Rigid Bronchoscopy Flashcards
(9 cards)
A 71-year-old patient requires a rigid bronchoscopy for biopsy and possible laser resection of an endobronchial tumour.
List possible options to maintain anaesthesia
Volatile via connection of the anaesthetic circuit to the side port of the rigid bronchoscope.
(Gas delivery may be intermittent as the passage of tools via the bronchoscope will result in a loss of seal at the proximal end, because, unlike an endotracheal tube, the bronchoscope is unsurprisingly not cuffed at the distal end, and O2 delivery would need to be paused during laser treatment.)
TIVA, which can be used with any option for “gas exchange management”
Intermittent IV Boluses
Topicalisation of the airway with local anaesthetic in an otherwise spontaneously breathing patient
NB in addition to general anaesthesia, topicalisation of the airway will help reduce the overall anaesthetic requirements, and immobility using NMBD or short acting opioids may be required for resection
A 71-year-old patient requires a rigid bronchoscopy for biopsy and possible laser resection of an endobronchial tumour.
List possible options to maintain gas exchange
High-frequency automated jet ventilation (e.g., Monsoon) attached at the jet ventilation port
Manuel Low Frequency Jet Ventilation (e.g., Sander’s manual jet ventilator) attached at the jet ventilation port
Ventilation via the side port of a ventilating bronchoscope either using:
1) Controlled ventilation via the anaesthetic circuit attached to the 22mm side port (the oropharynx is packed with gauze and silicone caps can be placed over the proximal bronchoscope openings through which instruments are passed to reduce loss of gas)
2) Spontaneous ventilation via the anaesthetic circuit attached at the 22mm side port with intermittent manual assistance, although this is unlikely to be sufficient for long cases or if laser is required as the patient will need to be still
High Flow supplemental O2 for apnoeic oxygenation
ECMO, infrequently used, however may be required in cases where the location of a tumour/mass means that alternative options for gas exchange are not feasible
What specific patient safety considerations are there if a laser is required during a rigid bronchoscopy
The fraction of inspired oxygen needs to be kept as low as possible, ideal 0.21 but at most 0.4
Do not use nitrous oxide
Saline soaked gauze in the airway over mouth and teeth
Goggles for the patient
Ensure readiness for airway fire management i.e. saline syringes to flood the airway, self inflating bag and mask (or other method to ventilate with room air after the initial removal of the bronchoscope)
Ensure that O2 rich pockets of gas are not allowed to develop during any breathing circuit of oxygen tubing disconnections e.g. under the surgical drapes
Ensure that all equipment that will be used during instrumentation of the airway while the laser is in use is laser compatible, non reflective and that “meltable devices” such as suction catheters are withdrawn before the laser is activated
What general theatre considerations are their for safe laser use?
Goggles for Staff
Laser signs on doors
Theatre doors are locked
Blinds on the doors are down
Presence of laser trained staff members
Appropriate equipment maintenance
What are the anaesthetic complications of a rigid bronchoscopy
Barotrauma associated with jet ventilation (e.g. pneumothorax, pneumomediastinum, pneumoperitoneum, subcutaneous emphysema)
Awareness, secondary to intermittent anaesthesia delivery if an inhalational technique was used
Inadequate gas exchange causing hypercapnia, hypoxia (patients with existing lung pathology are at higher risk)
Laryngospasm / Bronchospasm
Impaired venous return, due to high intrathoracic pressures associated with gas trapping resulting in cardiovascular instability
Dysrhythmia and associated cardiovascular instability associated with jet ventilation
Airway contamination, from ventilating without airway protection.
What are the surgical complications of rigid bronchoscopy
Soft tissue trauma: E.g. Lips, tongue, vocal cords, trachea, bronchi. Airway oedema as a result of this may lead to airway compromise or obstruction post procedure
Dental damage
Major Haemorrhage associated with soft tissue damage, resection of lesion or direct trauma to major blood vessel.
Pneumothorax due to resection or biopsy
Cervical spine damage
(assess the patient’s range of movement preoperatively, consider radiological assessment if the patient has a risk factor such as rheumatoid arthritis_
