The first, and probably most critical, concern for the anesthetist caring for the patient with RRP revolves around securing the patient’s airway. HPV papillomas in the respiratory tract may be found anywhere from the nose to, and into, the lungs. Most are found in the oropharynx, epiglottic, and glottic areas. With the patient awake, muscle tone may maintain an airway that is functionally adequate but quite tenuous. Induction of general anesthesia, with or without muscle paralysis, or even provision of a moderate degree of sedation may reduce the patient’s muscle tone to the point of complete obstruction. The patient may become a “can’t ventilate/can’t intubate” patient almost instantly. Attempts at direct laryngoscopy must be undertaken with extreme caution; ideally, laryngoscopy should be delayed until the patient’s airway reflexes are sufficiently suppressed, all the while striving to maintain spontaneous ventilations by the patient. Despite the apparent contradiction, this can be accomplished with a slow, careful, deliberate inhalation induction utilizing sevoflurane. If the patient is a small child, particularly one with stridor while at rest, the anesthetist should opt for an awake intubation. Intubation, whenever necessary, should be carried out with a smaller than usual endotracheal tube. Because of the high probability of papillomas in the oropharynx and the friability of those papillomas, the use of a laryngeal mask airway is best avoided.

Because of the close proximity of the surgical site to the patient’s airway, whether natural or artificial, an airway fire is always a very real potential hazard. Airway fire can be particularly devastating and potentially fatal. The anesthetist must strive to use the lowest fraction of inspired oxygen possible, on the order of 0.25% to 0.35%, where feasible. The fraction of inspired oxygen should be reduced using helium (Helox) or nitrogen, but nitrous oxide should be avoided because it, too, supports combustion. The airway should be secured with either a special, laser-safe endotracheal tube or with an endotracheal tube wrapped with a reflective material, such as aluminum foil, to reduce the possibility of tube puncture and initiation of combustion. In the event of an airway fire, extinguishing it is the first priority. The steps to follow in the event of an airway fire are as follows: the endotracheal tube must be clamped, the balloon deflated, the tube removed, the patient ventilated by mask, and the airway inspected via direct laryngoscopy. After these steps have been completed, the patient should be re-intubated if possible or the patient may require tracheostomy to secure the airway. The lower respiratory tract should be inspected via bronchoscopy and any visible debris removed, which may require bronchial lavage. The degree of pulmonary dysfunction produced by the thermal injury should be assessed by obtaining an arterial blood gas sample. The anesthetist may need to initiate supportive pharmacologic treatment in the form of corticosteroid(s) and antibiotics, plus racemic epinephrine combined with highly humidified oxygen. The surgical procedure will have to be terminated immediately with the exception of any necessary hemostasis.

Patients with RRP should remain intubated after the surgical procedure has been completed until their airway reflexes have fully returned, even in uncomplicated cases. The patient should not be extubated until fully awake because of the high potential for postoperative airway edema and compromise. For this same reason, the patient should receive humidified supplemental oxygen and be closely monitored postoperatively.