BRONCHOSCOPY

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Bronchoscopy is a medical procedure that involves the examination of the respiratory system, including the trachea, bronchi, and lower airways, using a thin, flexible tube called a bronchoscope. This tube is equipped with a light and a small camera at its tip, which allows the doctor to visualize the airways and diagnose various respiratory conditions.

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There are two types of bronchoscopy:

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1. Flexible bronchoscopy: This is the most common type, where a flexible, fiberoptic bronchoscope is inserted through the patient's nose or mouth and passed down the throat to reach the airways. It is generally well-tolerated and requires only local anesthesia or moderate sedation.

2. Rigid bronchoscopy: In this type, a rigid metal tube is used instead of a flexible bronchoscope. It is less commonly performed, typically in cases where a larger airway opening is needed or when removing foreign objects, tumors, or large amounts of secretions. This procedure often requires general anesthesia.

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The flexible scope allows more peripheral subdivisions to be inspected than a rigid scope.

 

The disadvantage of the flexible scope is that foreign objects or thick mucus cannot be removed through the lumen.

 

Bronchoscopy can be performed for various purposes, including:

• Diagnosing respiratory conditions, such as infections, tumors, or airway blockages.

• Collecting samples of lung tissue or fluids for laboratory analysis (biopsies or bronchoalveolar lavage).

• Treating airway problems, such as removing foreign objects, controlling bleeding, or dilating narrowed airways with stents.

• Assessing the extent of lung damage or disease, such as in patients with chronic obstructive pulmonary disease (COPD) or interstitial lung disease.

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                                                             Anesthetic Implications for Bronchoscopy

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Anesthesia type: General, topical local anesthesia, total intravenous anesthetic (TIVA), MAC, regional anesthesia

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Airway: Endotracheal tube (> 8.0 tube) or LMA

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Preoperative:

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• Glycopyrrolate (antisialagogue) can be administered to decrease airway/oral secretions

• Albuterol can be administered for wheezing 

• Consider LTA lidocaine and dexamethasone administration

• Rigid bronchoscopy is preferred when airway patency is important

• Suctioning ability is better with a rigid scope

• Higher risk of damage to soft tissue with rigid scope

• Tooth guard can be placed to protected teeth from scope

• Spontaneous ventilation can be maintained when using a flexible bronchoscope

• Special attention should be given to the patient’s pulmonary function

• High incidence of COPD and respiratory disease in this population

• Patients may have limited cardiac and pulmonary function

• Have bronchoscopy adapter to connect to ETT or LMA

• General anesthetic with paralysis is the preferred 

• MAC and LMA associated with risk of laryngospasm and bronchospasm

• Be prepare to intervene if rapid oxygen desaturation and airway obstruction occur

• Regional anesthesia via a superior laryngeal nerve block (blocks cough reflex)

• Presence of stridor may alert to the potential narrowing in the upper airway

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Intraoperative:

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• Position: The head of the table may be turned away at least 90 to 180 degrees

• Laser may be used for the removal of tracheal papillomas

• Prevent airway fire by using fire-resistant ETT and keeping FiO2 as low as possible

• Avoid using nitrous oxide with laser, as this gas is highly combustible

• Leaking of gases can occur around bronchoscope 

• Maintain our patients on 100% oxygen due to the possibility of inadequate ventilation and frequent leaks

• Duration 10-30 minutes

• EBL minimal

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Postoperative:

 

• Pain management

• Observation for complications

• Respiratory care

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Complications:

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• Bleeding

• Bronchospasm

• Laryngospasm

• Airway fire

• Sore throat

• Infection

• Pneumothorax

• Hypoxia

• Arrhythmias

• Damage to teeth or airways

• Laryngeal edema

• Airway obstruction

• Risk of local anesthetic systemic toxicity (LAST)

• Barotrauma

• Inadequate anesthetic level and awareness

• Inadequate ventilation

• Air emboli

• Aspiration pneumonia

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Sources:

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Galway U, Zura A, Khanna S, Wang M, Turan A, Ruetzler K. Anesthetic considerations for bronchoscopic procedures: a narrative review based on the Cleveland Clinic experience. J Thorac Dis 2019;11(7):3156-3170. doi: 10.21037/jtd.2019.07.29

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Lentini C, Granlund B. Anesthetic Considerations For Bronchoscopic Procedures. [Updated 2022 May 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

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Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. 

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Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). 

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Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.

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