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6314 Current Pharmaceutical Design, 2012, 18, 6314-6324

Anesthesia for Bronchoscopy

Basem B. Abdelmalak*, Thomas R. Gildea‡ and D. John Doyle†
*
Associate Professor of Anesthesiology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. Director,
Anesthesia for Bronchoscopic Surgery, Departments of General Anesthesiology and OUTCOMES RESEARCH, Anesthesiology Institute,
Cleveland Clinic, Cleveland, Ohio; ‡Staff, Department of Pulmonary, Allergy and Critical Care Medicine & Transplant Center,
Head, Section of Bronchoscopy, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio; †Professor of Anesthesiology, Cleveland
Clinic Lerner College of Medicine of Case, Western Reserve University; Staff, Department of General Anesthesiology, Anesthesiology
Institute, Cleveland Clinic, Cleveland, Ohio
Abstract: Bronchoscopic procedures are at times intricate and the patients often very ill. These factors and an airway shared with the
pulmonologist present a clear challenge to anesthesiologists. The key to success lies in the understanding of both the underlying pathol-
ogy and procedure being performed combined with frequent two-way communication between the anesthesiologist and the pulmonolo-
gist. Above all, vigilance and preparedness are paramount.
Topics discussed in this review include anesthesia for advanced diagnostic procedures as well as for interventional/ therapeutic proce-
dures. The latter includes bronchoscopic tracheal balloon dilation, tracheobronchial stenting, endobronchial electrocautery, broncho-
scopic cryotherapy and other techniques. Special situations, such as tracheoesophageal fistula and mediastinal masses, are also consid-
ered.
Keywords: Airway management, airway lasers, anesthesia, bronchoscopic surgery, EBUS, ENB, metallic stents, silicone stents, broncho-
scopy.

INTRODUCTION
There has been a recent proliferation in bronchoscopic interven-
tional procedures leading to an increasing demand for anesthesia
services for these often challenging procedures [1]. A number of
thoracic surgery procedures such as mediastinal staging, that were
traditionally performed in the operating room with an inpatient stay
can now be done on an outpatient basis using minimally invasive
bronchoscopic methods[2]. As a result, a number of facilities have
constructed specially equipped interventional pulmonology suites
independent from the ORs. A development of which are the “Hy-
brid ORs”, capable of accommodating both advanced diagnostic,
interventional, and minimally invasive procedures as well as classi-
cal open procedures. The intent is to establish centers of excellence
for these highly specialized procedures, using standardized proto-
cols that nevertheless allow for individualized approaches that
match clinical conditions.
Patients presenting for interventional pulmonology procedures
often carry high anesthetic risk.[3] Anesthesia providers frequently
have to deal with the combination of severe lung pathology with
additional multisystem comorbidities such as obesity, diabetes and
coronary heart disease. During bronchoscopic surgery anesthesiolo-
gists and pulmonologists must share the airway occasionally with
conflicting clinical objectives. (For instance, the pulmonologists
may require a motionless operating field, whereas the anesthesiolo-
gist requires lung movement to maintain oxygenation and ventila-
tion.) A clear method of communicating clinical needs in a respect-
ful environment is essential.
Finally, the challenge of contemporaneous record keeping ex-
ists due to the dynamic nature of bronchoscopic interventional pro-
cedures. Changing airway conditions and anesthetic requirements
may leave little time for documentation. This may require an auto-
mated anesthesia Information Management System (AIMS) or a
second individual focused on this task.
As a result of these special requirements, it is essential for the
anesthesiologist to be conversant with all these procedures, familiar
*Address correspondence to this author at the Department of General Anes-
thesiology – E31, Cleveland Clinic, 9500 Euclid Avenue/ E31, Cleveland,
Ohio, USA 44195; Tel: (216) 444-3746; Fax: (216) 444-2294;
E-mail: abdelmb@ccf.org
with the commonly used anesthetic techniques, and skilled in the
various airway management options for these often challenging
patients.
FREQUENTLY PERFORMED PROCEDURES
Diagnostic Bronchoscopy, Including Brushings, Washings, and
Biopsies
Bronchoscopic examination of the airway allows visual inspec-
tion (look for lesions, areas of compression etc.) and diagnostic
procedures (brushings, washings, and biopsies of tracheal and/or
bronchial lesions). These are accomplished through either a flexible
bronchoscope or (less commonly) a rigid bronchoscope.
To obtain bronchial brushings a brush is advanced to the lesion
via the bronchoscope channel either using either direct visualization
or (for distant peripheral lesions) fluoroscopy. The lesion is then
gently brushed, the brush withdrawn, and the brushings transferred
onto glass slides for cytological review. Sometimes a special brush
sealed in a protective catheter is employed to obtain “protected
brushings” for microbiologic studies.
To obtain bronchial washings, the bronchoscope is passed in the
usual manner while isotonic saline (0.9%) is instilled through the
bronchoscopic channel into the target area. Fluid is then aspirated
into a trap attached to the suction tubing, followed by cytological or
other analysis.
Finally, bronchoalveolar lavage (BAL) is commonly performed
for diagnostic/therapeutic purposes. In BAL aliquots of approxi-
mately 20 mL - 40 ml of isotonic saline are administered via the
bronchoscope and then suctioned. An important therapeutic varia-
tion of BAL is therapeutic whole-lung lavage, which is usually
done for pulmonary alveolar proteinosis (PAP) [4]. Whole-lung
lavage is usually performed using a left-sided double-lumen en-
dotracheal tube so as to allow lung isolation in order to allow venti-
lation of one lung while lavaging the other. Compared to BAL, the
infused volumes are enormous - up to 50 L of isotonic saline are
sometimes used. Typically, done on a sequential manner, one lung
is lavaged on a single day followed by the other lung a few days
later, although at the authors’ institution, bilateral therapeutic whole
lung lavage is often performed in the same setting, on the same day.

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Anesthesia for Bronchoscopy Current Pharmaceutical Design, 2012, Vol. 18, No. 38 6315

To obtain endobronchial biopsies, the bronchoscope is passed

in the usual manner into the vicinity of the suspicious area. Biopsy
forceps are then passed down through the bronchoscope channel, its
jaws are opened and closed on the tissue, and the forceps are re-
moved. The obtained tissue is then transferred into a formalin-
containing container for fixation. For large tissue samples that can-
not pass through the bronchoscope channel, continuous suction is
applied to hold the sample in place at the tip of the bronchoscope
while the entire bronchoscope is then withdrawn with the tissue
sample held at the bronchoscope tip by suction. Attempting trans-
bronchial biopsies involves a higher risk of bleeding and pneumot-
horax since the lung parenchyma near the pleural surface is typi-
cally the target for diagnosing diffuse lung disease while tumors
typically have increased vascular supply and may be closer to bron-
chial artery braches. The appropriate position of a bronchoscope in
these types of procedures is wedged in an airway to serve as a bar-
rier to any bleeding and to tamponade the otherwise non-
compressible biopsy site. Fig. (1). The CRE™ Pulmonary Balloon Dilator system from Boston Scien-
tific is used to endoscopically dilate airway strictures. Reprinted with per-
Tracheobronchial Balloon Dilation mission, Cleveland Clinic Center for Medical Art & Photography © 2011-
2012. All rights reserved.
The most common cause of subglottic or tracheal stenosis is
prolonged tracheal intubation, it can also occur after relatively short
periods of intubation. This may be, as a result of traumatic intuba-
tion, or from other causes (e.g., inhalational injury, previous laryn-
geal surgery, or as a complication of cervical spine trauma).
Wegener's granulomatosis and sarcoidosis are rare conditions caus-
ing tracheal and bronchial stenosis that may be encountered in ter-
tiary care centers. In addition, lower airway stenosis related to lung
transplantation is not uncommon. in the ideopathic causation is
illustrated in a series by Rahman et al. [5], of 115 patients present-
ing with benign tracheal stenosis, 106 were the result of intubation /
mechanical ventilation, while only nine were from other etiologies
(of which four were idiopathic).
The procedure for tracheal or bronchial balloon dilation can be
performed in a number of ways, for instance using a guide wire and
fluoroscopy, or via the bronchoscope’s working channel [6, 7],
(Fig. 1). In one method using a flexible fiberoptic bronchoscope, a
balloon catheter is threaded over a guidewire and positioned across Fig. (2). Metal and silicone stents are frequently used to support and main-
the stenotic area. Under bronchoscopic visualization, the balloon is tain the tracheal lumen, restore integrity of a disrupted airway, and support
an airway wall from a compressing mediastinal mass. Here we show a Y-
then inflated to several atmospheres pressure for 30 to 120 seconds,
shaped silicon stent that has been cut to size, with the edges being smoothed
the specifics depending on the manufacturer’s recommendations. using a high-speed sander. Reprinted with permission, Cleveland Clinic
Repeat inflation-deflation cycles are performed to achieve the de- Center for Medical Art & Photography © 2011-2012. All rights reserved.
sired result. Apnoea is required during the periods of balloon infla-
tion (when treating tracheal and not bronchial stenosis) and some
desaturation may occur. Limiting the inflation time. The duration of
apnea until this occurs depends upon age, severity of underlying
lung disease, comorbidity, and body habitus. Not infrequently, the
procedure is used in conjunction with other techniques (dilation
using a rigid bronchoscope, cryotherapy, Nd: Yag laser ablation,
stent placement).
Potential procedure complications include bleeding, perfora-
tion, wall injury or rupture (often resulting in pneumomediastinum),
pneumothorax, mediastinitis, chest pain, bronchospasm, and atelec-
tasis.

Tracheobronchial Stenting
In the last two decades, considerable progress has been made in
the endoscopic management of central airway obstruction. In par-
ticular, the use of new types of self-expanding metallic stents
(SEMS and hybrid stents) placed bronchoscopically has provided
new clinical options [8]. Metal, hybrid and silicone stents (Fig. 2)
are frequently used to support and maintain the tracheal lumen,
restore integrity of a disrupted airway, and support an airway wall
from a compressing mediastinal mass. These can be placed under
direct vision with the use of rigid bronchoscope (Fig. 3) or with the
assistance of a guide wire using fluoroscopic guidance and a flexi-
ble bronchoscope.
Fig. (3). Rigid bronchoscope with ventilating sidearm. Note the use of wet
gauze packing around the rigid bronchoscope barrel to minimize leakage
around the bronchoscope. Reprinted with permission, Cleveland Clinic
Center for Medical Art & Photography © 2011-2012. All rights reserved.
Airway Laser
Nd:YAG, CO2, YAP and argon lasers are generally used to
debulk endotracheal and/or bronchial tumors to achieve airway
patency [9]. Airway fire is of particular concern in these procedures
and the risk of fire should always be considered and minimized.
6316 Current Pharmaceutical Design, 2012, Vol. 18, No. 38
Endo-bronchial Electrocautery
This technique is equally effective and less expensive than Nd:
YAG laser therapy for intraluminal airway obstruction [10, 11]. It is
thought to produce less airway scarring and subepithelial fibrosis
compared with the use of Nd: YAG laser [12]. Moreover, there are
also several instruments used with this technique like snares,
blades, probes and hot forceps to address several technical issues
not fully addressed by simple laser technique.
Bronchoscopic Cryotherapy
This procedure is an alternative to using a laser that entails the
therapeutic application of extreme cold for local destruction of tis-
sue by freezing-induced coagulation necrosis. Nitrous oxide is used
as a cryogen by virtue of the cooling of gas on expansion (Joule-
Thomson effect).. The technique uses special probes applied via a
flexible bronchoscope. Lacking the risk of fire, tissue perforation or
smoke plume the technique can be used in the presence of high
inspired concentrations of oxygen. This technique is also very use-
ful for removing large airway clots, semi-solid foreign bodies or
mucus plugs [13, 14]. There is a new spray cryotherapy technology
under study but clinical utility and safety have not yet been fully
addressed with regard to venting high volume gas expansion from
the liquid to gas phase of nitrous oxide.
Management of Airway Fistulas
Diseases like esophageal cancer may develop airway invasion
and cause aerodigestive fistulae that may be palliated with either
single or dual lumen stenting when surgery is not possible [15].
Similarly the use of cyanoacrylate glue and similar methods have
been advocated to manage inoperable cases of airway stump dehis-
cence or bronchopleural fistulae [16] .
Removal of Foreign Bodies
The removal of foreign bodies was one early use of broncho-
scopy. This may be accomplished with either a flexible or rigid
bronchoscope depending on the nature of the foreign body and the
clinical status of the patient. A wide range of tools have been de-
signed for this purpose including wire baskets, forceps and other
grasping instruments, endoscopic magnets, cryotherapy probes etc.
Lung Transplant Airway Dehiscence Restoration
Airway dehiscence is a potentially fatal complication typically
arising in the early postoperative period (days to several months)
following lung transplantation [17]. In most cases temporary metal-
lic airway stenting can be used to provide airway support while
infection treatment and healing may occur [18, 19]. Long term
management is often an important challenge in these patients.
Endobronchial Treatment of Inflammatory Airway Diseases
Benign airway diseases such as Wegener’s granulomatosis,
sarcoidosis, and strictures related to mycobacterial or fungal disease
may be treated with combination of endobronchial steroid injection,
cryotherapy, balloon dilation, dilation using a rigid bronchoscope
and application of topical mitomycin-c [20].
ADVANCED DIAGNOSTIC PROCEDURES
Endobronchial Ultrasound-guided Transbronchial Needle As-
piration (EBUS-TBNA)
An EBUS bronchoscope is a flexible bronchoscope containing
both conventional bronchoscopic optics and a linear array ultra-
sound probe. This combination allows the operator to perform di-
rected needle aspiration of abnormal mediastinal structures instead
of “blind” transbronchial needle aspirations. It is an accurate, safe
and cost-effective technique that facilitates the biopsy of mediasti-
nal lymph nodes and peribronchial lesions [21, 22].
Abdelmalak et al.
Complete Mediastinal Staging Using EBUS-TBNA
EBUS-TBNA has proven to be valuable for mediastinal lymph
node staging of lung cancer [23] with the ability to sample lesions
even beyond the reach of standard mediastinoscopy. These proce-
dures can be fairly lengthy as all lymph nodes found to be over
5mm in size sampled, working from higher nodal stations (N3)
through lower stage nodal stations (N1) during a systematic medi-
astinal staging procedure.
Electromagnetic Navigational Bronchoscopy (ENB)
ENB is designed to enable the operator to biopsy lesions within
the periphery of the lung, beyond the reach of the bronchoscope.
This is a catheter-based system used through the working channel
of a bronchoscope. It is comprised of the following [9]:
1. a sensor probe able to navigate the bronchial tree and commu-
nicate real-time information concerning its position;
2. an electromagnetic location board;
3. an extended working channel;
4. a computer system that converts CT scans into multiplanar
images with 3-D virtual lung reconstruction.
The use of such a system will require certain requirements in-
cluding specialized non-magnetic procedure (OR) bed, and if
needed a non-magnetic breathing circuit holder (Fig. 4). This set-up
allows navigational guidance within the lungs to endobronchially
invisible targets beyond the limits that the standard bronchoscope
can reach, followed by a tissue biopsy, in a manner similar to
stereotactic brain biopsies. Both moderate (conscious) sedation and
general anesthesia techniques are used in this setting.
Fig. (4). A non-metallic breathing circuit holder for use with navigational
bronchoscopy (SuperDimension ®). This is used instead of the usual metal
design in order to avoid interference with the electromagnetic imaging sys-
tem. (Circuit holder design courtesy of Ken Barclay, Cleveland Clinic)
Reprinted with permission, Cleveland Clinic Center for Medical Art &
Photography © 2011-2012. All rights reserved.
ADVANCED THERAPEUTIC PROCEDURES
Fiducial Implantation
Stereotactic radiosurgery is a treatment possibility for inoper-
able lung tumors. Fiducial markers are placed in or near the target
tumor to facilitate precise tumor ablation. For peripheral lung le-
sions, ENB may offer an attractive alternative to CT-guided place-
ment of these fiducials [24] with less risk of pneumothorax.
Pleural Dye Marking
In cases where a small lesion may not be palpable during video
assisted thoracotomy (VATS) or thoracotomy, ENB can be used for
guidance to inject a small amount of indigo carmine dye close to
the target lesion and at the pleural surface as a guide for surgical
resection.
Anesthesia for Bronchoscopy
Endoscopic High dose Rate Brachytherapy
In cases where malignant airway obstruction is recalcitrant to
maximum dose external beam radiation therapy and where pallia-
tive techniques like stenting or laser resection continue to be limited
by extrinsic compression and tumor in-growth, additional radiation
can be delivered by placing a catheter through which a radiation
source may be used to give additional radiation therapy. Broncho-
scopy is used to precisely place this catheter, which is typically
placed under conscious sedation [25].
Bronchoscopic Lung Volume Reduction (BLVR)
This is still an experimental technique, with several variations,
used to treat severe emphysema. The goal is to replace open lung
volume reduction surgery with its associated morbidity and mortal-
ity with a minimally invasive option. Technologies like valves,
thrombin glue, airway bypass techniques, coils and steam ablation
etc. are not yet approved for use in the US but the Spiration
IBV
system and the PneumRX coils have the CE mark and are currently
approved for use in treating severe emphysema elsewhere. These
patients have end-stage chronic obstructive pulmonary disease and
can present challenges with both oxygenation and ventilation.
Bronchoscopic Valve Implantation for Persistent Bronchopleu-
ral Fistula
In exceptional circumstances air leaks from the lung paren-
chyma may persist following thoracic surgery. In those with an
intractable leak, under a human device exemption (HDE) the FDA
has approved the use of the Spiration IBV valves to treat prolonged
air-leak after thoracic surgery [26].
Bronchial Thermoplasty
Bronchial thermoplasty is a bronchoscopic procedure in which
controlled heat is applied endobronchially to reduce the mass of the
airway smooth muscle as a treatment for severe high-dose inhaled
steroid dependent asthma [27]. This procedure is performed over
three bronchoscopic sessions, each session treating different parts
of the lungs. The procedure recently has been FDA approved and
has been shown to reduce asthma symptoms and trips to ER as well
as lost days of work [28, 29]. These procedures are done with con-
scious sedation with asthma premedication and several assessments
of asthma control prior to and after the procedure.
MODERN BRONCHOSCOPY SUITES
Today's modern bronchoscopy suites (Fig. 5) are sometimes
actually "hybrid" ORs that allow surgeons and pulmonologists to
perform combined open, minimally invasive, and image guided
procedures in the same operative setting. These interdisciplinary,
multifunctional rooms employ cutting edge technology with the
goal of improving patient outcomes.
Fig. (5). Modern bronchoscopy suite with anesthesia machine and auto-
mated record keeping system, along with C-arm, and electromagnetic navi-
gation equipment. Photo courtesy of Cleveland Clinic. bronchoscopy Suite.
Reprinted with permission, Cleveland Clinic Center for Medical Art &
Photography © 2011-2012. All rights reserved.
Current Pharmaceutical Design, 2012, Vol. 18, No. 38 6317
ANESTHETIC CARE
Pre-operative Evaluation
The extent of preoperative evaluation depends on several con-
siderations, such as whether the procedure is elective, urgent or
emergent, and how stable or critical the airway is. In elective cases,
pre-operative assessment is usually conducted in the customary
fashion with special attention to the following:
• The nature and extent of the proposed procedure.
• Common associated conditions and co-morbidities: heavy
tobacco smoking coronary artery disease and chronic obstruc-
tive/restrictive pulmonary disease, chronic alcoholism, malnu-
trition and aspiration pneumonitis.
• Airway evaluation and review of possible symptoms of airway
compromise, such as hoarseness, stridor, use of accessory
muscles of respiration, dysphagia, or orthopnea.
• A review of the clinical notes concerning the size of the lesion,
its location and extent, especially relative to vital structures. A
computerized tomographic scan of the neck and chest will help
rule out airway abnormalities or mediastinal masses.
• A history of type and duration of chemotherapy and its possi-
ble effects on vital organs (especially the heart and lungs).
Interventional Pulmonology Procedures and the Difficult Air-
way
Patients undergoing bronchoscopic procedures are potentially
difficult airway cases, although in the majority of these cases the
problem is that of lower airway pathology and so does not impact
significantly on intubation. Even in patients with critical tracheal
stenosis, ventilation is usually very possible, and intubation is usu-
ally achieved with a small endotracheal tube.
Pre-medication
Pre-medication with sedatives and anxiolytics should be con-
sidered only for very anxious patients, because the pulmonary
status of many bronchoscopy patients is poor, and because some of
the medications used in these patients may have respiratory depres-
sant effects. Nevertheless, when it is considered necessary to use
them, judicious care should be exercised, with small titrated doses.
Once medicated, these patients should not be left alone without
monitoring. As an added safety precaution, supplemental oxygen
should be provided before sedation is administered. Premedication
with atropine was once popular to counteract possible bradycardia
and manage secretions; however the routine use of atropine as a
premedication is no longer recommended [30].
Monitored Anesthesia Care
Monitored anesthesia care is a commonly used technique, espe-
cially outside the OR. The majority of uncomplicated and routine
diagnostic as well as some simple therapeutic bronchoscopic proce-
dures can be performed under moderate sedation, at least in selected
patients undergoing selected procedures. However, in more com-
plex cases, such as when the lung is compromised, or when a pa-
tient becomes unable to tolerate the respiratory depressant effects of
many of the commonly used sedatives, ventilation support may
become necessary. It should also be noted that because of their
detailed understanding of the lung pathology and their special
knowledge of the respiratory status of a patient, pulmonologists are
able to make very accurate judgments in determining which patient
would be a good candidate for moderate (conscious) sedation pro-
vided by a sedation nurse while supervised by the pulmonologist,
versus those cases requiring deep sedation/monitored anesthesia
care (MAC) or general anesthesia by an anesthesiologist. In the
latter situation, many sedatives have been successfully employed,
including midazolam, fentanyl, morphine, remifentanil, alfentanil,
and propofol. More recently dexmedetomidine and fospropofol
have been added to the list of drug options [31-33]. The required
6318 Current Pharmaceutical Design, 2012, Vol. 18, No. 38
depth and technique of anesthesia to safely facilitate these proce-
dures will have implications for the qualifications of the provider;
for example, in Ohio sedation nurses are limited to monitoring
moderate (conscious) sedation under the supervision of the pul-
monologist and may not ordinarily be involved in providing deep
anesthesia.
General Anesthesia
A total intravenous anesthetic technique (TIVA), typically an
infusion of pure propofol administered at between 50 and 150
mcg/kg/min, is usually preferred over an inhalational anesthetic
technique. This is for several reasons. First, it ensures continuous
delivery of anesthesia compared to an inhalation technique where
ventilation leaks occur around the rigid bronchoscope [34], or with
the flexible bronchoscope being inserted into and removed from the
airway, or with the insertion of instruments like balloons, forceps,
and cautery, or with techniques such as intermittent apnea or jet
ventilation in addition to the intermittent airway suctioning per-
formed by the pulmonologists for optimal visualization. Secondly,
TIVA avoids pollution of the operating room by inhalational anes-
thetic agents. Third, it avoids the risk of exposing operating room
personnel to anesthetic vapors. Finally, it should be noted that with
TIVA, the integrity and functionality of the intravenous line should
be monitored throughout the procedure. In addition, the Bispectral
index monitor ( BIS Monitor
) ( Covidien, Dublin, Ireland) can be
used to help monitor the depth of anesthesia and avoid intraopera-
tive recall [35].
The Utility of Muscle Relaxation
Muscle relaxation facilitates both SGA and ETT insertion. Re-
laxation of the jaw muscles makes easier insertion of a rigid laryn-
goscope for suspension laryngoscopy, as well as insertion of rigid
bronchoscopes much easier and safer. Muscle relaxation also im-
proves overall lung compliance by eliminating the chest wall com-
ponent. Finally, by the virtue of providing a motionless patient, it is
advantageous in situations where unexpected patient movement
might result in serious consequences. For example, during laser–
based procedures a motionless patient drastically decreases the risk
of unwanted misdirection of the laser beam that might result in
damage to normal airway tissues, to major vessels or to the esopha-
gus. A motionless patient will also help increase precision in biop-
sying small paratracheal nodes decreasing the number of sampling
attempts and shortens the procedure. In cases where a SGA is used
muscle relaxation also helps minimizing trauma to the vocal cords
caused by the frequent insertion and removal of the bronchoscope
against contracted cords—which often happens when muscle relax-
ants are not used.
Fluid Management in Bronchoscopic Surgery
It is prudent to restrict intravenous fluid administration to the
minimum volume required, as many have limited lung reserve and
are at risk of pulmonary congestion or even frank pulmonary
edema, especially if they have concomitant cardiac disease, such as
left-sided or right-sided heart failure, which may have been a com-
plication of their long standing lung pathophysiology (cor pulmon-
ale).
The use of Corticosteroids in Bronchoscopic Surgery
Many anesthesiologists and surgeons use corticosteroids, in
particular dexamethasone, as a prophylactic measure to decrease
airway edema after airway surgery. Steroids might be usefult to
reduce post-operative vocal cord edema when the flexible fiberoptic
bronchoscope (alone or through an SGA and in the absence of ETT)
has been inserted into and removed from the airway several times,
rubbing against the vocal cords in the process, or alternatively
where a rigid bronchoscope has been used for a prolonged duration.
Steroids are also used in cases where extensive tracheobronchial
tissue trauma has been done during a prolonged procedure. The
Abdelmalak et al.
clinical utility of steroids in this context is controversial. Evidence
supporting the use of steroids includes its efficacy prior to certain
maxillofacial procedures due to their proven benefit in reducing the
degree of postoperative edema and inflammation [36-38]. On the
other hand, Hughes et al have shown that steroids are ineffective in
reducing airway edema following carotid endarterectomy [39].
Additionally, steroids are also beneficial as an anti-nausea medica-
tion (vide infra) [40]. Finally, many bronchoscopic surgery patients
with underlying lung conditions (e.g. Wegener’s granulomatosis)
that require chronic steroid therapy are treated by many clinicians
with 100 mg of hydrocortisone (the so-called “stress dose” steroids)
to avoid adrenocortical insufficiency in the face of chronically sup-
pressed suprarenal gland by the exogenously administered steroid.
However, again the effecacy of this treatment has not been scien-
tifically demonstrated [41].
Anti-nausea Prophylaxis
Nausea and vomiting and a likely increased risk of aspiration
could be detrimental to some bronchoscopy patients because of
limited pulmonary reserve. Also, since an ETT is used only in a
limited number of these patients, the majority of the procedures are
done with techniques that do not fully protect against aspiration—
such as use of a rigid bronchoscope, a SGA or no artificial airway
whatsoever (natural airway). The use of maximum anti-nausea pro-
phylaxis, especially in patients with risk factors for complications,
is therefore justified. In such cases, the use of propofol TIVA is
helpful, as is the avoidance of inhalation anesthetics and of nitrous
oxide. Dexamethasone in dosages of 4-10 mg IV of commonly used
[40] as well as other agents.
Management of the FiO2
Administrating 100 % fraction of inspired oxygen (FiO2) in
bronchoscopy procedures is very common. However, it is usually
necessary to maintain oxygen concentrations at the lowest tolerable
level, below 40%, during thermal treatment with Nd: YAG lasers as
well as with other procedures where an airway fire could occur.
Periods of extended apnea and complete airway obstruction can be
expected during some especially challenging cases. Complete air-
way occlusion frequently occurs during the critical phase of remov-
ing the stent or stent fragments or when inflated balloon dilators are
used for tracheobronchial dilation. Therefore, it is always advisable
to return to ventilation with 100% oxygen before extraction of the
stent, prior to exchange of airways, and prior to extubation. Finally,
if during thermal treatment patients cannot tolerate lower oxygen
levels, it may become necessary to defer treatment temporarily, and
ventilate with higher oxygen concentrations and consider using
therapy such as debulking via a rigid bronchoscope or via cryoabla-
tion, where oxygen concentrations may be maintained at higher
levels.
AIRWAY MANAGEMENT CHOICES FOR BRONCHO-
SCOPIC PROCEDURES
• Natural Airway
This is a popular technique, especially when relatively short
procedures are performed in a remote bronchoscopy suite where an
anesthesia machine is unavailable. A moderate (conscious) sedation
technique is appealing for these procedures as spontaneous ventila-
tion can be maintained. Special emphasis should be placed on good
airway topical anesthesia to allow the patient to tolerate the bron-
choscope without the need for deep planes of sedation and their
associated risks. Bronchoscopy may be performed in this setting
either trans-nasally or trans-orally using a bite block or other airway
designed for FOB use.
• Endotracheal Tube (ETT)
When a standard 5.9 mm diagnostic bronchoscope is used, a
size 7.5 ETT may be used but when using a 6.7 mm therapeutic
Anesthesia for Bronchoscopy Current Pharmaceutical Design, 2012, Vol. 18, No. 38 6319

bronchoscope the 8.0 ETT is the smallest preferred tube. Obviously

the larger the endotracheal tube the less likely that the broncho-
scope will get stuck or that high airway pressures will be an issue.
Most commonly size 8.5 or 9.0 mm ID ETT are used for these pro-
cedures to allow for enough room around the operating broncho-
scope for easy and adequate ventilation.
There are several types of bronchoscopy adaptors (Fig. 6) that
incorporate diaphragms to reduce the air-leak, although higher gas
flows are generally needed to continue to deliver adequate ventila-
tion to compensate for the remaining leak.
The ETT can and should be cut short (preferably after intuba-
tion, to facilitate navigation of the fiberoptic bronchoscope (Fig. 6).
However if there is a significant risk of bleeding it may be advis-
able to leave the tube long enough to enable potential need for en-
dobronchial intubation and one lung ventilation to isolate a poten-
tially asphyxiating bleed. Intubating patients with a tracheal stent,
whether a SEMS stent or a silicone stent, requires special caution,
as it risks distorting or dislodging the stent distally that may occlude
the airway. A shortened large-bore ETT can be used via an existing
tracheotomy using flexible bronchoscopic instruments (Fig. 7). As a Fig. (7). This patient had a remote laryngectomy for cancer, and later devel-
general principle, ETT provides a secure airway, which is helpful in oped tracheal stenosis just below the stoma. Later on he also developed
patients with severe gastroesophageal reflux disease, hiatal hernia, tumor invasion at the level of the carina. Here we see an 8.0 mm ID en-
post esophagectomy with stomach pull through operation, and/or dotracheal tube used as a conduit for the bronchoscope. Only the tip of the
tube could be accommodated in the stenotic trachea; the tube cuff func-
there is a need to insert the EBUS scope esophageally to obtain tioned as an external seal. This improvised arrangement allowed positive
transesophageal biopsies of nodes and lesions that are closer to the pressure ventilation while also allowing for dilation the trachea using the
esophagus than the tracheo-bronchial tree (Fig. 8). Of note that ETT flexible bronchoscope. This allowed the use of a small diameter rigid bron-
will also provide protection to the vocal cords against repeated choscope to deploy a silicone stent to the carina. Reprinted with permission,
trauma and friction with the bronchoscope in long procedures that Cleveland Clinic Center for Medical Art & Photography © 2011-2012. All
would require multiple insertions and retractions of the broncho- rights reserved.
scope.

Fig. (6). A large diameter endotracheal tube (ETT) is used for a broncho-
scopic procedure, please note the blue Portex swivel adapter, that facilitates
simultaneous spontaneous ventilation during diagnostic and therapeutic
bronchoscopy. Here the ETT was cut short to facilitate decrease resistance
to bronchoscope going in an out of the ETT, as well improve its maneuver-
ability. Reprinted with permission, Cleveland Clinic Center for Medical Art
& Photography © 2011-2012. All rights reserved.
• Rigid Bronchoscope (Fig. 3)
A rigid bronchoscope is preferred for major airway interven-
tions such as:
1. The insertion and removal of silicone stents because of their
size and their noncompressible material,
2. For removal of large broncholiths and granulation tissue,
Fig. (8). An EBUS bronchoscope is inserted esophageally next to an exis-
ting ETT for biopsying lesions that are closer to the esophagus than the
trachea. Reprinted with permission, Cleveland Clinic Center for Medical Art
& Photography © 2011-2012. All rights reserved.
3. For coring out a large tumors invading the tracheo-broncheal
tree,
4. To maintain airway patency in the face of a large mediastinal
mass causing airway compression.
When the rigid bronchoscope is used, ventilation can be
achieved either by attaching the anesthetic circuit to the broncho-
scope side port for conventional ventilation [42], or via jet ventila-
tion, where the jetting device is attached to the bronchoscope side
port through a special adaptor. Leaks around the rigid bronchoscope
are common, but are easily remedied by increasing the fresh gas
flow, and packing the mouth with saline-soaked gauze. Special
6320 Current Pharmaceutical Design, 2012, Vol. 18, No. 38 Abdelmalak et al.

attention should be given to protecting the lips and teeth. In addi-

tion care should be taken at the end of the case when removing the
gauze so as to avoid subsequent airway obstruction from retained
gauze pieces when the bronchoscope is removed.

• Supraglottic Airway
In cases where the tracheal lesion is subglottic, a supraglottic
airway (SGA) can be used to advantage [43, 44], as it does not enter
the glottis (Fig. 9 and Fig. 10A and B). This arrangement allows
access to the subglottic lesion by providing a conduit for a flexible
bronchoscope, as well as providing a means of ventilation (Fig.
11A and B). However, since it is a less definitive airway, it does not
guarantee protection against aspiration.
The techniques described above require clear communication
between the anesthesiologist and the pulmonologist. Use of a fiber-
optic swivel connector adapter will allow continuous ventilation
(Fig. 11B), thereby avoiding circuit disconnection during flexible
bronchoscopy, in a manner similar to use of an ETT.

• The use of Airway Exchange Catheters in Bronchoscopic

Surgery
Airway exchange devices can be useful during bronchoscopic
procedures because of the dynamic nature of the procedures that
might require different forms of airway during the same procedure
and because one may encounter situations in which the airway is
expected to be difficult to intubate. Accordingly it is advisable to
Fig. (9). Illustration of a balloon dilator being passed through a bronchosco-
start with awake intubation, with a relatively small-sized ETT, pref- pe for the treatment of subglottic stenosis. The i-gel SGA as shown above
erably a Parker Flex-Tip™ Tracheal Tube. Compared to the stan- allows access to treat subglottic lesions while allowing positive pressure
dard tube, use of the Parker tube has reduced from 89% to 29% (P ventilation. Fig. (1) shows how the balloon is inflated. Reprinted with per-
< 0.0001) the need to reposition the tube during insertion into the mission, Cleveland Clinic Center for Medical Art & Photography © 2011-
trachea [45]. Then an airway exchange catheter can be used to re- 2012. All rights reserved.
place it with a larger tube to facilitate the flexible bronchoscopic
procedure. If a rigid bronchoscope is required, the exchange cathe- after removing the rigid bronchoscope. An exchange catheter can
ter could be used for access to the airway until the laryngeal inlet is also be effective for intubation through an LMA but it is possible
visualized through the rigid bronchoscope and the scope is secured that the exchange catheter may slip behind the glottis and result in
in position. The same principle can be applied again after finishing esophageal intubation, so standard methods of assessing tube posi-
with the rigid bronchoscope; here, the exchange catheter is intro- tion must still be used [46].
duced through the rigid bronchoscope and used to insert an ETT

Fig. (10). Left (A): Illustration showing the use of an EBUS equipped bronchoscope for the ultrasonic imaging of paratracheal nodes via an endotracheal tube.
Notice how the presence of the tube limits the region that the EBUS probe can scan and also provides for suboptimal probe alignment. Right(B): These two
limitations are overcome by the use of a supraglottic airway – in this case an i-gel. Reprinted with permission, Cleveland Clinic Center for Medical Art &
Photography © 2011-2012. All rights reserved.
Anesthesia for Bronchoscopy
POSTOPERATIVE CARE
Most of the procedures described above are performed as out-
patient procedures, where patients are discharged the same day.
However, extremely ill patients with borderline functional may
benefit from overnight admission. This compares favorably with
invasive thoracic surgery, which requires post-operative ICU ad-
mission and a prolonged hospital stay.
MANAGEMENT OF UNIQUE AIRWAY CASES
Long Term Management of Post Airway Fire Complications
Survivors of extensive airway fires often present periodically to
tertiary and quaternary care facilities for long term management of
their complex airway pathology; developed as a result of the airway
fire or subsequent complex tracheal repair. Such patients tend to
suffer from recurrent tracheal stenosis due to recurring scar build
up. When the tracheal lumen becomes significantly narrowed, the
symptoms of stridor, shortness of breath and limited functionality
capacity require management.
Treatment consists of balloon dilation, electrocautery or laser-
ing of the scars with or without mitomycin application. This treat-
ment sequence may require a variety of airway interventions de-
pending on the severity and extent of the stenosis, and stage of the
procedure. The procedure generally begins with bag mask ventila-
tion, then passage of a supraglottic airway through which an operat-
ing bronchoscope may be introduced. Some degree of dilatation
Uvula
Fig. (11A). A well seated i-gel, view from the nasopharynx, used for EBUS
biopsy of high tracheal lymph node.
Fig. (11B). Many bronchoscopic cases under general anesthesia may be
conducted using a supraglottic airway (SGA). Illustrated here is the use of
an i-gel SGA in conjunction with a (blue) Portex flexible bronchoscope
adapter. Notice the black flexible bronchoscope inserted through the Portex
adapter. The large SGA lumen and the use of a Portex adapter allows for
easy positive pressure ventilation in such a setting, although appropriate
attention to avoid excessive airway pressures is always needed. Reprinted
with permission, Cleveland Clinic Center for Medical Art & Photography ©
2011-2012. All rights reserved.
Current Pharmaceutical Design, 2012, Vol. 18, No. 38 6321
Fig. (12). A tracheal rupture was encountered as a complication of tracheal
balloon dilation, and was managed surgically with tracheal graft, and posto-
perative ventilation accomplished through the insertion of two microlaryn-
geal tubes (MLT) with the tube cuff positioned distal to the repaired tear in
both right and left bronchi, and the two MLTs were connected together with
a standard double lumen tube connector to the breathing circuit. Reprinted
with permission, Cleveland Clinic Center for Medical Art & Photography ©
2011-2012. All rights reserved.
is accomplished with balloon dilation, laser cautery, etc. This may
be followed by either an the passage of an ETT or rigid broncho-
scope by the interventional pulmonologist. In extreme cases where
there is very tight continually recurring stenosis of a short tracheal
segment, an ENT or a thoracic surgeon performs an operative tra-
cheal resection and re-anastomosis.
Management of Anterior Mediastinal Mass (AMM)
The presence of an anterior mediastinal mass can predispose
patients to severe respiratory or cardiovascular complications, dur-
ing anesthesia. These may include airway obstruction, compression
of the cardiac chambers, and compression of the pulmonary artery
[47].Therefore, particular caution is required in managing these
patients.
Spontaneous ventilation has been highly recommended in the
anesthetic management of AMM patients, because muscle relaxants
are not used and negative intrapleural pressure is maintained [48].
Several conservative anesthetic plans have been proposed for man-
aging AMM [49]. Some propose that the patient should be intu-
bated awake after being topicalized and sedated while positioned in
the least symptomatic position. The use of dexmedetomidine, a
selective
2 agonist with sedative, analgesic, amnestic [50], and
antisialagogue properties [51] has been suggested as having particu-
lar utility as a sedative adjunct in this regard. This drug maintains
spontaneous respiration with minimal respiratory depression and
has been used in the management of AMMs [52]. Patients under
dexmedetomidine sedation are generally easy to arouse [53], a
property that has been exploited during awake fiberoptic-assisted
intubation [31]. However, this advantage, may not hold under
higher doses (off label). An anesthetic induction using inhalational
agents while maintaining spontaneous respiration is another poten-
tial course of action. This would seem of particular utility in unco-
operative patients.
Severe cases that include the management of patients with
larger AMMs (causing > 50% reduction in airway diameter as seen
on a computed tomography scan) should not be treated outside of
the OR. Some authorities recommend that cardiopulmonary bypass
6322 Current Pharmaceutical Design, 2012, Vol. 18, No. 38
be available on stand-by and that femoral vessel cannulation should
be secured prior to induction [49, 54]. As a precaution against cata-
strophic loss of the airway after induction.
Tracheoesophageal Fistulas (TEF)
Although tracheoesophageal fistulas (TEF) are best known to
medical students in the context of congenital anomalies involving
the embryology of the trachea and esophagus, more commonly they
may occur as a result of malignant disease or following radiation
treatment for such disease.
A malignant tracheoesophageal fistula is a pre terminal condi-
tion in esophageal cancer and is associated with significant suffer-
ing; in particular, regurgitation into the trachea via the fistula is a
continuing concern. The general consensus concerning management
is to use stents to cover the fistula.
Stent placement is often accomplished under general endotra-
cheal anesthesia. In such cases, the ETT tip should be placed distal
to the site of the TEF to avoid blowing gasses into the fistula with
positive pressure ventilation. However, this is not always possible.
Awake fiberoptic intubation methods usually work best in such a
setting, as well as the maintenance of spontaneous ventilation pre-
vents gas loss through the fistula.. While this can be accomplished
utilizing inhalational anesthetics, concerns include operating room
contamination from leaking anesthetic gases with the risk of inade-
quate anesthesia for patients, and contamination of the operating
room staff with anesthetic agent. An alternative would be very care-
ful titration of intravenously administered anesthetic, like propofol,
and/or dexmedetomidine.
COMPLICATIONS
Potential Complications of Bronchoscopic Procedures
Potential complications of bronchoscopic procedures are nu-
merous, and range from hypercarbia , hypoxemia and cough to
major bleeding, loss of airway integrity, endobronchial fire damage,
pneumothorax formation, and injury to glottic structures. The use of
jet ventilation can be complicated by pulmonary barotrauma. Laser
air (CO2) cooled or Argon plasma related cerebral or cardiac emboli
have been reported as well [55]. Other disease specific risks may
include acute carcinoid syndrome and acute bronchospasm.
High Risk Procedures
Metallic stent removal has a high associated risk of complica-
tions. Potential complications include retention of stent pieces,
mucosal tears with bleeding, re-obstruction, the need for postopera-
tive mechanical ventilation pneumothorax, damage to the pulmo-
nary artery, and death [56]. When the stent is fractured during re-
moval, unwanted fragments may remain permanently embedded in
the tissue. In one report, critical airway obstruction occurred during
removal of a tracheal stent using a rigid bronchoscope under general
anesthesia, and cardiopulmonary bypass had to be instituted ur-
gently; the stent was eventually removed by directly opening the
trachea [57].
Airway Fire Associated with Laser Surgery
One particularly devastating complication is the occurrence of
an airway fire. Management is summarized as follows:
Steps to Take in Case of Airway Fire Include
1. Discontinue laser and turn off O2 (as well as N2O if it was
mistakenly used.)
2. Remove the burning endotracheal tube and drop it in a bucket
of water.
3. Flush area with water or normal saline.
4. Re-intubate immediately and resume ventilation with 100%
O2 .
Abdelmalak et al.
5. When the condition has stabilized, assess the damage with a
ventilating rigid bronchoscope; remove any debris and foreign
bodies.
6. Consider the use of IV steroids; however, their efficacy is not
proven.
7. Use antibiotics.
8. Implement supportive therapy, including ventilation, and extu-
bate when clinically indicated.
9. Perform tracheotomy if necessary.
Tracheal Rupture
Tracheal rupture or loss of tracheal integrity may complicate
any of the above-mentioned procedures. However, they occur more
frequently with traumatic intubation, tracheostomy, rigid broncho-
scopic dilation, balloon dilation, or complicated metallic stent re-
moval. Reported risk factors for tracheal rupture include advanced
age, chronic obstructive pulmonary disease, weakened tracheal
walls, (usually secondary to chronic airway inflammation), previous
procedures, infection, and steroid therapy [58-61].
The signs and symptoms of tracheal rupture are non-specific,
but a combination of such non-specific symptoms and signs in the
clinical setting should lead to a high degree of suspicion. Dyspnea
and a dry cough are sometimes the only signs evident in an awake
patient. Cyanosis and tachycardia may also be evident. Other signs
include hemoptysis, persistent air leak, subcutaneous emphysema,
pneumomediastinum, and pneumothorax [62-64].
Bronchoscopy is the gold standard for the diagnosis of tracheal
rupture. It is also critical in assessing the extent of the tear. Routine
chest radiographs and bronchoscopy are usually sufficient for diag-
nosis in most cases.
The management of a tracheal tear can be observational (con-
servative) or surgical (Fig. 12), depending on the extent of the in-
jury, the presenting signs and symptoms, and the general condition
of the patient. In general, small, shallow tears that do not lead to
severe compromise in ventilation and oxygenation can be treated
conservatively [65, 66] If the patient is dependent upon positive
pressure-assisted ventilation, however, surgical treatment is needed.
Regardless of the choice of management, the status of the trachea
should be monitored with frequently repeated tracheoscopy.
Ventilatory management consists of adequate oxygenation and
ventilation of the patient, and the prevention of worsening subcuta-
neous emphysema, pneumomediastinum, or pneumothorax. This
can be achieved by positioning the ETT so that the cuff is distal to
the level of the injury (Fig. 12), and by close monitoring of the
airway pressure, keeping it at the lowest possible level. A higher
FiO2 and respiratory rate may be required. Selective or bilateral
bronchial intubation can be performed in tears located above or
near the carina. It is important to note that standard direct intubation
is potentially hazardous, because a false passage can be easily cre-
ated. Fiberoptic-guided intubation may be safer.
Other possible management options include high frequency
oscillating ventilation or hyperbaric oxygen therapy [67, 68]. In rare
situations, cardiopulmonary bypass or percutaneous cardiopulmon-
ary support systems have been used [69, 70]. Pneumothoraces
should be treated with chest tubes, pain should be managed, and
hemodynamics should be monitored and supported where needed.
SUMMARY
Interventional pulmonology is a fast-growing field. These pro-
cedures are at times complex, and the patient population is very
sick. Many of these surgeries are performed out of the operating
rooms. Anesthesiologists need to stay abreast of the advances in
this field, and of the anesthetic challenges that might come with it.
The key to favorable outcomes lies in deep understanding of the
underlying lung pathology, open two-way communication between
Anesthesia for Bronchoscopy
the anesthesiologist and pulmonologist, understanding the nature of
the procedure, and above all, extreme vigilance and preparedness.
CONFLICT OF INTEREST
Support was provided solely from institutional and/or depart-
mental sources. The authors have no conflicts of interest to declare.
ACKNOWLEDGEMENT
The authors wish to thank the pulmonologists and the staff of
The Cleveland Clinic Bronchoscopy Suite who facilitated and par-
ticipated in the included pictures. We also wish to thank the tal-
ented artists of the Cleveland Clinic Center for Arts and Photogra-
phy for the outstanding illustrative cartoons.
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