Abstract: The report, in this issue, by Denton and his colleagues (see page 1086) of a major complication using the Nd: Yag laser in the treatment of a tracheobronchial neoplasm brings home the point that this powerful clinical tool can also be a dangerous one. After a treatment modality becomes accepted in clinical practice, there is a tendency to become complacent about the risks involved in its use. The Nd: YAG laser has had several serious complications reported. These include: a risk of death from hemorrhage of 2 percent,1Brutinel W.M. Cortese D.A. McDougall J.C. Gillio R.G. Bergstralh E.J. A two-year experience with the neodymium-YAG laser in endobronchial obstruction.Chest. 1987; 91: 159-165Crossref PubMed Scopus (145) Google Scholar fire in the tracheobronchial tree,2Casey K.R. Preventing endotracheal fires [letter].Chest. 1987; 91: 637Crossref Scopus (5) Google Scholar,3Casey K.R. Fairfax W.R. Smith S.J. Dixon J.A. Intratracheal fire ignited by the Nd-YAG laser during treatment of tracheal stenosis.Chest. 1983; 84: 295Crossref PubMed Scopus (81) Google Scholar pneumothorax, esophageal fistula, bronchial perforation, and hypoxemia. It is incumbent upon the clinicians using this laser to do all that is possible to reduce these risks. It is also important that this procedure, which is palliative, be used in a manner to increase the quality of life of our terminally ill cancer patients with the least morbidity possible. We would agree with the general conclusions of the authors that: (1) There must be close communication between the laser bronchoscopists and the anesthesiologist and his team. (2) That the FIO2 should be kept at 0.5 or less during laser treatment and hemoglobin saturation should be continuously monitored during the whole procedure. (3) Adequate number of laser fibers should be available and nonsheathed quartz monofilament fibers should be used with extreme caution, if at all. (4) The operating room team must be prepared to act quickly in the case of an endobronchial fire to protect the patient, and the operating room staff. However, in all likelihood, this fire could have been prevented by the use of the rigid bronchoscope. Despite greater than five years of clinical experience with the Nd: YAG laser, controversy still surrounds how best to use it. Initially, we used the flexible fiberoptic bronchoscope with general anesthesia, and our experience has been previously reported.1Brutinel W.M. Cortese D.A. McDougall J.C. Gillio R.G. Bergstralh E.J. A two-year experience with the neodymium-YAG laser in endobronchial obstruction.Chest. 1987; 91: 159-165Crossref PubMed Scopus (145) Google Scholar,4McDougall J.C. Cortese D.A. Neodymium-YAG laser therapy of malignant airway obstruction: preliminary report.Mayo-Clin-Proc. 1983; 58: 35-39PubMed Google Scholar Since then, we have switched to using the rigid bronchoscope under general anesthesia. Anesthetic gases are easily given through a rigid bronchoscope. We use little intravenous anesthesia and the vast majority of our patients are extubated in the operating suite at the end of the procedure. In experienced hands, damage to the upper airways is extremely rare. Rigid bronchoscopy easily reaches the trachea and mainstem bronchi which we feel are the most efficacious areas of treatment with this technique. If necessary, the flexible fiberoptic bronchoscope can be used through the rigid bronchoscope to reach more distal lesions. The rigid instrument permits more efficient debridement resulting in shorter operating times. There is better continuous visualization of the operative field due to the ability to simultaneously apply suction (to remove blood and debris) and treat with the laser. The risk of fire is negligible. The only materials in the airway that can burn are the flexible suction catheter and the laser fiber. We have found, that with these materials, it is difficult if not impossible to sustain combustion, and both can be removed quickly without having to remove the rigid bronchoscope. Also, the rigid bronchoscope improves our success at opening an obstructed airway during a single treatment session. We now rarely have to treat more than once to either achieve relief of obstruction or determine that further laser photoresection will be of no benefit. The median hospital stay is one day for our patients; many are dismissed the same day. We now feel that the rigid bronchoscope is indicated in the treatment of over 95 percent of our patients and reserve the flexible fiberoptic bronchoscope for situations where the rigid scope can not be used. We would strongly urge all laser bronchoscopists to acquire rigid bronchoscopy skills and to use them. We are certain that once tried, the advantages of combining the Nd: YAG laser and the rigid bronchoscope will become obvious.