Sign in

Review Note

Last Update: 02/20/2025 12:48 AM

Current Deck: ACG Part 2::Thoracic SSU

New Card (Unpublished)

Currently Published Content

Front
Back

No published tags.

Pending Suggestions

Field Change Suggestions:
SS_TS 1.12 Discuss the anaesthetic management of the following endobronchial procedures: 
• Flexible bronchoscopy 
• Diagnostic bronchoscopy 
• Bronchoalveolar lavage 
• Bronchoscopic ultrasound and biopsy 
• Placement of endobronchial stent 
• Rigid bronchoscopy 
• Spontaneous versus jet ventilation 
• Removal of foreign body in airway 
• Laser of endobronchial tumour

  1. Flexible bronchoscopy
    • Sedation or GA, topicalisation of airway
    • Can ventilate via LMA/ETT
    • Coughing to be expected, haemoptysis common after biopsy (care taken with those on anticoagulation 
  2. Rigid bronchoscopy
    • GA, muscle relaxant, TIVA
    • Can use jet ventilation side arm or THRIVE
    • Preoperative: check for airway obstruction, review imaging if tracheal tumour
    • If high risk regurgitation, may need PPI premed
    • +/- dex for reduction airway swelling
    • Beware blood clot or airway haemorrhage → intubation
  3. Bronchoalveolar lavage → eg. alveolar proteinosis
    • Warm saline into bronchial lumen, physiotherapy, passive drainage
    • Absolute requirement for DLT with good isolation
  4. EBUS and biopsy
    • LA +/- sedation or GA (TIVA)
    • Can be done like flexi bronch, via LMA or SLT; anticipate high airway pressures
  5. Endobronchial stent
    • Usually require GA as rigid bronchoscopy used, can consider conscious sedation +/- THRIVE if flexible being used 
    • More commonly used for management of central airway obstruction. Can be inserted for benign or malignant pulmonary or extrapulmonary pathologies 
    • In extreme cases ECMO may be required if inducing anaesthesia and PPV thought to cause complete obstruction 
    • Jet ventilation often required during airway stenting procedures using either manual low frequency or electrically powered high frequency 
  6. Spontaneous vs jet ventilation
  • Should be covered in airway/ENT section 
  • Jet ventilation : can be done through variety of systems  : 
    • Low frequency (RR8-30) done manually 
    • High frequency 120-600 impulses per min with 1-3ml TV 

  1. Removal foreign body
( from a BJA for paeds where this is most common )
Pre-op:
  • Usually medical/surgical emergency
  • usually managed with a rigid bronchoscopy
  • May need management outside of a specialist centre due to clinical urgency
  • Particular problems include 
    • maintenance of a patent airway and avoidance of airway obstruction; 
    • induction and maintenance of satisfactory anaesthesia for a very stimulating procedure; 
    • a high risk of hypoxaemia during the ‘shared airway’ 
    • the prevention and management of possible postoperative airway problems
  • Focussed history and exam depending on clinical status
  • If emergency/hypoxic:
    • AMPLE history (allergies, medications, past medical/anaesthesia history, last meal, events leading up to the presentation), and ask about family history of problems with anaesthesia. 
    • Examine the child with a focus on the airway. 
  • Investigations: Look at neck and chest radiographs for the position of any radio-opaque foreign body
Intra-op:
  • Goals: Keep the child breathing spontaneously. 
    • Theoretically, positive pressure may push the foreign body further down the airway; maintaining spontaneous ventilation is a safe option.
  • Airway: Rigid bronchoscope, keep airway patent with mask until ready for bronchoscope
  • Breathing: Spontaneous - IPPV may push the fb down further
  • Circulation: Will want to secure IV access prior to induction
  • Induction:
    •  Inhalation or intravenous.
    • A safe approach is to induce anaesthesia with sevoflurane in oxygen.
    • Or i.v. induction with fentanyl 0.5 mg kg1 followed by incremental boluses of propofol (initial dose 1 mg kg1 , then increments of 0.5 mg kg1 or less) until the child loses consciousness. 
    • Another option is to start with i.v. dexmedetomidine 1 mg kg1
  • Maintenance:
    • Either inhalational or IV, aim to continue spontaneous breathing
    • Inhalational - can give via ventilating bronchoscope, but may have periods where scope not in place/breaks in ventilation + exposure to operating room staff to sevo
    • TIVA - can continue no matter what is happening with airway however more difficult to maintain spont ventilation + adequate depth. Usually prop + remi.
    • Technique: Deepen (while still spont venting), then apply local anaesthetic to larynx, cords and trachea under direct vision with laryngoscope (Lignocaine up to 4 mg/kg, concentrated works better and faster)
    • Once deep + local has taken effect surgeon will introduce rigid ventilating bronchoscope, once it is through the cords attach the circuit to maintain oxygenation, can also place ETT through nares to oxygenate during periods where bronchoscope is not in place
    • Very stimulating procedure and patient needs to remain deep and still (but breathing), as coughing and bucking on the rigid bronchoscope risks trauma and bronchial or tracheal perforation. Removal of the foreign body through the larynx is a high-risk time: some anaesthetists give a bolus of propofol to ensure adequate depth of anaesthesia
Post-op:
  • Prolonged period in PACU
  • May use SAD until emergence, or hold airway with mask
  • If significant swelling/trauma may need period of intubation + ICU
  • If stridor in PACU nebulised adrenaline + urgent ENT review required
https://www.bjaed.org/action/showPdf?pii=S2058-5349%2819%2930015-0

  1. Laser of endobronchial tumour
    • Shared airway case, MDT discussion , prepare for potential loss of airway 
    • Ventilaiton choice, If posterior tumour then ETT may inhibit access. 
      • Conventional PPV with laser safe ETT eg laser-flex 
      • High pressure jet ventilation via SG, TG or TT route 
      • HFO2 with tubeless field 
        • Spontaneous (hypo)ventilation 
        • Apnoeic 
    • Variable results with usually temporary success (like dilation)
    • A CO2 laser can be used to pallaite unresectable airway tumours 
      • Care taken to avoid the ignition of ETT 
      • Laser safety practices 
        • Limit O2 during laser application 
    • Consider optimisation of airway with preoperative steroids, nebulized adrenaline, beta-agonists and anti-sialogues 
    • Consider marking cricothyroid membrane in anticipation for airway demise 


https://academic.oup.com/bjaed/article/17/7/242/3921240

Terms of Service | Privacy Policy | Imprint (German)

Copyright © AnkiCollab. Website Template Designed & Developed by Quixlab 2018