Anesthesia for Bronchoscopy-An Update

Abstract

The field of interventional pulmonology has grown immensely and is increasingly recognized as a subspecialty. The new procedures introduced in the last decade pose unique challenges, and anesthesiologists need to readapt to their specific demands. In this review, we extensively discuss the pathophysiology, technical aspects, preprocedural preparation, anesthetic management, and postprocedural challenges of many new procedures such as navigational bronchoscopy, endobronchial valve deployment, and bronchial thermoplasty. Majority of these procedures are performed under general anesthesia with an endotracheal tube. Total intravenous anesthesia with rocuronium as a muscle relaxant seems to be the standard US practice. The easy availability and proven safety and efficacy of sugammadex as a reversal agent of rocuronium has decreased the need for high-dose remifentanil as an agent to avoid muscle relaxants. Additional research is available with regard to the utility of nebulized lidocaine and is discussed. Finally, two newer drugs administered for conscious sedation (typically without the need of an anesthesiologist) are likely to gain popularity in the future. Remimazolam is a new short-acting benzodiazepine with a relatively faster offset of clinical effects. Dexmedetomidine, a selective adrenergic agonist, is increasingly employed in bronchoscopy as a sedative during bronchoscopic procedures.

Keywords: bronchoscopy; dexmedetomidine; endobronchial valve; navigational bronchoscopy; remimazolam; thermoplasty.

Figure 1

Pre-procedure chest X-ray (CXR): Pt is a former smoker, who smoked 30 cigarettes a day for 15 years and quit 20 years ago, with severe COPD and deemed suitable for bronchial valve. L—indicated left side, EY—the initials of the radiographer, the dots in the 3 squares are electrocardiogram electrodes.

Figure 2

CXR, taken about 16 h after placement of bronchial valve. Large left pneumothorax with rightward mediastinal shift. Left basilar atelectasis. L—indicated left side.

Figure 3

CXR interval placement of a left chest tube. Likely residual loculated pneumothorax at the left lung base. Left upper lobe opacification. L—indicated left side.

Figure 4

CXR left upper lobe volume loss (day 2). Moderate left pleural effusion compatible with hemothorax (which was seen on CT scan). Stable cardiac silhouette. Left apical chest tube. Left hilar endobronchial valves. L—indicates left side, EY—the initials of the radiographer.

Figure 5

Bronchial valve placed (size 4, left upper lobe).