A non-tracheal intubation (tubeless) anesthetic technique with spontaneous respiration for upper airway surgery

Background The most important consideration for administration of anesthesia in upper airway surgery is maintenance of a patient’s airway for optimal surgical exposure, adequate ventilation and sufficient depth of anesthesia. The tubeless anesthetic techniques, including total intravenous anesthesia with a combination of propofol and remifentanil or inhalation anesthesia with the insufflation of anesthetic gas, are considered experimental in many countries. Methods Fifteen pediatric (8 to 60 months) and 16 adult (23 to 55 years) patients were included in the study. Anesthesia (gas insufflation) was induced into the pediatric patients by inhalation of 8% sevoflurane in 8 L/min oxygen flow. An endotracheal tube, inserted through the nasal or oral cavity with its tip in the laryngopharynx, was used to maintain anesthesia with 3%-6% sevoflurane in 4 L/min oxygen flow. Total intravenous anesthesia was induced in adult patients by inhalation, 8% sevoflurane in 8 L/min oxygen flow, combined with intravenous injections of propofol (1.5-2 mg/kg) and fentanyl (1.5-2 μg/kg). Assisted ventilation was maintained by use of a face or laryngeal mask. Propofol infusion at 200-300 μg/kg/min, combined with remifentanil infusion at 0.06-0.2 μg/kg/min, was used for maintaining anesthesia. Results All patients had surgery under tubeless anesthesia with steady spontaneous respiration. The mean time from induction of anesthesia to unconsciousness was 16±3 s and 36±14 s in pediatric and adult groups, respectively. The average times from induction of anesthesia to the attainment of necessary anesthetic level for surgery while keeping steady spontaneous respiration was 4.17±0.96 min and 8.69±3.17 min in pediatric and adult groups, respectively. The frequency and extent of respiration and heart rate were maintained within the normal range; SpO2 was > 98%. None of the patients developed complications. Conclusion Tubeless anesthesia with spontaneous ventilation induced in patients can provide both an interference-free operative field and continuous observation of airway activity, which may provide an effective approach in excellent surgical conditions for the actual airway operation.