Anesthesiology

Bronchoscopy

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What the Anesthesiologist Should Know before the Operative Procedure

Anesthesia for rigid and flexible bronchoscopy in infants and children requires meaningful cooperation and communication between the endoscopist and anesthesiologist. There is overlap for the indications for flexible versus rigid bronchoscopy.

Foreign body in larynx or bronchus

  • Evaluation of upper and lower airways by pulmonologist

  • Bronchoalveolar lavage

  • Bronchial cell brushings and biopsies

  • Examination of peripheral zones of lungs

  • Removal of small foreign bodies

  • Used as a guide for endotracheal tube during difficult intubation

Indications for rigid bronchoscopy

  • Evaluation of upper and lower airways by the otolaryngologist

  • Upper and lower airway exam of infants and small children because of better optics and available suction ports.

  • Bypass an obstructing mass in the airway

  • Obtaining large biopsy specimens

  • Removal of foreign body

Flexible bronchoscopy

First introduced in 1966, the flexible bronchoscopes contain a fiberoptic system that transmits images from the tip of the scope to the eyepiece or camera. Through the use of Bowden cables, the tip of the bronchoscope can be directed to allow visualization of more distal aspects of the lung. Most flexible bronchoscopes also have an additional port that allows for suction or small instruments for biopsies, injections, etc. The smallest fiberoptic bronchoscope has an external diameter of 1.8 mm distally and 2.2 mm proximally. Due to their size, the smallest bronchoscope does not have a port for suction or instrumentation. Thus, cannot be used for bronchoalveolar lavage or biopsies in infants and small children.

It is the most common type of bronchoscopy and can visualize the trachea down to the third-generation bronchi. It can be used to sample, diagnose, and treat lesions and pathology in those distal segments. The flexible bronchoscope can be introduced nasally or orally under local anesthesia with or without general anesthesia or through an endotracheal tube or LMA under general anesthesia.

Rigid bronchoscopy

There are various types of bronchoscopes and laryngoscopes designed to allow introduction of the bronchoscope into the larynx, trachea, and bronchus. Some instruments that allow passage of a telescope do not have the capability to allow for positive pressure ventilation but only for entrained oxygen. Examples are the Parsons and Benjamin Lindholm laryngoscopes used to suspend the larynx (Figure 1). Using these laryngoscopes as a guide for a telescope with a ventilation port to examine the upper and lower airways may require the proceduralist to intermittently intubate the trachea with an endotracheal tube when apnea or inadequate ventilation and or oxygenation by entrainment leads to hypoxia (Figure 2).

Figure 1.

Benjamin Lindholm laryngoscopes used to suspend the larynx. Note endotracheal tube adapter for connection to anesthesia circuit for oxygen entrainment in the spontaneously breathing patient.

Figure 2.

Setup while performing rigid bronchoscopy through the Benjamin Lindholm laryngoscope in a spontaneously breathing patient.

Jet ventilation is another option, but the hope is that spontaneous respiration will allow oxygenation and prevent apnea from occurring. The Stortz-Hopkins rigid bronchoscope with sidearm allows for positive ventilation and oxygenation with 100% oxygen (Figure 3).

Figure 3.

A. Light source and telescope. B. Prismatic light detector and attachment to light source. C. Aspiration and instrumentation channel. D. Connector to anesthesia. E. Telescope bridge.

Usual Indications for rigid Bronchoscopy by the otolaryngologist

Stridor

  • Evaluation of patients who after a prolonged period of intubation who continually fail extubation

  • Management of mass lesions of the airway including recurrent respiratory papillomatosis

  • Vascular anomalies such as vascular rings

  • Tracheal and laryngomalacia

  • Tracheotomy surveillance

  • Evaluation following laryngotracheal reconstruction

  • Evaluation of chronic cough

  • Evaluation of hemoptysis

  • Diagnosis of gastroesophageal reflux

  • Evaluation of chronic laryngotracheal and pulmonary infections

  • Evaluation of airway trauma

In the pediatric operating room, it is the pulmonologist who usually performs the airway exam with a flexible bronchoscope and the otolaryngologist who us both the rigid bronchoscope and flexible bronchoscope to exam the airway.

Indications for flexible bronchoscopy

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Emergency Rigid Bronchoscopy

  • Aspirated foreign body causing respiratory distress.

  • Trauma to the larynx and/or trachea causing respiratory distress.

  • Pneumomediastinum and crepitus to the neck can worsen with positive pressure ventilation.

  • The time of the last meal should be established to assess the risk of aspiration.

  • Full stomach places child at risk for aspiration; however, there are no reports of aspiration of gastric contents in the literature surveyed, although fatal progression of obstruction has been reported.

2. Preoperative evaluation

Perioperative evaluation

Establish the child’s baseline respiratory parameters by history, chart review, physical exam, and discussion with the child’s physicians. The anesthesiologist must understand the indication for rigid bronchoscopy. Evaluate airway patency, and establish baseline oxygenation and ventilation statues.

The urgency for evaluation is usually based on

  • The acuteness of the breathing problem

  • The progression of respiratory compromise

  • The age of the patient

Neonates with upper airway compromise usually present in the second or third week of life with acute stridor caused by subglottic stenosis or cysts. Laryngomalacia is the most common cause of stridor in infants and is most often due to a long epiglottis that prolapses posteriorly and prominent arytenoid cartilages with redundant aryepiglottic folds that prolapse into the glottic opening during inspiration.

The definitive diagnosis is obtained by direct laryngoscopy and by rigid or flexible bronchoscopy. The evaluation of a child scheduled for airway examination begins with taking a thorough history. The age at symptom onset helps suggest a cause; laryngotracheomalacia and vocal cord paralysis are usually present at or shortly after birth, whereas cysts or mass lesions develop later in life.

Information indicating positions that make the stridor better or worse should be obtained, because placing a child in a position that allows gravity to aid in reducing obstruction can be of benefit during induction.

Other highlights of the history and physical examination

  • History of prematurity

  • Cardiac history

  • Respiratory history

  • Fasting status

  • Allergies

  • Current medications

  • Previous surgeries

  • Previous anesthetics

  • Anesthetic complications

  • Family or patient history of malignant hyperthermia

  • Current history of breathing problems including a timeline of the respiratory problems

  • Review MRIs, CT scans, and plain films of the airway

  • Review results of previous fiberoptic or rigid bronchoscopy

  • Review baseline arterial blood gases if available

  • Review echocardiogram and ECG if available

  • Physical exam should emphasize the airway, lungs, and heart

  • The airway exam should emphasize signs of difficult intubation or risk of dental injury

Physical findings consistent with a difficult airway include:

  • Microstomia – small mouth

  • Macroglossia – large tongue

  • Retrognathia – small or recessed jaw

  • Temporomandibular joint disease – Limited mouth opening

  • Disambiguation – overbite

The cardiopulmonary history and physical exam can give some insight as to if the child will tolerate spontaneous breathing during the procedure. Breathing spontaneously under general anesthesia may not be possible with patients with heart disease, where an increase in the work of breathing would compromise systemic circulation. Children with hypoplastic left ventricles who have yet entered the fontan staging process would be an example. Patients in congestive heart failure would be another example. Also, patients who have muscle weakness as a baseline such as patients with muscular dystrophy or spinal muscular atrophy provide examples of disease states that might not be compatible with spontaneous breathing during the airway procedure.

3. What are the implications of co-existing disease on perioperative care?

Many children requiring rigid bronchoscopy have coexisting diseases including syndromes that include difficult airway. Each child should be fully evaluated for their ability to tolerate anesthesia and whether they will not tolerate spontaneous breathing under a deep plane of anesthesia. Some of the common syndromes with associated laryngotracheal abnormalities requiring airway evaluation are listed below. These children will require a perioperative evaluation specific to the syndrome as well as the general preoperative evaluation discussed below.

  • Craniofacial dysmorphology (with micrognathia and glossoptosis)

  • Pierre Robin syndrome

  • Treacher Collins syndrome (mandibulofacial dysostosis)

  • Hallermann-Streiff (oculomandibular) syndrome

  • Moebius syndrome

  • De Lange syndrome

  • Freeman-Sheldon syndrome (whistling face)

  • Macroglossia

  • Beckwith syndrome

  • Congenital hypothyroidism

  • Glycogen storage diseases

  • Down syndrome

  • Diffuse muscular hypertrophy of the tongue

  • Mucopolysaccharidosis

The following signs and symptoms of respiratory distress should be identified. If the following signs and symptoms are acute, measures must be taken to improve oxygenation and ventilation prior to the procedure.

  • Cyanosis

  • Use of accessory muscles of respiration

  • Nasal flaring

  • Chest retractions

  • Stridor

  • Wheezing

  • Neck or mouth swelling

  • Drooling

  • Oxygen saturation less than 90% in room air (except in patients with cyanotic heart disease)

After assessing the patient for acute respiratory distress, the preoperative assessment should include a complete perioperative history and physical.

1. Establish the child’s baseline respiratory parameters by history, chart review, physical exam and discussion with the child’s physicians.

The anesthesiologist must understand the indication for rigid and flexible bronchoscopy. Each patient's physical exam should include:

  • Evaluate Airway patency

  • Establish baseline oxygenation and ventilation status

  • The urgency for evaluation is usually based on:

The acuteness of the breathing problem

The progression of respiratory compromise

The age of the patient.

Neonates with upper airway compromise usually present in the second or third week of life with acute stridor caused by subglottic stenosis or cysts. Laryngomalacia is the most common cause of stridor in infants and is most often due to a long epiglottis that prolapses posteriorly and prominent arytenoid cartilages with redundant aryepiglottic folds that prolapse into the glottic opening during inspiration. The definitive diagnosis is obtained by direct laryngoscopy and by rigid or flexible bronchoscopy.

The evaluation of a child with stridor begins with taking a thorough history. The age at symptom onset helps suggest a cause; laryngotracheomalacia and vocal cord paralysis are usually present at or shortly after birth, whereas cysts or mass lesions develop later in life. Information indicating positions that make the stridor better or worse should be obtained, because placing a child in a position that allows gravity to aid in reducing obstruction can be of benefit during induction.

Other highlights of the history and physical include:

  • · History of prematurity

  • · Cardiac history

  • · Respiratory history

  • · Fasting status

  • · Allergies

  • · Current medications

  • · Previous surgeries

  • · Previous anesthetics

  • · Anesthetic complications

  • · Family or patient history of malignant hyperthermia

  • · Current history of breathing problems including a timeline of the respiratory problems

  • · Review MRIs, CT scans, and plain films of the airway

  • · Review results of previous fiberoptic or rigid bronchoscopy

  • · Review baseline arterial blood gases if available

  • · Review echocardiogram and ECG if available

Physical exam should emphasize the airway, lungs, and heart. The airway exam should emphasize signs of difficult intubation or risk of dental injury. Physical findings consistent with a difficult airway include:

  • · Microstomia – small mouth

  • · Macroglossia – large tongue

  • · Retrognathia – small or recessed jaw

  • · Temporomandibular joint disease – Limited mouth opening

  • · Disambiguation – overbite

The cardiopulmonary history and physical exam can give some insight as to if the child will tolerate spontaneous breathing during the procedure.

c. Pulmonary:

d. Renal-GI:

e. Neurologic:

f. Endocrine:

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

4. What are the patient's medications and how should they be managed in the perioperative period?

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

i. What should be recommended with regard to continuation of medications taken chronically?

j. How to modify care for patients with known allergies

k. Latex allergy - If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

l. Does the patient have any antibiotic allergies - Common antibiotic allergies and alternative antibiotics

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia (MH)

Documented: Avoid all trigger agents such as succinylcholine and inhalational agents. Follow a proposed general anesthetic plan: total intravenous anesthesia with propofol ± opioid infusion ± nitrous oxide. Ensure an MH cart is available [MH protocol].

5. What laboratory tests should be obtained and has everything been reviewed?

Common laboratory normal values will be same for all procedures, with a difference by age and gender.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Anesthetic Approach

The anesthesiologist is concerned about maintaining a patent airway, oxygenation, adequate ventilation, preventing aspiration, minimizing laryngeal motion, and preventing cardiac dysrhythmias, and the surgeon needs a clear view of a motionless field for a reasonable time. Sometimes, these goals may conflict.

The anesthetic goals during bronchoscopy are:

Control of the airway

Decrease airway reflexes – The key to a stress-free bronchoscopy is properly placed topical anesthesia. Although topicalization of the laryngeal structures helps the child tolerate the procedure, it may interfere with assessment of normal vocal cord movement. For that reason, topicalization is often performed after initial evaluation of the upper airway and just before insertion of the bronchoscope for evaluation of the distal airway structures. Before endoscopy, the glottis and trachea are topically anesthetized with 2% to 4% lidocaine (up to 5 mg/kg) under the direct vision.

Goals

  • Amnesia

  • Unobstructed view of immobile surgical field

  • Minimize time restriction on surgeon inherent in the anesthetic technique

  • Prevention of aspiration

  • Smooth emergence

  • Safe extubation

  • Minimization of secretions

  • Prevention of adrenergic reflexes

To achieve these goals, anesthetic management must be individualized based on the patient’s age, concurrent illnesses, goals of endoscopy, skill of the anesthesiologist, and the proven track record of the anesthetic technique. The anesthetic approach should be individualized, with good communication between the endoscopist and anesthesiologist. All children should be monitored with a pulse oximeter, end-tidal CO2 monitor, precordial stethoscope, electrocardiogram, and automated blood pressure. Direct rigid laryngoscopy and bronchoscopy are mainly performed for diagnostic or therapeutic reasons. The anesthetic approach to diagnostic and therapeutic rigid bronchoscopy will be discussed separately.

Retrieval of an aspirated foreign body is the main therapeutic use of rigid bronchoscopy in children. Regardless of the indication, the three major anesthetic concerns during rigid bronchoscopy involve the methods of induction, the method of ventilation during bronchoscopy, and the maintenance of anesthesia.

Induction of anesthesia – methods

The use of premedication in these children should be individualized. Small infants may be brought into the operating room without premedication. Anticholinergic medications such as glycopyrrolate and atropine are useful to dry secretions. If no intravenous catheter is in place and the child is not in respiratory distress, usually an inhalational induction with sevoflurane is performed. Nitrous oxide can be used initially if tolerated to speed the induction and then discontinued before the examination. If intravenous catheter is in place prior to induction, a propofol bolus (1 to 3 mg/kg) to induce anesthesia but maintain spontaneous ventilation, followed by propofol infusion between 200 and 400 mcg/kg per minute with the goal of maintaining spontaneous breathing is a common approach.

A propofol-based total intravenous anesthesia (TIVA) technique has the advantage that it can be infused continuously during the procedure, resulting in a more stable level of anesthesia than can be achieved with inhalational agents and intermittent ventilation. Propofol can be supplemented with ketamine or dexmedetomidine to decrease the need for high doses of propofol that can lead to apnea. Supplementation with low dose remifentanil can further ablate laryngeal responses. In older infants and children, spontaneous breathing may be maintained during the entire procedure.

This technique for laryngoscopy and bronchoscopy with spontaneous breathing is useful for the evaluation of stridor, laryngomalacia, and tracheobronchomalacia. Some techniques used for direct rigid bronchoscopy do not allow for positive pressure ventilation (see above).

a. Regional anesthesia

b. General anesthesia

c. Monitored Anesthesia Care

6. What is the author's preferred method of anesthesia technique and why?

Foreign body

Foreign bodies in the larynx are more likely to cause total airway obstruction than are foreign bodies below the glottis. Foreign bodies located in the bronchi may dislodge from cough or change in position and cause total obstruction. In case of acute respiratory distress and hypoxemia with a laryngeal foreign body, anesthesia is induced with the patient in a sitting position with an inhaled anesthetic and oxygen while the patient is monitored with a precordial stethoscope, pulse oximeter, and electrocardiogram. Spontaneous breathing is preferable; positive pressure ventilation may cause the foreign body to be displaced and further obstruct the airway.

Anesthetic approach for foreign body aspiration

As soon as the child is anesthetized, the endoscopist must ensure that no foreign body is present above the vocal cords. If the laryngeal outlet is clear, the larynx is sprayed with 2% to 4% lidocaine, and a bronchoscope is inserted through the laryngeal inlet. Immediately after the bronchoscope passes the glottis, the anesthesia circuit is connected to the breathing sidearm of the bronchoscope, and manual ventilation or spontaneous breathing with manual assist is resumed.

It is important to remember that, with extremely high flow resistance through the side arm of the bronchoscope, spontaneous breathing is all but ineffective and the respiratory rate (especially the expiratory phase) must be kept very slow to allow sufficient time for passive exhalation. Inspiratory gas flow is adjusted to accommodate for the leak around the bronchoscope.

During the procedure, the anesthesiologist’s attention should be focused on the breath sounds detected by the precordial stethoscope, the symmetry of respiratory excursion, and oxygen saturation measured by a pulse oximeter. Close communication and cooperation between the bronchoscopist and the anesthesiologist are essential throughout bronchoscopy.

It is important to remember that the lumen of the bronchoscope is narrowed by the telescope and the use of instruments, especially when a suction catheter is inserted through the side port, the same narrow channel through which the patient must be ventilated. The period of apnea or severe hypoventilation therefore should be closely observed and communicated with the endoscopist.

The rate of rise in end-tidal Pco2 in apneic infants and young children is extremely high, at the rate of approximately 9 mm Hg/min.

The physician must make sure that after each period of hypoventilation or apnea, the telescope, forceps, or endobronchial suction catheter through the bronchoscope’s side arm is removed. The distal end of the bronchoscope should be pulled above the carina, and the proximal open end of the bronchoscope is occluded with the endoscopist’s thumb or a glass obturator cap, so that the child can be hyperventilated before instrumentation is resumed. Keep in mind that during the crucial moment of foreign body retrieval, ventilation sometimes must be held until the oxygen saturation begins to fall.

When the foreign body or its fragment is successfully grasped with the forceps, the forceps and the bronchoscope are carefully pulled out of the trachea and the larynx together as a single unit. It is imperative that the upper airway and glottis are totally relaxed, allowing the foreign body to pass through without being dislodged prematurely.

The patient is mask ventilated until the bronchoscope is reintroduced into the trachea. This maneuver may be repeated when the foreign body is fragmented. If a large, obstructive foreign body is removed from the bronchus but is dislodged in the trachea or larynx during the process of retrieval, it can cause serious obstruction of the entire respiratory system unless it is removed immediately. If prompt removal is not possible, the foreign body should be pushed back into one of the main bronchi so that ventilation can be resumed with at least one lung.

Intraoperative complications include laryngospasm, bronchospasm, hypoxia, arrhythmias, vagal induced bradycardia, and pneumothorax. They are preventable by maintaining adequate anesthesia, oxygenation, ventilation, and muscle relaxation. Premature ventricular contraction, although rare, can usually be treated with hyperventilation and intravenous lidocaine (1 mg/kg) if necessary. Pneumothorax, although infrequent, must be kept in mind if acute deterioration of ventilation and gas exchange occurs. Although greater than normal CO2 tensions are inevitable with intermittent ventilation, they are generally well tolerated in the presence of sevoflurane or propofol. Adequate oxygenation should be maintained in these infants throughout the procedure. Because ventilation may be intermittent and at times suboptimal, it is recommended that 100% oxygen be used as the carrier gas during the bronchoscopic examination.

During ventilation of the infant with the telescope in place, high resistance may be encountered as a result of partial occlusion of the lumen. This is especially likely when the 2.5-, 3.0-, and 3.5-mm internal diameter scopes are used.

Large fresh gas flow rates, large tidal volumes with high inflation pressures, and large inspired volatile anesthetic concentrations (or TIVA) are often necessary to compensate for leaks around the ventilating bronchoscope and the high resistance encountered when the viewing telescope is in place.

Sufficient time for exhalation must be provided for passive recoil of the chest. In small infants, there may be room for only the rod-lens-telescopic light source, which does not have a ventilation channel. In these cases, insufflation of oxygen via a small tube placed in the hypopharynx via the nose or mouth will delay the onset of desaturation in a spontaneously breathing child. If (when) desaturation occurs, the surgeon must stop and allow the child to be oxygenated before continuing with the examination.At the conclusion of bronchoscopy, the surgeon may wish to size the larynx and determine the degree of airway narrowing. An uncuffed ETT is inserted beyond the narrowest portion of the obstructed airway, and the airway is assessed by applying positive pressure between 10 and 25 cm H2O to the airway and listening with a stethoscope for an air leak around the ETT at the level of the suprasternal notch.

The outer diameter of the appropriate ETT is compared with the inner diameter of the child's larynx and trachea, and the percentage of obstruction is calculated. Grade I obstruction involves up to 50% of the airway, grade II is from 51% to 70%, and grade III is greater than 70%.

Dexamethasone in a dose of 0.5 mg/kg IV (maximum dose, 10 to 20 mg) is frequently administered during the procedure to decrease postoperative laryngeal swelling and the possibility of croup.

At the conclusion of rigid bronchoscopy, an ETT can be placed in the trachea to control the airway during recovery from anesthesia or if ventilation is adequate, and the anesthetic depth is not excessive, the child can be allowed to emerge breathing 100% oxygen by a face mask.

Anesthesia for flexible bronchoscopy is similar to rigid bronchoscopy. However, there are several different options available for flexible bronchoscopy. Primary and backup plans for airway management during the procedure need to be discussed with the proceduralist prior to the procedure. Diagnostic flexible bronchoscopy for the evaluation of the upper airway often precedes rigid bronchoscopy and often requires spontaneous respirations. The dynamics of the larynx and trachea are evaluated for various pathologies. Exam is usually performed directly through nares or through an LMA.

Premedication is used based on the evaluation of the patient. The risk of worsening airway obstruction and respiratory depression must be balanced with the benefits of amnesia and cooperation. Mask induction can be utilized to gain intravenous access placement. If an intravenous catheter is in place, propofol 2 to 3 mg/kg or Ketamine 1 to 2 mg/kg slowly administered IV with a pretreatment of an antisialagogue is acceptable. Muscle relaxants are avoided so as to maintain spontaneous respirations if observation of vocal cord movement or diagnosis of bronchomalacia or laryngomalacia is necessary.

Maintenance

Standard volatile maintenance is acceptable for airway evaluations requiring laryngeal visualization; however, ventilation and perfusion defects may lead to lightening of the anesthetic during the flexible fiberoptic exam. Thus, TIVA with spontaneous ventilation is a better option. An FIO2 of 100% should be considered as the flexible bronchoscope increases resistance of breathing and ventilation-perfusion mismatch that can result in hypoxia. Ventilation assistance by the way of CPAP can also be used to mitigate the increased resistance caused by the flexible bronchoscope when an LMA or ETT is used as a conduit. A flexible bronchoscope adaptor is made to be fitted in between the mask and anesthesia circuit. This allows access to the oral or nasal cavity while maintaining a good mask seal and assisted CPAP.

Short-acting opioids are often used to supplement the maintenance phase by reducing the sympathetic response to instrumenting the airway. Longer-acting opioids are typically not required. Dexmedetomidine can also be used in conjunction with the TIVA technique. Dexmedetomidine may lower the doses of propofol and opioids required, thereby reducing the risk of apnea. Diagnostic flexible bronchoscopy is also used for bronchoalveolar lavage (BAL), needle biopsies, bronchial cell washings, endobronchial ultrasound, or other distal laryngeal evaluations.

Many of these procedures do not require visual access to the upper airway; an LMA or ETT is used for airway maintenance. BAL is used to obtain fluid or secretions from the lower respiratory tract for cytology or infectious pathogen identification. It is performed after general bronchial inspection, but prior to any cell brushings or biopsies (if applicable). The flexible bronchoscope is gently wedged into a distal bronchus and nonbacteriostatic normal saline is instilled. The amount of fluid instilled is dependent on the patient size. It ranges from 10 mL in newborns to 50 mL in adult-sized teenagers. The fluid is then withdrawn into a suction trap and delivered to pathology for microscopy and culture.

The volume of saline suctioned is a fraction of what was instilled. As little as 2 to 3 mL per 10 mL may return to the suction trap. The BAL may have to be repeated multiple times on the same patient during the same procedure. This can lead to a substantial amount of saline instilled into the lung by the end of the procedure.

Bronchial cell brushings and biopsies are usually performed for diagnosis of the etiology of diffuse disease (e.g., lung transplant rejection, certain widespread pneumonias).

Induction

A standard induction can be used with less regard to maintaining spontaneous respirations. Based on the patient’s evaluation, an LMA or ETT can be placed after induction; keeping in mind the flexible bronchoscope decreases the cross-sectional area of the LMA/ETT, thereby increasing resistance. Muscle relaxants can be used as spontaneous respirations are usually not required.

Maintenance

Both volatile agents and TIVA techniques have been described.

Emergence

Standard emergence guidelines are followed. Tracheal extubation is performed with the patient fully awake with complete neuromuscular reversal, if applicable.

  1. A witnessed choking event is highly suggestive of aspiration.

  2. A history of cough is highly sensitive but not specific for aspiration.

  3. Cyanosis or stridor is very specific but not sensitive for aspiration.

  4. Air trapping on chest radiograph has high specificity but low sensitivity.

a. Neurologic:

b. If the patient is intubated, are there any special criteria for extubation?

c. Postoperative management

What's the Evidence?

Avital, A, David, G. "Retrieval of aspirated foreign bodies in children using a flexible bronchoscope and a laryngeal mask airway". J Bronch. vol. 9. 2002. pp. 6-9.

Collins, CE. "Anesthesia for pediatric airway surgery: recommendations and review from a pediatric referral center". Anesthesiol Clin. vol. 28. 2010. pp. 505-17.

Fidkowski, CW, Zheng, H, Firth, PG. "The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases". Anesth Analg. vol. 111. 2010. pp. 1016-25.

Folch, E, Mehta, AC. "Airway interventions in the tracheobronchial tree". Semin Respir Crit Care Med. vol. 29. 2008. pp. 441-52.

Landsman, IS, Motoyama, EK, Davis, PJ. "Anesthesia for pediatric otorhinolaryngologic surgery". Smith’s Anesthesia for infants and children. Mosby.

Zur, KB, Litman, RS. "Pediatric airway foreign body retrieval: surgical and anesthetic perspectives". Paediatr Anaesth. vol. 19. 2009. pp. 109-17.

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