Rigid Bronchoscopy

Airway: Rigid bronchoscope. Usually ETT afterwards.
Access: 1× large IV.
Pain: Minimal.
Position: Supine, head elevated, neck extended.
Time: Variable.
Blood loss: Not usually required. Bleeding causes more issues via airway obstruction.
Special: Ventilation strategies.

Placement of a rigid bronchoscope into the trachea, which allows passage of instruments and facilitates:

Considerations

  • A
    • Position
      Requires extreme ramping to facilitate intubation.
    • Secretion
      Consider anti-sialogogue.
  • B
    • Ventilatory and oxygenation demands
      Risk ↑ in patients with:
      • Poor exercise tolerance
      • Respiratory distress
      • PaO2 ⩽70mmHg
      • PacO2 ⩾45mmHg
  • D
    • Volatile vs. TIVA
      Dependent on ventilatory technique: volatile only achievable with intermittent volume ventilation.
    • TIVA
      Generally preferred; exact technique used will depend on desire for spontaneous or controlled ventilation.
      • Propofol/remifentanil
        Post-operative analgesia requirements are usually minimal.
      • Propofol/fentanyl
  • H
    • Coagulopathy

Preparation

Induction

Intraoperative

Ventilation

Strategies include:

  • Spontaneous ventilation
    Usually only appropriate in children.
    • Spontaneous respiration is ideal in inhaled foreign body cases
      Prevents distal propagation of the foreign body.
    • Oxygenation may be facilitated with:
      • Continuous nasal oxygen
        Via suction catheter or nasal ETT in nasopharynx.
      • High-flow humidified oxygen
  • Controlled ventilation
    Usually required in adults to facilitate tracheal placement of the bronchoscope. Methods include:
    • Jet (Venturi) Ventilation
      Most common method, and involves high-pressure oxygen delivered through the side port at the proximal end of the scope.
      • Breaths delivered at 10-20/minute at ⩽50psi
        Lower rates facilitate passive exhalation via elastic recoil of lung and chest wall.
      • Entrainment of air with oxygen facilitates ventilation and oxygenation
      • Ensure there is an avenue of escape for the insufflated air to prevent barotrauma
      • Monitor chest rise to prevent excessive VT and gas trapping
      • May be automatic or manual
        Higher risk of pneumothorax or pneumomediastinum with manual technique.
    • High Frequency Jet Ventilation
      Automated system giving low VT breaths at a rate of 60-300/min.
      • Motionless operating field
      • Difficult to assess adequacy of ventilation
        May require repeated blood gas analysis.
      • VT < V~Dead Space~
        Gas transport mechanisms include laminar flow, longitudinal dispersion, pendelluft, molecular diffusion.
    • Intermittent Volume ventilation
      Ventilation tubing connected to proximal end of bronchoscope.
      • Ventilation provided via the bronchoscope
      • Leak minimised by occluding:
        • Bronchoscope ports with silastic caps
        • Mouth packed with gauze
      • Occlusion of the mouth and nose may be required to prevent leak
      • Only provides intermittent viewing by the proceduralist
    • Continuous insufflation/Apnoeic oxygenation
      Continually flow of fresh gas via the side-port. Largely abandoned.

Complications of ventilation:

  • Hypercarbia
  • Hypoxia
  • Hypotension
  • Pneumothorax
    Secondary to barotrauma from rigid bronchoscopy.
    • Occurs in ⩽1% of cases

Emergence

Considerations:

  • Intubate following procedure to normalise blood gases
  • Extubation associated with violent coughing to clear secretions and blood
  • Consider:
    • Remifentanil
    • Lignocaine 1mg/kg IV
    • Early suctioning
    • Humidified O2

Postoperative

Pain usually minimal.

References

  1. Nicastri DG, Weiser TS. Rigid Bronchoscopy: Indications and Techniques. Operative Techniques in Thoracic and Cardiovascular Surgery. 2012 Mar 1;17(1):44–51.
  2. Pathak V, Welsby I, Mahmood K, Wahidi M, MacIntyre N, Shofer S. Ventilation and Anesthetic Approaches for Rigid Bronchoscopy. Annals ATS. 2014 Mar 17;11(4):628–34.