Since the advent of
the carbon dioxide laser, many alternative lasers have been
developed, each intended for a specific target.23 The KTP
laser was developed in the 1980s from the Nd:YAG laser
and preferentially targets oxyhemoglobin.24 The KTP laser
he
introduction
of
lasers
revolutionized
otolaryngology–head and neck surgery by allowing the
surgeon to use energy to precisely cut and coagulate
University Voice and Swallowing Center, Department of Otolaryngology–
Head and Neck Surgery, University of California, Irvine School of Medicine,
Irvine, California, USA
This article was presented as a poster at the 2012 AAO-HNSF Annual
Meeting & OTO EXPO; September 29 to October 3, 2013; Vancouver,
British Columbia, Canada.
Corresponding Author:
Sunil P. Verma, MD, University Voice and Swallowing Center, Department of
Otolaryngology–Head and Neck Surgery, University of California, Irvine
School of Medicine, 62 Corporate Park, Ste 115, Irvine, CA 92606, USA.
Email: verma@uci.edu
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740
Otolaryngology–Head and Neck Surgery 149(5)
is especially useful in laryngeal surgeries as it is fiber based
and able to be angled and targeted precisely toward the
intended tissue.25-28 To date, 1 study has been performed
evaluating the safety of the KTP laser on reinforced laryngeal mask airways (LMAs).23 Multiple studies have been
performed to evaluate the effect of patties as a safety buffer
to protect the airway and ETT during carbon dioxide laser
surgery, but the interaction of patties and ETTs with the
KTP laser has not been assessed.7,15,29
To our knowledge, there has been no investigation of the
interaction of the KTP laser with commonly used transoral
laser surgery supplies. In this study, we evaluated the safety
of the KTP laser in transoral laser surgery by testing the
time to perforation of various ETTs after exposure to a KTP
laser. We also tested the time to perforation of surgical patties after exposure to a KTP laser to gauge the safety of current practices in transoral laser surgery.
Methods
Laser Source
An Aura XP 532-nm KTP laser (American Medical Systems,
Minnetonka, Minnesota) with a 600-nm fiber was used in
pulsed and continuous modes in an empty operating room at
the University of California, Irvine Medical Center. In the
pulsed mode, the laser was set at 35 watts with a 15-ms pulse
width and 5 pulses/s. In continuous mode, the laser was set at
8 watts. The laser beam was focused a distance of 0.5 cm
from the shaft and balloon of 4 ‘‘laser-safe’’ ETTs, a PVC
ETT, and surgical patties. The laser was applied for a maximum of 90 seconds before the trial was discontinued.
Target: Endotracheal Tubes, Endotracheal Tube Cuffs,
and Surgical Patties
Four laser-safe endotracheal tubes were tested: (1) a
Xomed Laser-Shield II silicone elastomer tube with an
outer aluminum strip covered by a polytetrafluoroethylene
sheet (7060300; Medtronic, Jacksonville, Florida); (2) a
Mallinckrodt Laser Oral/Nasal Tracheal Tube made of stainless steel (86398; Coviden, Mansfield, Massachusetts); (3) a
Rusch Lasertubus with an off-white rubber tube, corrugated
copper foil, and outer absorbent sponge (102004060;
Teleflex, Research Triangle Park, North Carolina); and (4) a
Hudson RCI Sheridan Laser-Trach with a red rubber tube
surrounded by copper foil and an absorbent sponge (5-20612;
Teleflex).30 A ‘‘standard’’ Mallinckrodt Hi-Lo PVC ETT
(86448; Coviden) was also tested. All tubes were 6.0 in size.
These tubes were placed on wet towels throughout the
experiment. The handheld KTP laser was held steady at a
distance of 0.5 cm from the target at an angle of incidence of
90 degrees. A white note card was placed behind the target
or within the ETT and the time to penetration of the card
was measured by a stopwatch and determined by visual
examination. All ETTs were evaluated in 3 separate trials,
and the results were averaged for the final result.
Two laser-safe endotracheal tube cuffs and a standard
PVC ETT cuff were tested in 3 trials each. Standard
Figure 1. Xomed Laser-Shield II, Rusch Lasertubus, and polyvinyl
chloride endotracheal tubes filled with 10 mL of saline.
instructions for use of the endotracheal tube cuffs were followed for all laser-safe ETTs. The Xomed and Rusch endotracheal tube cuffs were filled with 10 mL of saline (Figure
1). The cuffs of the Mallinckrodt and Sheridan ETTs were
not tested due to insufficient supplies for thorough testing.
The PVC ETT cuff was tested while filled with either air or
saline. The time taken for the laser beam to penetrate through
the ETT cuff was recorded in seconds, and the mean of 3
trials was recorded.
In addition, the interaction and time to perforation
between the laser and ½ 3 3-inch Codman surgical patties
was examined. These patties were tested in 2 conditions:
dry and soaked in normal saline for 15 seconds. The white
cottonoid portion and blue radiopaque blue strip of the patty
were independently exposed to the laser in both wet and dry
conditions in 3 trials each (Figure 2).
Results
Endotracheal Tube Shafts
None of the ETT shafts were perforated by the KTP laser in
continuous or pulsed mode, including the PVC ETT. The
laser was able to perforate the outer absorbent layer of the
Sheridan Laser-Trach, Xomed Laser-Shield II, and Rusch
Lasertubus instantaneously (Figure 3). The KTP laser was
unable to perforate the metallic layer of these tubes. The
KTP laser in pulsed and continuous mode did not react with
the clear, unmarked portion of the PVC ETT and was
unable to perforate the ETT in this area after 90 seconds of
uninterrupted contact with the laser. The beam did react
with the black number markings on the PVC ETT by producing a spark. The beam was unable to perforate the ETT
at this location after 90 seconds of direct contact with the
beam despite the presence of an initial spark. In summary,
the PVC ETT was resistant to perforation by the KTP laser
in all trials, but the laser did react to the black markings on
the ETT by producing an instantaneous spark.
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Coughlan and Verma
741
Discussion
Figure 2. The Codman surgical patty with a white absorbent
sponge and blue radiopaque strip, used for easy localization with xray.
Figure 3. Perforation of the outer sponge layer of the Sheridan
Laser-Trach tube after exposure to a 532-nm fiber-based KTP laser,
revealing the copper metal sheet underneath.
Endotracheal Tube Cuffs
The KTP laser was nonreactive with all ETT cuffs except
the Rusch Lasertubus ETT cuff. In 2 of 3 trials of the Rusch
Lasertubus cuff, no damage was noted. However, in 1 of the
3 trials, the outer cuff was perforated at 29 seconds. The
second, inner cuff stayed intact for all 90 seconds. The laser
was unable to penetrate the Xomed cuff as well as the PVC
ETT cuff when filled with either saline or air.
Surgical Patties
Results of the trials with Codman surgical patties are summarized in Table 1. The laser reacted differently with the
white absorbent portion of the patty as compared with the
blue radiopaque strip. Minor sparking was visualized when
the pulsed beam first made contact with the blue strip
(Figure 4).
Airway fire has long been a concern with the use of lasers
in head and neck surgery.5,6,8-14 In fact, attention to fire
safety has been emphasized by the Food and Drug
Administration and the Joint Commission.5,31 As a result of
these efforts, the assessment of fire risk is now a standard
portion of the surgical ‘‘timeout’’ procedure prior to the
initiation of surgery.5
The Aura KTP laser was introduced to laryngologic surgery in 2003 and is commonly used at many medical centers. As a fiber-based laser, it can be aimed toward specific
targets at a very close distance and is often used near the
endotracheal tube. Despite the frequency with which fiberbased KTP lasers are used, this is the first investigation of
the effects of the 532-nm pulsed and continuous KTP laser
on ETTs, ETT cuffs, and surgical patties.
In this study, the bodies of all ETTs were found to be
resistant to the laser beam. Only the black markings on the
shaft of the PVC ETT and the absorbent sponges on the surface of the Xomed Laser-Shield II, Rusch Lasertubus, and
Sheridan Laser-Trach tubes were found to react with the
laser. The absorbent outer layer is important to create a dull
surface on the laser-safe endotracheal tube that does not
reflect the beam toward an unintended target.30 If the beam
is in contact with this absorbent surface for a prolonged
period, however, it can penetrate this layer and hit the
underlying metallic, reflective surface. This metallic surface
is important to protect the endotracheal tube from penetration but can lead to tissue injury by reflecting the beam
toward unintended targets.
The findings in this study are consistent with the results
of a study by Pandit et al23 in which a KTP laser reacted
with solely the black markings of a laryngeal mask airway,
causing an instant flare that produced a ‘‘crater filled with
silica ash.’’ The laser was ultimately unable to penetrate the
LMA tube. These findings are in agreement with our own:
although a spark was ignited, the tube was not penetrated.
The ETT cuffs appear to be similarly resistant to the
KTP laser. Typical laser-safe ETT cuffs are reinforced and
are saline-filled rather than air-filled for improved protection.30,32,33 In this study, the KTP laser was resistant to all
ETT cuffs, including the PVC cuff filled with air. The lone
exception was 1 trial with the Rusch Lasertubus outer cuff.
This tube has both an inner and outer saline-filled cuff. In
this trial, the inner cuff remained intact. These findings are
different from the results of studies evaluating the safety of
ETTs and the CO2 laser, which show almost instantaneous
perforation of ETT cuffs with application of the CO2 laser
beam.14 Given these findings, it is possible that the use of a
standard PVC ETT without any black markings could be
equally efficacious as the laser-resistant tubes at the power
levels typically used in clinical practice.
Surgical patties are commonly used in practice as another
safety measure to protect the tissues surrounding the target
area as well as the cuff of the endotracheal tube from unintended injury. The effects of the carbon dioxide laser on these
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742
Otolaryngology–Head and Neck Surgery 149(5)
Table 1. Interactions between portions of a Codman surgical patty and the 532-nm KTP laser.
KTP Continuous Mode
Dry
White sponge
Blue strip
KTP Pulsed Mode
Wet
Perforated in 15
seconds
Spark, then
perforated in 3 seconds
Dry
Wet
Unable to perforate
Unable to perforate
Unable to perforate
Flame, then unable
to perforate
Spark, then perforated
in 4.8 seconds
Spark, then unable
to perforate
All results are reported as the mean of 3 trials.
Figure 4. Perforation of a dry surgical patty after the laser was
aimed at the blue strip after a mean time of 4.8 seconds.
patties have been evaluated, but the interaction with a KTP
laser has not.7 Results from this study demonstrate that the
various portions of the patty interact differently with the KTP
laser energy. The white absorbent sponge is slow to interact
with the laser, especially when saturated with saline. The
radiopaque blue strip, however, quickly reacted with laser
energy with an instantaneous flame in all trials, even when
wet. This blue strip can present a serious fire hazard in laser
surgery. Unfortunately, the strip is necessary as it is the sole
portion of the patty that is radiopaque, an important safety
measure. It would be interesting to investigate whether a different color or material of radiopaque ribbon would react differently with a KTP laser.
The importance of keeping patties wet is also highlighted
by the results of this study since the wet patty was unable to
be perforated in 90 seconds of continuous laser energy. The
surgeon should be vigilant about constantly moistening patties as they can become dry from suction, from passage of
air, and during the course of a normal surgery. The results
of these trials question whether the patty is necessary in the
course of KTP laser surgery to protect the ETT. The blue
radiopaque strip produced a spark in both the dry and wet
conditions, creating a high risk for an airway fire. Although
patties may have value in protecting unintended tissue targets from aberrant laser energy, the risk of an airway fire
outweighs the benefit of protecting the tissues.
As the cost of health care continues to rise, it is important to continually reevaluate the effectiveness of expensive
treatments and materials in comparison to more costconscious options. In the case of transoral laser surgery, the
cost of laser-resistant ETTs can be up to 100 times the cost
of the standard PVC ETT. At our institution, the PVC ETT
costs approximately $1.50 for a size 6.0. By comparison,
the Xomed Laser-Shield II 6.0 costs roughly $150. A PVC
ETT could potentially be minimally reengineered for KTP
laser surgery and in the process confer a great cost savings
compared with existing laser-safe endotracheal tubes.
Further study must be performed before these results can
be implemented into clinical practice. Before widespread
changes are initiated, variables such as the power settings as
well as the distance between the laser and the target should
be examined. Initially, we planned to vary the distance of
the laser from the target. However, when the ETT showed
no reactivity at a close distance in continuous mode, the
trials were limited to this one, close distance, which most
commonly approximated clinical practice. Similarly, power
settings that are often used were chosen for this study.
Variations in the angle of incidence between the laser
and targets may be investigated in future studies as well.
Ahmed et al7 demonstrated that a carbon dioxide laser was
able to perforate an endotracheal tube in less than 1 seconds
when aimed at 90 degrees to the ETT, while the time
increased to 42 seconds when the beam was aimed at a 45degree angle. Given these results, this study was limited to
90-degree beams of incidence to test the most powerful setting. When the laser was unable to perforate the tube at this
incidence, we refrained from further trials at a more indirect
angle.
Finally, it is important to evaluate the effect of blood on
these supplies. Sosis et al34 evaluated the effect of blood on
laser-resistant ETTs and found increased flammability in
some trials with the Mallinckrodt Laser-Flex tube and also
copper- and aluminum-wrapped PVC tubes. Given the KTP
laser’s affinity for oxyhemoglobin, investigating the effect
of blood on the ETT, ETT cuff, and surgical patty is absolutely necessary for future study.
Conclusions
The fiber-based 532-nm KTP laser may be used safely with
a number of laser-safe ETTs. The black number markings
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Coughlan and Verma
743
on a standard PVC ETT are the only areas that were noted
to interact with the laser in this study. Care should be taken
with use of surgical patties, as a fire may occur if they are
not maintained in a moist condition or if the laser beam is
aimed toward the blue radiopaque strip.
Acknowledgments
We thank Universal Health Systems for donating all laser supplies.
Also, we thank Medtronic, Inc and Teleflex, Inc, which donated
multiple ETTs for evaluation in this study.
Author Contributions
Carolyn A. Coughlan, acquisition of data, drafting of the manuscript, analysis and interpretation of data, critical revision of the
manuscript, and final approval; Sunil P. Verma, study concept
and design, acquisition of data, analysis and interpretation of data,
critical revision of the manuscript, final approval, study supervision, and administrative, technical, and material support.
Disclosures
Competing interests: Sunil P. Verma is an educational/consulting
liaison for Acclarent.
Sponsorships: None.
Funding source: None.
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