Flexible Fiberoptic

Question 1

why Flexible instead of fiberoptic bronchoscopy DESCRIPTION
VPA
does not allow what?

Answer 1

Visualize the larynx, trachea, bronchi and all the way down to the bronchioles. (LTBB)
Performed to obtain biopsies, removal of foreign bodies, tumor staging, washouts and other diagnosis.

Question 2

Flexible Fiberoptic POSITION and

NEURO

Answer 2

Supine with head elevated 30-45 degrees:

NEURO – Have patients position themselves comfortably before induction to prevent nerve damage

Question 3

ENSUre this with Fiberoptic Flexible

and patient may need that?

Answer 3

Ensure the bite block is placed prior to start of propofol infusion. The patient should not be as deeply sedated as with an EGD or colonoscopy.
The patient still needs to be able to control their own airway reflexes and cough.
Patient should receive a Lidocaine nebulizer ahead of time to help numb the airway.

Question 4

INDUCTION FOR FLEXIBLE FIBEROPTIC
PREOP amnestic
Spray ?

Answer 4

Preop: Versed 1-2mg IV for anxiety.
Glycopyrrolate 0.2-0.3 mg IV.
Anesthetic: Nebulizer spray in oropharynx and base of tongue using Lidocaine 4% to blunt gag reflex

Block SLN internal branch (sensory innervation to epiglottis, arytenoids, & vocal cords) using pledgets in piriform fossa using Krause Forceps with Lidocaine 2%.

Question 5

Flexible Fiberoptic have this?

Answer 5

Lidocaine 2% 1 mg/kg IV, propofol 40mg prior to insertion of the scope. Bolus doses of 10-20mg of propofol to keep patient sedated but responsive.
Spraying lidocaine in the trachea as FOB is advanced to block airway reflexes. Provide minimal narcotics if needed, Fentanyl 25mcg IV.

Question 6

Flexible fiberoptic EMERGENCE

Answer 6

Emergence: Do not provide small boluses of Propofol 5-10 minutes prior to end of procedure. Continue to monitor O2 saturation and keep HOB at 35 degrees.
Plan B: GETA – for patient’s comfort, unable to cooperate, severe anxiety, hx of gastric reflux & aspiration, has severe OSA, or a history of waking during the procedure

Question 7

TIVA Flexible Fiberoptic PREOP and induction

ETT SIZE

Answer 7

TIVA using ETT 8.0

Preop: Versed 1-2mg IV and Glycopyrrolate 0.2-0.3mg IV.

Question 8

TIVA Flexible Fiberoptic maintenance

Answer 8

Maintenance: Start Propofol 50-150 mcg/kg/min and remifentanil 0.1-0.3 mcg/kg/min (both medications titrate to effect), assisted spontaneous ventilation provided to patient. Titrate O2 to keep >94%.

Question 9

TIVA Flexible Fiberoptic EMERGENCE

Answer 9

Stop infusing propofol 10 minutes prior to end of procedure. Suction oral airway prior to extubation. If no contraindication, consider Ketoralac 30mg IV.

Provide O2 via NC 2-4LPM and keep HOB 30 degrees.
*LMA (at least 2.5) can be used if need to assess proximal airways

Question 10

Potential Post OP Issues:

Flexble fiberoptic

Answer 10

Airway obstruction/Aspiration – pt to remain NPO for several hours until local anesthetics wear-off. Monitor pt O2 saturation.
Sore throat – Throat lozenges and ice to help with the pain.

Question 11

CV –

Answer 11

BP cuff placed on opposite arm from IV.

Question 12

How do you know ready to extubate?

Answer 12

If pt able to pull at least 5ml/kg of TV on spontaneous ventilation; and if no fade on post tetanic potentiation, sustained head lift, hand grip for 5 secs, and max inspiratory 40-50 cmH20 or greater = can extubate pt.

Question 13

*Volatile Anesthetics can also be used but

Answer 13

difficult to achieve the required %MAC from resistance to flow with FOB inside ETT and from frequent suctioning

Question 14

RESP– as soon as patient in the room

Answer 14

As soon as patient is in the room place NC with ETCO2 sampling to start building an FRC reserve (denitrogenation) while placing other monitors.

Question 15

To blunt Gag reflex do this Preoxygenated with 100% FiO2.

Answer 15

Nebulizer spray in oropharynx and base of tongue to blunt gag reflex and plidgets

Question 16

Pledgets in piriform fossa why to

Answer 16

block SLN internal branch.

Question 17

Induction for fiberoptic

ETT Size

Answer 17

Lidocaine 1mg/kg, Propofol 2mg/kg, succinylcholine 2mg/kg (to avoid fasciculation) insert ETT 8.0 to minimize resistance to air flow.

Question 18

Glossopharyngeal nerve- sensory innervation to (PTP)

Answer 18

pharynx, tonsils, and posterior 3rd of the tongue).

Question 19

Lidocaine to block Superior Laryngeal Nerve innervation which innervates.

Answer 19

Block SLN internal branch
(sensory innervation to epiglottis, arytenoids,and vocal cords) using pledgets in piriform fossa using Krause Forceps with Lidocaine 2%

Question 20

Flexible also used to

Answer 20

aid and confirmation of ETT and tracheostomy tube placement.

Question 21

Flexible does not

Answer 21

not allow removal of foreign objects and thick mucus.