Safety application of muscle relaxants and the traditional low-frequency ventilation during the flexible or rigid bronchoscopy in patients with central airway obstruction: a retrospective observational study

Abstract

Background Bronchoscopy treatments of central airway obstruction (CAO) under general anesthesia are high-risky procedures, and posing a giant challenge to the anesthesiologists. We summarized and analyzed our clinical experience in patients with CAO undergoing flexible or rigid bronchoscopy, to estimate the safety of skeletal muscle relaxants application and the traditional Low-frequency ventilation. Methods Clinical data of 375 patients with CAO who underwent urgent endoscopic treatments in general anesthesia from January 2016 to October 2019 were retrospectively reviewed. The use ratio of skeletal muscle relaxants, dose of skeletal muscle relaxants used, the incidence of perioperative adverse events, adequacy of ventilation and gas exchange, post-operative recovery between rigid bronchoscopy and flexible bronchoscopy therapy, and risk factors for postoperative ICU admission were evaluated. Results Of the 375 patients with CAO, 204 patients were treated with flexible bronchoscopy and 171 patients were treated with rigid bronchoscopy. Muscle relaxants were used in 362 of 375 patients (including 313 cisatracurium, 45 rocuronium, 4 atracurium, and 13 unrecorded). The usage rate of muscle relaxants (96.5% in total) was very high in patients with CAO who underwent either flexible bronchoscopy (96.6%) or rigid bronchoscopy (96.5%) therapy. The dosage of skeletal muscle relaxants (Cisatracium) used was higher in rigid bronchoscopy compared with flexible bronchoscopy therapy (10.8 ± 3.8 VS 11.6 ± 3.6 mg, respectively, p < 0.05). No patient suffered the failure of ventilation, bronchospasm and intraoperative cough either in flexible or rigid bronchoscopy therapy. Hypoxemia was occurred in 13 patients (8 in flexible, 5 in rigid bronchoscopy) during the procedure, and reintubation after extubation happened in 2 patients with flexible bronchoscopy. Sufficient ventilation was successfully established using the traditional Low-frequency ventilation with no significant carbon dioxide accumulation and hypoxemia occurred both in flexible and rigid bronchoscopy group (p > 0.05). Three patients (1 in flexible and 2 in rigid) died, during the post-operative recovery, and the higher grade of American Society of Anesthesiologists (ASA) and obvious dyspnea or orthopnea were the independent risk factors for postoperative ICU admission. Conclusion The muscle relaxants and low-frequency traditional ventilation can be safely used both in flexible and rigid bronchoscopy treatments in patients with CAO. These results may provide strong clinical evidence for optimizing the anesthesia management of bronchoscopy for these patients.

Anesthesia for interventional pulmonology

“…The concomitant use of long-acting benzodiazepines and opioids is usually not warranted in general anesthesia because recovery may be impaired. Muscle relaxants are commonly used to optimize conditions during stimulating procedures or when strict immobility is required and are considered safe [15].…”

“…When rigid bronchoscope is indicated, general anesthesia with muscle relaxation is the current standard [15]. However, cases of rigid bronchoscopy under local anesthesia and sedation have also been reported [16 ▪ ].…”

Non-intubated bronchoscopic tracheobronchial surgeries with electroencephalogram-monitored intravenous anesthesia: feasibility and outcomes

“…However, anesthesia for shared airway and intra-airway manipulation for BTS remains a unique challenge for maintaining intraprocedural oxygenation ( 4 - 7 ). Mostly, anesthesia for BTS is induced with general anesthesia with endotracheal tube insertion (ETGA) ( 7 , 8 ) and muscle relaxants ( 9 ). However, ETGA might lead to perioperative bleeding, inoperability ( 10 , 11 ), loss of muscle tone ( 12 ), and postoperative pulmonary complications ( 13 ).…”

“…Without an endotracheal tubes, anesthesia could be precisely controlled with electroencephalogram (EEG)-derived anesthetic methods such as bispectral index (BIS) monitoring ( 14 ) and target-controlled infusion (TCI). Monitored anesthesia with adequate spontaneous ventilation, can prevent hypoxemia and severe hypercapnia, which delays recovery ( 9 ). However, manipulations for BTS are associated with extremely noxious stimulations and possibly complete airway obstruction.…”

Comparison of the Effects of Esketamine/Propofol and Sufentanil/Propofol on the Incidence of Intraoperative Hypoxemia during Bronchoscopy: Protocol for a Randomized, Prospective, Parallel-Group Trial

“…Bronchoscopy has been an important tool in the evaluation and management of respiratory disease for many years [ 1 , 2 , 3 ]. It is a complicated, highly stimulating, painful, and irritating operation performed in patients with pulmonary disease, with a relatively high risk of hypoxemia, coughing, wheezing, and dyspnea [ 4 , 5 , 6 ]. Intraprocedural sedation, local anesthesia, and general anesthesia have been implemented to avoid such problems in patients undergoing bronchoscopy [ 7 , 8 , 9 , 10 ].…”