|Year : 2020 | Volume
| Issue : 3 | Page : 128-132
New order of the ages: Anesthesia in bronchoscopy – current clinical practice
P Amal Johnson1, A Ganapathy2, R Narasimhan1
1 Department of Respiratory Medicine, Apollo Main Hospital, Chennai, Tamil Nadu, India
2 Department of Anesthesia, Apollo Hospitals, Chennai, Tamil Nadu, India
|Date of Submission||10-Mar-2021|
|Date of Decision||14-Mar-2021|
|Date of Acceptance||17-Mar-2021|
|Date of Web Publication||28-Apr-2021|
P Amal Johnson
Apollo Hospitals, Greams Road, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
The advent of advanced diagnostic bronchoscopy has shown an increased demand for anesthesiologists to administer anesthesia in the bronchoscopy suite. Although many of these procedures can be accomplished under conscious sedation, there has been a shift toward general anesthesia especially for complex interventions. The administration of general anesthesia provides an immobile patient, which is often needed by the pulmonologist and results in higher satisfaction for both, the patient and the pulmonologist. This review elaborately discusses the recent practice guidelines used along with the drugs, both old and new used in the current setup.
Keywords: Bronchoscopy, intravenous, total intravenous anesthesia
|How to cite this article:|
Johnson P A, Ganapathy A, Narasimhan R. New order of the ages: Anesthesia in bronchoscopy – current clinical practice. J Assoc Pulmonologist Tamilnadu 2020;3:128-32
|How to cite this URL:|
Johnson P A, Ganapathy A, Narasimhan R. New order of the ages: Anesthesia in bronchoscopy – current clinical practice. J Assoc Pulmonologist Tamilnadu [serial online] 2020 [cited 2021 Sep 20];3:128-32. Available from: http://www.japt.com/text.asp?2020/3/3/128/314965
| Introduction|| |
Total intravenous anesthesia (TIVA) is a technique of general anesthesia which uses a combination of agents given exclusively by the intravenous (IV) route without the use of inhalational agents (Gas anesthesia) including nitrous oxide, but oxygen, compressed air, or helium are exception.,
John Baird lain Glen is the father of modern TIVA technique-he developed the first Propofol TCI in 1996.
Indications of TIVA:
- Short procedures-computed tomography (CT), magnetic resonance imaging, cardiac catheterization
- Daycare surgery
- Trainee teaching
- Patient choice
- Anesthesia in nonoperative locations where inhalational anesthetics were difficult
- Myasthenia gravis/neuromuscular disorders
- Malignant hyperthermia risk
- Long QT syndrome
- Transfer of an anesthetized patient between environments.
Advantages of TIVA:
- No mask over the face
- No sudden concentration of gas/vapor
- Low incidence of postoperative delirium
- Better cerebral autoregulation
- Reduced postoperative nausea and vomiting
- No risk of room contamination.
Disadvantages of TIVA:
- Pain on injection
- Injection is irreversible
- IV bacterial contamination.
Method of deliver of TIVA:
- Either with a single drug or with a combination of drugs
- By single syringe technique with mixture of drugs or with only one drug
- Continuous IV infusion through pumps
- With syringe infusion pumps
- With TCI (Target Controlled infusion) machines
- Automated drug delivery through closed loop systems.
Anesthesia for bronchoscopy poses unique challenges for the anesthesiologist. By definition, bronchoscopy is an endoscopic technique to visualize the inside of the airways for diagnostic and therapeutic purposes. This procedure needs specific technical precision because both the anesthesiologist and operator share the same working space, that is, the airway. Advances in drugs, monitoring and instrumentation have made it a much safer procedure now.
[TAG:2]Pre Anesthetic Assessment[/TAG:2]
The pre procedural assessment for bronchoscopy includes clinical examination and upper airway evaluation with vitals, complete blood count, and coagulation profile. Adequate control of comorbidities likes systemic hypertension, diabetes mellitus, chronic renal failure, or hypothyroidism if possible with medication. Withdrawal of the anticoagulants for at least 5 days before the procedure in high risk bronchoscopy is ideal to avoid intraoperative bleeding. Cardiac investigations including electrocardiogram (ECG), ECHO and if needed a cardiologist opinion can be obtained regarding clearance for procedure. Pulmonary function test, chest X-ray, CT chest, and other relevant investigations should be reviewed for prompt planning during procedure. Finally, an arterial blood gases is done in patients at risk of respiratory failure, both hypoxic and hypercapnic.
[TAG:2]Contraindications of Bronchoscopy[/TAG:2]
The list of contraindications of bronchoscopy-absolute and relative have been listed in [Table 1].
| Intraoperative Planning|| |
The commonly used drugs for premedication are:
- Antisialogogues – Injection atropine or injection glycopyrrolate
- Benzodiazepines – Injection midazolam
- Bronchodilators – If needed in patients with severe obstructive airway disease.
The patient is usually kept in supine position at the edge of the table and the head is extended by keeping a sandbag or shoulder roll. The head is placed on a ring with the chin pointing upward [Figure 1].
Standard monitoring based on Helsinki Declaration including ECG, Pulse oximetry, Non Invasive Blood Pressure and if needed End tidal carbon dioxide monitoring is done for patient safety.
Spontaneous-assisted ventilation is usually used in TIVA. Supplemental oxygen is provided during procedure. Anesthesia is maintained through titrated injection/infusion of IV drugs [Table 2]. A moderate level of sedation, conscious sedation is administered wherein the patient responds to verbal commands. The dose should be decreased in elderly patients as there is a risk of bradycardia, hypotension, and respiratory depression.
[TAG:2]Drugs Used for Sedation in Bronchoscopy,[/TAG:2]
An ideal sedative should be easy to use, have a rapid onset, short duration of action, potent, lipid soluble, low cost and provide a rapid recovery [Table 3].
These drugs are commonly used for sedation. They enhance the effect of gamma amino butyric acid and have sedative, hypnotic, anxiolytic, anticonvulsant and muscle relaxing properties. Midazolam is the drug of choice because of the short elimination half-life and faster onset of action.
They are frequently used because of their analgesic, antitussive and sedative properties. Fentanyl is used frequently as part of balanced anesthesia.
It is a short acting anesthetic agent used in bronchoscopy for moderate sedation. It has a rapid onset of action and rapid recovery. It is used for its hypnotic, antiemetic and antipruritic effects. It also attenuates the upper airway reflexes but can cause respiratory depression. It can be used as a bolus dose or in continuous infusion. Because of the narrow therapeutic index between moderate sedation and anesthesia it is recommended for use only by anesthesiologists.
| Newer Sedatives|| |
- Fospropofol– It is a pro drug of propofol. It has a delayed onset of action by shorter half-life. It does not cause pain on injection, and leads to predicable level of sedation
- Remifentanil– It is a novel u receptor agonist with potency similar to fentanyl and lesser nausea and vomiting compared to fentanyl
- Dexmedetomidine– It is a selective alpha 2 agonist and has sedative and analgesic properties. It has the advantage of causing milder respiratory depression and reduces the secretions but does have sympatholytic and vagomimetic actions that cause bradycardia and hypotension. Patients are well oriented and easily arousable after dexmedetomedine and this makes it the most appropriate drug for high risk patients.
[TAG:2]Lung India Guidelines (2019) for Intravenous Anesthesia in Bronchoscopy[/TAG:2]
- Anticholinergic premedication should not be administered before bronchoscopy routinely
- Dextromethorphan may be considered as an antitussive to optimize patient comfort prior to the procedure
- Administration of IV sedation should be considered to improve patient tolerance
- Bronchoscopy can also be safely performed without IV sedation
- Combination of midazolam or propofol with an opioid is preferred over either alone
- Choice of sedation (midazolam/propofol/dexmedetomidine/fentanyl) should be made depending on the operator preference and availability of anesthetists/trained medical personnel.
- IV sedation with midazolam or fentanyl can be safely administered by the proceduralist.
| Administration of Total Intravenous Anesthesia|| |
- Infuse drugs into an IV line as close to the catheter as possible
- No nitrous oxide or volatile anesthetic agents
- Recommended continuous drug infusions
- Propofol alone
- As the sole agent does not provide reliable amnesia and awareness is possible
- Propofol plus adjuvants.
- Propofol plus tranquilizer (midazolam) plus opioid (fentanyl)
- If hypertension/tachycardia/sweating/movement present - increase rate of propofol and not opioid
- Turn off opioid infusion 10-15 min before anticipated end of procedure
- Turn off propofol 5-8 min before anticipated end of procedure [Table 4].
| Postoperative Care|| |
Bag and mask ventilation with 100% oxygen is given immediately after bronchoscopy which is tapered to oxygen through face mask to maintain oxygen saturation until anaesthesia is completely reversed. It is imperative to monitor patient in recovery room post procedure for 1–2 h. About 5%–10% of patients require reintubation in post procedure for respiratory distress and respiratory depression. In addition, nebulized bronchodilators are given through oxygen in patients having bronchospasm post bronchoscopy. IV steroids are given post procedure when patient is predisposed for airway edema and IV tranexemic acid given to reduce post procedure bleeding. IV fluids are gradually tapered in maintenance and discontinued before discharge.
| Anesthesia for Interventional Bronchoscopic Procedures–Institutional Practice|| |
The majority of advanced diagnostic, interventional and therapeutic bronchoscopies generally are done one of two ways:
- General anesthesia with a supraglottic airway (SGA)
- General anesthesia with an endotracheal tube (ETT).
- Preoperative laboratory testing is individualized and focuses on relevant testing only
- After application of monitors and preoxygenation, the patient is placed under general anesthesia
- Antisialogogue like glycopyrrolate is administered to dry out the secretions due to airway handling. Propofol with lidocaine is commonly used. Bronchoscopy is a stimulating but not a painful procedure thus induction and intraoperative doses of opioids are used very less
- The majority of interventional bronchoscopic procedures (EBUS, bronchial thermoplasties and bronchoscopies involving biopsies) are accomplished using a SGA LMA
- If an ETT is used (cryobiopsies to avoid injury to vocal cord), the internal diameter should be above 8.5 or 9 mm to accommodate the larger bronchoscopy scopes and allow simultaneous ventilation
- Ventilation is achieved with oxygen and nitric oxide mixture (50:50)
- A swivel adaptor is attached to the ETT to enable simultaneous ventilation and bronchoscopy
- Muscle paralysis with a nondepolarizing agent like atracurium is commonly used in all patients undergoing general anesthesia. Although SGA placement itself does not need muscle paralysis, paralyzed vocal cords in adduction position facilitates bronchoscopy. Furthermore, muscle paralysis eliminates the risk of coughing and patient's movements during the procedure
- General anesthesia is maintained with a TIVA regimen using a continuous propofol infusion. This is preferred to volatile anesthetics as the frequent suctioning as well as manipulation of bronchoscopes in and out of patients' airway inevitably interrupts the delivery of inhalational anesthesia
- Muscle relaxation is obligatory reversed at the conclusion of the procedure and the patient is emerged from anesthesia. Suctioning is important as there tends to be copious secretions secondary to the irritation of the tracheobronchial tree. This can predispose the patient to laryngospasm, bronchospasm, and continued coughing
- Indeed, it is common for the patient to cough for some time during their recovery period. Seldom is it required to give lignocaine instillation in the bronchial tree, IV hydrocortisone and nebulized bronchodilators electively in the recovery room to counter post procedure bronchospasm
- The patients generally recover in the bronchoscopy suite recovery room and are discharged home that day.
| Total Intravenous Anesthesia for Routine Diagnostic Bronchoscopic Procedures|| |
- TIVA is preferred in most diagnostic bronchoscopies where only bronchoalveolar lavage is needed
- After induction with propofol, small dose of a short acting opioid analgesic fentanyl and antisialogogue glycopyrrolate, intermittent boluses of propofol are administered to maintain anesthesia. Titration of propofol is doses in such a way to maintain spontaneous respiration and avoid apnea
- Propofol suppresses cough reflex to certain extent. In addition, the little cough while scope enters the trachea, settles usually with local lignocaine with “spray as you go” technique through Bronchoscopy channel. As it is complete anesthesia, patients have retained cough reflex and they do not remember anything post procedure. Hence, recovery will be very smooth and the whole anesthesia experience will be pleasant
- Oxygen supplementation throughout the procedure via nasal prongs
- Airway interventions like inserting a nasopharyngeal airway is best avoided, as it narrows the nostril and makes it difficult for the bronchoscopist
- Continuous jaw thrust during the procedure is provided and patient put on lateral side immediately post procedure to avoid airway obstruction due to tongue falling back
- Recovery with this type of TIVA is very quick without the need for any reversal agents and patient will be ready to be shifted to recovery room immediately after the procedure. After propofol TIVA, the patient will be brisk and most outpatients can be quickly discharged within 1 h into recovery room. Giving sedation with hypnotics like midazolam makes the patient sedated at least for 2–3 h. Also post procedure nausea and vomiting is very less with propofol anesthesia as it has antiemetic properties.
- Only short comings of this technique are:
- Patient may complain of mild jaw pain due to jaw thrust applied during the procedure and
- Turning the patient to lateral from supine under general anesthesia should be done carefully to avoid any injuries.
| Conclusion|| |
TIVA with propofol is a safe and effective technique for diagnostic flexible bronchoscopy. Patient satisfaction with TIVA is very high compared to topical anesthesia with mild sedation. It does not occupy much of the bronchoscopic suite timings as TIVA with propofol maintains the patient in spontaneous respiration and no need to reverse the anesthesia at the end of the procedure. Last but not the least, at these COVID times doing diagnostic flexible bronchoscopies under TIVA reduces the patient cough and increases the medical personnel safety.
Thanks to the Department of Anaesthesiology, Apollo hospitals, Chennai.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chadha M, Kulshrestha M, Biyani A. Anaesthesia for bronchoscopy. Indian J Anaesth 2015;59:565-73.
] [Full text]
Nimmo AF, Absalom AR, Bagshaw O, Biswas A, Cook TM, Costello A, et al
. Guidelines for the safe practice of total intravenous anaesthesia (TIVA): Joint Guidelines from the Association of Anaesthetists and the Society for Intravenous Anaesthesia. Anaesthesia 2019;74:211-24.
Wahidi MM, Herth FJ, Ernst A. State of the art: Interventional pulmonology. Chest 2007;131:261-74.
Stolz D, Pollak V, Chhajed PN, Gysin C, Pflimlin E, Tamm M. A randomized, placebocontrolled trial of bronchodilators for bronchoscopy in patients with COPD. Chest 2007;131:765-72.
MellinOlsen J, Staender S, Whitaker DK, Smith AF. The Helsinki declaration on patient safety in anaesthesiology. Eur JAnaesthesiol 2010;27:592-7.
Al-Rifai Z. Principles of total intravenous anaesthesia: Practical aspects of using total intravenous anaesthesia. BJA Educ 2017;17:41.
Wahidi MM, Jain P, Jantz M, Lee P, Mackensen GB, Barbour SY, et al
. American College of Chest Physicians consensus statement on the use of topical anesthesia, analgesia, and sedation during flexible bronchoscopy in adult patients. Chest 2011;140:1342-50.
Clarkson K, Power CK, O'Connell F, Pathmakanthan S, Burke CM. A comparative evaluation of propofol and midazolam as sedative agents in fiberoptic bronchoscopy. Chest 1993;104:1029-31.
Crawford M, Pollock J, Anderson K, Glavin RJ, MacIntyre D, Vernon D. Comparison of midazolam with propofol for sedation in outpatient bronchoscopy. Br J Anaesth 1993;70:419-22.
Stolz D, Kurer G, Meyer A, Chhajed PN, Pflimlin E, Strobel W, et al
. Propofol versus combined sedation in flexiblebronchoscopy: A randomisednoninferioritytrial. Eur Respir J 2009;34:1024-30.
Reyle-Hahn M, Niggemann B, Max M, Streich R, Rossaint R. Remifentanil and propofol for sedation in children and young adolescents undergoing diagnostic flexible bronchoscopy. Paediatr Anaesth 2000;10:59-63.
Mehta A, Prakash U, Garland R, Haponik E, Moses L, Schaffner W, et al
. American College of Chest Physicians and American Association for Bronchology Consensus Statement. Chest 2005;128:1742-55.
Morton N. Total Intravenous Anesthesia (TIVA) and Target Controlled Infusions (TCI) in Children. Curr Anesthesiol Rep 2012;3:37-41.
[Table 1], [Table 2], [Table 3], [Table 4]