Ventilation and Anesthetic Approaches for Rigid Bronchoscopy

Abstract

Due to growing interest in management of central airway obstruction, rigid bronchoscopy is undergoing a resurgence in popularity among pulmonologists. Performing rigid bronchoscopy requires use of deep sedation or general anesthesia to achieve adequate patient comfort, whereas maintaining oxygenation and ventilation via an uncuffed and often open rigid bronchoscope requires use of ventilation strategies that may be unfamiliar to most pulmonologists. Available approaches include apneic oxygenation, spontaneous assisted ventilation, controlled ventilation, manual jet, and high-frequency jet ventilation. Anesthetic technique is partially dictated by the selected ventilation strategy but most often relies on a total intravenous anesthetic approach using ultra-short-acting sedatives and hypnotics for a rapid offset of action in this patient population with underlying respiratory compromise. Gas anesthetic may be used with the rigid bronchoscope, minimizing leaks with fenestrated caps placed over the ports, although persistent circuit leaks can make this approach challenging. Jet ventilation, the most commonly used ventilatory approach, may be delivered manually using a Sanders valve or via an automated ventilator at supraphysiologic respiratory rates, allowing for an open rigid bronchoscope to facilitate ease of moving tools in and out of the airway. Despite a patient population that often suffers from significant respiratory compromise, major complications with rigid bronchoscopy are uncommon and are similar among modern ventilation approaches. Choice of ventilation technique should be determined by local expertise and equipment availability. Appropriate patient selection and recognition of limitations associated with a given ventilation strategy are critical to avoid procedural-related complications.

Respiratory support with venovenous extracorporeal membrane oxygenation during stent placement for the palliation of critical airway obstruction: case series analysis

“…Various ventilation modes, including maintenance of spontaneous ventilation, intermittent positive pressure ventilation via a side port of a rigid bronchoscope, and low-or high-frequency jet ventilation have been introduced (18,19). Both spontaneous ventilation and intermittent positive pressure ventilation via the ventilating port were not feasible in our present study series because of severe and complicated airway obstruction.…”

“…During rigid bronchoscopy under procedural sedation or general anesthesia, intermittent positive pressure ventilation via a side port of a rigid bronchoscope is commonly performed to maintain oxygenation (19). However, during stent placement under fluoroscopic guidance, it is difficult to support oxygenation, and the patient's position is very important for ensuring successful stent placement.…”

The role of bronchoscopy in the diagnosis of airway disease

“…While an inhaled agent can be used with this system, delivery may be hampered by frequent pauses in ventilation and due to suctioning. Additionally, high flows (up to 20 L/min) may be required to compensate for leaks in the system, which leads to inefficient delivery of the inhaled anesthetic and leakage of gas into the operating room (4,7,8). Saline soaked gauze can be packed in the posterior oropharynx to help reduce the leak.…”

“…Jet ventilation uses an injector bronchoscope, however, some find it undesirable as it can create noise and aerosolized secretions (4). Additionally, patients are at risk for barotrauma and hypercarbia with this technique (6,8).…”

Total intravenous anaesthesia- Target Controlled Infusion and Superimposed High-Frequency Jet Ventilation – an anaesthetic protocol for interventional bronchoscopy in cancer patients

“…Historically, several methods of ventilation have been used: apneic oxygenation, spontaneous assisted ventilation, controlled ventilation in a closed system, manual jet ventilation and highfrequency jet ventilation (HFJV) [1]. Jet ventilation techniques, defined as the injection of a gas through a small tube using a high pressure gas source (1-3 bar), are now increasingly applied in ENT surgery, pneumology, thoracic surgery and intensive care.…”