Interventional Pulmonology

Interventional Pulmonology

Anesthesia in Interventional Pulmonology 2016 Mark S Weiss, MD Department of Anesthesiology and Critical Care EBUS: What are they doing? Using a bronchoscope and ultrasound to: Diagnostic: Biopsy adjacent to or within airway (trachea, bronchus, lung, mediastinum) Therapeutic: Increase airway patency (stent) Anesthetic Technique

EBUS GA TIVA (propofol, remifentanil, phenylephrine) LMA Standard Monitors Antibiotic not usually given

Pretty much, the same thing every single time Ipulm Procedures BUT. In certain cases, the case complexity may require a rigid bronchoscopy or jet ventilation to improve gas exchange in a more closed system LMA with open bronchoscopy adapter may provide unsatisfactory ventilation/oxygenation

For Rigid bronchoscopy, there may be a need for temporary paralysis (discuss with proceduralists) Every case must evaluate risk of succinylcholine, risk of residual NMBD, hemodynamic effect of high dose remifentanil Other cases: Pleurex catheter placements, medical thoracotomy for biopsies that may be preformed under MAC with moderate deep sedation Room Set Up NORA precautions

TIVA setup should be- Propofol, Remifentanil and Phenylephrine in series Anesthesia machine suboptimal drawer set-up Use Mayo stand for emergency airway setup, make sure to add 9.0 ETT LMA Troubleshooting Tips So you fit the LMA through the mouth, you feel it curve along the soft palate, you go to squeeze the bag and

No/low tidal volumes No/abnormal ETCO2 tracing Whats the deal? Causes of LMA Problems Poor positioning: LMA opening not in line with tracheal opening

Too shallow/Too deep LMA twisted/rotated Suboptimal sniffing position of patient Epiglottis folded over LMA opening Cause of LMA Problems Poor airway seal/ air leak LMA size too small LMA hyperinflated/hypoinflated Max LMA pressure 60 mmHg Back of LMA mask not properly sealed to palate

Causes of LMA Problems Airway obstruction (difficult ventilation, phonation, stridor) Laryngospasm Pharygeal tissue obstruction Distal tip of mask in the glottic inlet compressing vocal cords Folding of cuff walls medially (LMA size too big)

Poor airway compliance (low tidal volumes without a major leak) Restrictive physiology- high chest wall pressure (ex. obesity) or low pulmonary compliance (ex. pulmonary fibrosis) Atelectasis Bronchospasm Laryngospasm Remifentanil Rigidity Troubleshooting Tips After LMA placement, manually ventilate with pop-off valve to

20cm H20-> listen for leak at ~20 cm H20 pressure, inject air in cuff to secure leak, look for adequate tidal volumes and ETC02 Reinsert at different depth and more careful positioning Perform jaw thrust, neck extension (if no cervical pathology) Digitally sweep back of LMA tip in the back of the mouth Confirm position with bronchoscope (Pulmonologist) Change LMA Size Intubate (may need to use 9.0 ETT) LMA Spasm Tips If laryngo- or broncho- spasm is suspected: If spontaneously breathing convert to positive pressure ventilator

setting Increase depth of anesthesia with IV meds (propofol, opioid, lidocaine) or inhaled agent Lidocaine may relax laryngeal musculature Muscle relaxants if desaturation (succinylcholine vs. non-depolarizers) Bronchospasm: consider albuterol, epinephrine, ketamine? LMA Contraindications Decreased lung or chest compliance Extreme morbid obesity Severe pulmonary restrictive disease

Increased airway resistance Glottic or subglottic airway obstruction Oropharyngeal anatomic abnormalities High risk for aspiration Remifentanil Rigidity Cause of challenging mask ventilation and poor pulmonary compliance with LMA during bolus induction dose Worse if you hand bolus Same effect can be seen in fentanyl/sufentanil except the rapid peak effect with remifentanil exacerbates this response

Severe rigidity takes place in: thoracic and abdominal muscles laryngeal muscles, which may cause closure of the vocal cords Bolus from infusion pump attenuates this response and shortens its effect Possible to pretreat with NMBD to dampen this response Jet Ventilation Safety measure to improve oxygenation and ventilation during more complex

procedures Bright Lights and Cold Steel: Rigid Bronch Beveled tip ideal for: Coring out tumor Dilating airway strictures Large Diameter facilitates Suctioning of blood/clot Ventilation Silicone Stent Insertion Requires extreme immobility/paralysis

What is Central Airway obstruction? Any pathologic process that occludes a large segment of the tracheo-bronchealpulmonary lumen Tumors Cysts Metastases Mediastinal masses H&N pathology- goiter Tracheal Stenosis Tracheomalacia Intraluminal obstruction

Trauma Burn/Smoke Injury Anastomosis (post- lung transplant) Sleeve resection of bronchus/trachea Lymphadenopathy Ascending Aortic Aneurysm Central Airway Obstruction (CAO) Degree of obstruction depends on several variables: the size of the airway at the site of the obstruction

Lesion that reduces airway to ~8.0 mm may produce symptoms with exercise Lesion that reduces airway to ~5.0 mm may produce inspiratory stridor at rest the location of the obstruction Intra vs Extra thoracic Extrathoracic- influenced by atmospheric pressure Intrathoracic- influenced by pleural pressure the nature of the lesion and its impact on the phase of ventilation

Fixed vs. Variable Transmural pressure = airway pressure external pressure If transmural pressure is negative -> collapse, if positive -> patent. Transmural pressure may change during respiratory cycle and determines if a CAO is fixed (unchanged) or variable (collapsed during part of respiratory cycle) Transmural Pressure Throughout the respiratory cycle, luminal airway pressure must be greater than the extra luminal pressure to establish airway patency

Negative pressure inspiration vs. positive pressure on expiration Central Airway Obstruction Evaluation Patient: tripod?, orthopnea?, activity level? Respiratory efforts, airway exam Inspiratory stridor suggests extrathoracic airway obstruction Expiratory stridor may be caused by an intrathoracic obstruction Chest CT- location of obstruction, does this impact ETT size or advancement Pulmonary Function tests- Flow-Volume Loop

Flow Loop in CAO (A) Normal maximum inspiratory and expiratory flow-volume (B) A flow-volume loop from a patient with a fixed obstruction. An extrathoracic and intrathoracic obstruction would have the same flow loop results. (A) ) Variable intrathoracic lesion- the degree of obstruction is increased during expiration (intrabronchial pressure falls on expiration-> negative

transmural pressure. On inspiration, intrabronchial pressure rises) (B) Variable extrathoracic lesion- the degree of obstruction is increased during inspiration (intra-tracheal pressure falls on inspiration -> negative transmural pressure. On expiration, intratracheal pressure rises) Anesthetic and Airway Management Approach Fixed CAO conventional IV induction with muscle relaxants is advised Variable intrathoracic obstruction inhalation induction to avoid the use of muscle relaxant before securing the airway Difficulty of DL should be no different than general population

If intubating: ETT must be carefully advanced down the trachea because if CAO is intraluminal, since it may cause bleeding Flexible fiberoptic-assisted intubation and ETT placement under direct vision should be considered for obstructions of the proximal trachea The airway distal to the ETT can collapse, so a rigid bronchoscope and personnel should be available to establish a patent airway

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