Anesthesia considerations to reduce motion and atelectasis during advanced guided bronchoscopy

Abstract

Partnership between anesthesia providers and proceduralists is essential to ensure patient safety and optimize outcomes. A renewed importance of this axiom has emerged in advanced bronchoscopy and interventional pulmonology. While anesthesia-induced atelectasis is common, it is not typically clinically significant. Advanced guided bronchoscopic biopsy is an exception in which anesthesia protocols substantially impact outcomes. Procedure success depends on careful ventilation to avoid excessive motion, reduce distortion causing computed tomography (CT)-to-body-divergence, stabilize dependent areas, and optimize breath-hold maneuvers to prevent atelectasis. Herein are anesthesia recommendations during guided bronchoscopy. An FiO2 of 0.6 to 0.8 is recommended for pre-oxygenation, maintained at the lowest tolerable level for the entire the procedure. Expeditious intubation (not rapid-sequence) with a larger endotracheal tube and non-depolarizing muscle relaxants are preferred. Positive end-expiratory pressure (PEEP) of up to 10–12 cm H2O and increased tidal volumes help to maintain optimal lung inflation, if tolerated by the patient as determined during recruitment. A breath-hold is required to reduce motion artifact during intraprocedural imaging (e.g., cone-beam CT, digital tomosynthesis), timed at the end of a normal tidal breath (peak inspiration) and held until pressures equilibrate and the imaging cycle is complete. Use of the adjustable pressure-limiting valve is critical to maintain the desired PEEP and reduce movement during breath-hold maneuvers. These measures will reduce atelectasis and CT-to-body divergence, minimize motion artifact, and provide clearer, more accurate images during guided bronchoscopy. Following these recommendations will facilitate a successful lung biopsy, potentially accelerating the time to treatment by avoiding additional biopsies. Application of these methods should be at the discretion of the anesthesiologist and the proceduralist; best medical judgement should be used in all cases to ensure the safety of the patient.

Combining Shape-Sensing Robotic Bronchoscopy With Mobile Three-Dimensional Imaging to Verify Tool-in-Lesion and Overcome Divergence: A Pilot Study

“…When hemodynamic tolerance is of utmost importance for patient safety, a PEEP of 10-12 cm H 2 O is recommended for upper lobe biopsies with even higher values for lower lobe biopsies, especially in obese patients (Katsis et al 22 used a ventilation protocol with a PEEP of 15 cm H 2 O achieving a pneumothorax complication rate of 2.5%). 23 , 22 , 24 …”

Out of the Box Thinking

“…Thus, best practice is to prevent atelectasis from occurring. 5 Atelectasis occurs due to neuromuscular weakness secondary to anesthesia ± neuromuscular paralysis, hyperoxia (100% fraction of inspired oxygen), length of procedure and body mass index. Current navigation bronchoscopy ventilation studies suggest using high tidal volume and positive end-expiratory pressure (PEEP) strategies to help overcome atelectasis.…”

“…4 Technology has assisted in making remote simulation and telesimulation accessible. 5 Furthermore, it has practical advantages including low cost, accessibility, and availability.…”

“…Atelectatic lung units have poor compliance and require significant changes in inflation pressure to result in minor changes in volume. Thus, best practice is to prevent atelectasis from occurring 5…”

Causes and Treatment of Hypoxia during Total Hip Arthroplasty in Elderly Patients: A Case Report

“…( B , C ) Atelectasis in the dependent regions of both lungs after anesthesia induction. Cone beam CT (CBCT) showing exacerbated atelectasis during surgery [ 8 ].…”