2.5 Rigid Bronchoscopy

Question 1

A 71-year-old patient requires a rigid bronchoscopy for biopsy and possible laser resection of an
endobronchial tumour.

a) Outline the options available to maintain anaesthesia (20%)

Answer 1

Maintenance of anaesthesia:
determined primarily by method of
management of gas exchange.

> > Volatile: use of volatile not possible
with jet ventilation, and awareness
more likely if volatile used with
intermittent ventilation technique.

> > Total intravenous anaesthesia:
can be used with any option for gas
exchange management.

> > Immobility should be assured for
resection with muscle relaxant or
remifentanil infusion,
and short-acting opioids are useful
due to the highly
stimulating nature of rigid bronchoscopy.

Question 2

A 71-year-old patient requires a rigid bronchoscopy for biopsy and possible laser resection of an
endobronchial tumour.

Outline the options available manage gas exchange. (30%)

Answer 2

Management of gas exchange:
depends on the specific bronchoscope used
as not all options are compatible with all bronchoscopes.

> > Intermittent ventilation with or
without oxygen insufflation via side-port.
This may be sufficient for the diagnostic
aspect of the procedure but
does not offer sufficiently
reliable ventilation for resection.

> > Controlled ventilation via the side
port of a ventilating bronchoscope.

> > Manual low-frequency jet ventilation,
e.g. with Sanders manual jet ventilator.

> > Automated high-frequency jet ventilation.

Question 3

b) How will use of the laser change the management of anaesthesia? (15%)

Answer 3

Patient safety:
» Maintain inspired oxygen concentration
as low as possible, certainly less
than 0.4 – therefore,
use with jet or conventional ventilation.

> > Saline-soaked gauze over mouth, teeth.

> > Goggles for patient.

> > Ensure that all equipment that will be used to instrument the airway is laser-compatible

General theatre safety:
» Goggles for staff.
» Signage on doors.
» Lock theatre doors.
» Blinds down.
» Presence of laser-trained staff member.
» Assurance of equipment maintenance.

Readiness for airway fire:
» Alertness.
» Syringes of saline ready for flooding airway.

> > Airway equipment prepared in case surgery needs to be abandoned and the patient needs to be intubated and ventilated on 100% oxygen.

Question 4

c) What are the possible complications of rigid bronchoscopy? (35%)

Answer 4

Anaesthetic complications:
» Barotrauma associated with jet ventilation: pneumothorax,
pneumomediastinum,
pneumopericardium,
pneumoperitoneum,
subcutaneous emphysema.

> > Awareness:
secondary to intermittent anaesthesia delivery.

> > Inadequate gas exchange:
hypercapnia,
hypoxia.
Patient with existing
lung pathology at higher risk.

> > Laryngospasm, bronchospasm.

> > Impaired venous return:
high intrathoracic pressures associated
with gas trapping,
resulting in cardiovascular instability.

> > Dysrhythmia and associated cardiovascular instability associated with jet ventilation.

> > Airway contamination:
ventilation without airway protection.

Surgical:
» Soft tissue trauma:
lips, tongue, vocal cords, trachea, bronchi.
Airway
oedema may cause airway compromise or obstruction post-procedure.

> > Dental damage.

> > Haemorrhage:
associated with soft tissue damage
or resection of lesion.

> > Pneumothorax: due to resection or biopsy.

> > Cervical spine damage:
assess range of movement preoperatively.
Consider radiological assessment if the patient has a risk factor such as rheumatoid arthritis.