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Bronchoscopic Procedures

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Principles and Practice of Anesthesia for Thoracic Surgery

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Abstract

Diagnostic flexible bronchoscopy is safely performed outside of the operating room with light to moderate sedation and topical anesthesia. Rigid bronchoscopy is typically performed in patients with central airway obstruction and major comorbidities. Primary concerns include the risk of complete airway obstruction and inability to ventilate or dynamic hyperventilation with hemodynamic compromise. A fluid transition between ventilation strategies is often required for these procedures. Extracorporeal membrane oxygenation may be implemented when conventional approaches are not feasible or deemed safe. Multimodal techniques employed by interventional bronchoscopists to acutely re-establish patency of obstructed central airways include stenting, laser, endobronchial electrosurgery, argon plasma coagulation, and balloon bronchoplasty. Major intraoperative complications associated with these techniques include hemorrhage, airway trauma, perforation, fire, systemic gas embolism, and dissemination of postobstructive pneumonia. Alternative indications for these procedures include treatment of low-grade malignancies and carcinoma in situ. These lesions may also respond to brachytherapy, cryotherapy, or photodynamic therapy. Interventional bronchoscopy is an evolving field with expanding applications with both diagnostic and therapeutic modalities covering benign and malignant pulmonary disease. Future indications may include endobronchial valve insertion for persistent air leaks and lung volume reduction in COPD as well as bronchial thermoplasty for treatment-resistant asthma.

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Authors and Affiliations

  1. Department of Anesthesiology, Division of Critical Care, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada

    Gordon N. Finlayson

  2. Interventional Pulmonology, Respiratory Medicine, and Integrative Oncology, St Paul’s Hospital, BC Cancer Agency and University of British Columbia, Vancouver, BC, Canada

    Tawimas Shaipanich

  3. Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia; Vancouver General Hospital, Vancouver, BC, Canada

    Chris Durkin

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  2. Tawimas Shaipanich
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  3. Chris Durkin
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Corresponding author

Correspondence to Gordon N. Finlayson .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, University of Toronto, Toronto, ON, Canada

    Peter Slinger

Clinical Case Discussion

Clinical Case Discussion

A 65-year-old woman with a remote transhiatal esophagectomy for cancer presented with 2 days of increasing dyspnea. She remains hypoxemic following intubation for respiratory failure in the emergency department, despite maximal conventional ventilation. CT imaging demonstrates near-complete obstruction of the left main bronchus and significant obstruction of the right main bronchus (Fig. 11.11). The Interventional Pulmonologist intends to perform balloon dilatation, tumor resection, and stent insertion in the left main bronchus via rigid bronchoscopy.

Fig. 11.11
figure 11figure 11

(a) Bronchoscopic picture of the right bronchus intermediate (RBI) stenosis and left main bronchial stenosis (Lt main); CT scan of the chest demonstrates near occlusion of the left main airway by tumor. (b) Balloon dilation of the left main bronchus (left). Fluoroscopy image shows stent insertion via rigid bronchoscopy (right) (c) Bronchoscopic examination shows left main airway stent and patent right main airway post balloon dilation and stent placement

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Questions

Outline the considerations of providing anesthesia for patients with central airway obstruction:

  • Risk of complete airway obstruction and impossible ventilation

  • Potential for dynamic hyperinflation resulting in hemodynamic compromise or barotrauma

  • Considerations and complications of rigid and interventional bronchoscopy

Describe the ventilation techniques applied during rigid bronchoscopy:

  • Spontaneous

  • Assisted

  • Sanders jet ventilation

  • HFJV

Describe the acute complications of balloon bronchoplasty, airway stenting, and electrocautery:

  • Tracheitis

  • Fever

  • Atelectasis

  • Bronchospasm

  • Airway disruption

  • Dissemination of obstructing pneumonia

  • Hemorrhage

  • Airway fire

  • Electromagnetic interference

Authors’ Management

General anesthesia was maintained by TIVA and neuromuscular blockade. Fiber-optic inspection of the tracheobronchial tree was expeditiously performed to further evaluate the tumor and characterize the anatomy of the obstruction. Given the degree of hypoxemia, an exchange catheter was inserted adjacent to the endotracheal tube, to allow for temporary oxygenation during the transition between tracheal extubation and access with the rigid bronchoscope. Ventilation following tracheal placement of the rigid bronchoscope was supported with a Sanders jet injector. Left mainstem patency was re-established using a combination of balloon dilation, electrocautery, and stent placement. Following restoration of normal gas exchange, balloon dilation of the right mainstem was employed, the trachea was extubated, and a laryngeal mask was inserted. Once the patient recovered from intravenous anesthesia, neuromuscular blockade was reversed, adequate spontaneous ventilation was established, and the patient was observed in the operating room until fully awake (Fig. 11.11).

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Finlayson, G.N., Shaipanich, T., Durkin, C. (2019). Bronchoscopic Procedures. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_11

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  • DOI: https://doi.org/10.1007/978-3-030-00859-8_11

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