Flexible bronchoscopy via the laryngeal mask: a new technique

The role of flexible bronchoscopy accomplished through a laryngeal mask airway in the treatment of tracheobronchial foreign bodies in children

INTRODUCTION

We here present our experience with children who underwent flexible bronchoscopy for removal of inhaled tracheobronchial foreign bodies under general anesthesia via a laryngeal mask airway (LMA).

MATERIALS AND METHODS

A total of 24 (16 male and 8 female, mean age: 30.75 ± 29.68 months) patients who underwent flexible bronchoscopy under general anesthesia using a LMA for suspicion of tracheobronchial foreign bodies between July 2016 and April 2018 were retrospectively reviewed.

RESULTS

The mean duration of admission to hospital was 162.56 ± 309.56 h. Sixteen (66.7%) patients were found to have tracheobronchial foreign bodies. All procedures were successfully accomplished through a LMA by using basket forceps, a Fogarty catheter and a suction without any need for rigid bronchoscopy. 11 (68.7%) of tracheobronchial foreign body locations were right bronchial, 3 (18.8%) were left bronchial and 2 (12.5%) were tracheal. The types of extracted tracheobronchial foreign bodies were organic in 14 (87.5%) and non-organic in 2 (12.5%). There were no complications except laryngeal edema noted in 2 (8.3%) patients, relieved within 48 h. The mean time of postoperative hospitalisation was 2.42 ± 0.97 days.

CONCLUSION

Flexible bronchoscopy accomplished through a LMA is a safe, easy and effective technique, not only as a diagnostic procedure, but also as the initial therapeutic modality for retrieving tracheobronchial foreign bodies in children with high success and low complication rates. With further reports aforementioned, we hope that the flexible bronchoscopy will become a standard method in children.

Critical airway obstruction: challenges in airway management and ventilation during therapeutic bronchoscopy

BACKGROUND

Endobronchial interventions are used to alleviate symptoms of airway stenosis. The ventilatory management may be challenging during these procedures, and may influence the choice of airway device. We report our experiences from 902 procedures.

METHODS

Patients undergoing interventional bronchoscopy procedures were consecutively registered from 1999 to 2012. Critical airway obstruction (CAO) was defined as stridor, tracheal diameter <5 mm, stenosis of both the main bronchi, or clots/tumor fragments occluding the trachea or both main bronchi. Choice of airway, ventilation strategy, and survival are reported. Results are presented as median (interquartile range), and P≤0.05 was considered significant.

RESULTS

A total of 561 patients underwent 902 interventional bronchoscopy procedures (mechanical debulking, laser resection, balloon dilatation, and stent placement). The procedures were performed using flexible bronchoscope through an endotracheal tube (68.2%) or laryngeal mask airway (10.4%), or by rigid bronchoscopy (9.3%). All patients were primarily ventilated by volume-controlled ventilation. CAO was classified in 60 procedures, with more frequent use of laryngeal mask airway (21.7%), and change of airway device in 20/60 procedures. The survival for patients with malignant disease with or without CAO was 100 and 182 days, respectively, with 90 days survival probability of 0.65 and 0.51 (P=0.14).

CONCLUSIONS

Bronchoscopic treatment in patients with CAO may require a change of ventilatory and airway strategy during the procedure. Despite various challenges in the management of patients with CAO, the short-term survival in these patients is comparable to that in patients without CAO.

Anesthesia for bronchoscopy and interventional pulmonology: from moderate sedation to jet ventilation

PURPOSE OF REVIEW

The field of interventional bronchoscopy has seen an evolving need for different types of anesthesia for various procedures. This review describes recent advances in the field of anesthesiology that have increased the suitability of conscious sedation under monitored anesthesia care or general anesthesia for prolonged and complex interventional bronchoscopic procedures, especially those performed on severely ill patients. Additionally, the pros and cons of performing bronchoscopic procedures in the bronchoscopy suite versus the operating room are analyzed.

RECENT FINDINGS

Although conscious sedation is the most commonly used form of anesthesia for simple bronchoscopic procedures, general anesthesia is emerging as a more appropriate technique for newer, more complex interventional bronchoscopic procedures. Large interventional pulmonology departments have state-of-the-art bronchoscopy suites in which both conscious sedation and general anesthesia are used. New advances in the field of anesthesiology such as the laryngeal mask airway, short-acting anesthetics with minimal effect on respiratory function, and mechanical jet ventilators are well suited for interventional bronchoscopic procedures.

SUMMARY

Interventional bronchoscopists are encouraged to examine the pros and cons of different types of anesthesia for various bronchoscopic procedures.

Unsuspected tracheal web inhibits endotracheal intubation: report of a case

A 66-year-old woman was scheduled for resection of a recurrent brain astrocytoma. During anesthesia induction, endotracheal intubation became impossible. Urgent bronchoscopy under laryngeal mask ventilation visualized a subglottic web 1 cm below the vocal cords. After bronchoscopic ablation with argon plasma coagulation, the airway intubation was successful.

Management of hypoxemia during flexible bronchoscopy

Under controlled conditions, FB is a safe procedure that has few significant adverse events. Significant hypoxemia may sometimes occur during FB despite the use of supplemental oxygen. UAO has been shown to be the dominant cause of hypoxemia during FB, and this is successfully managed with nasopharyngeal tube insertion. Other strategies that may need to be implemented include oxygen supplementation with intratracheal catheter, administration of sedation reversal medication, removal of the bronchoscope, bag-and-mask ventilation, and, rarely, endotracheal intubation and ventilation. Access to an anesthetist, availability of propofol, backup rigid bronchoscopy, and fluoroscopy are optional but desirable components in the bronchoscopy suite.

Laryngeal nerve identification during thyroid surgery -- feasibility of a novel approach

PURPOSE

Recurrent laryngeal nerve damage remains one of the most devastating complications of thyroid surgery. However, nerve identification is not always easy, and a reliable method to locate nerves intraoperatively is needed.

METHODS

Thirty consecutive patients were anesthetized for elective thyroid surgery using a standard technique. Indications for surgery covered a broad spectrum of conditions. In the technique described, the airway is secured with a micro laryngeal tube, and a laryngeal mask airway is inserted through which a fibreoptic scope is inserted to view the larynx. Movement of the arytenoids in response to nerve stimulation can be viewed at any time on a television monitor. The airway is secure throughout the procedure and nerve identification is continuously available.

RESULTS

In our study 30 patients were anesthetized and nerve stimulation used in all of them to identify both superior and recurrent laryngeal nerve. None of them developed intraoperative complications. One patient had temporary postoperative recurrent laryngeal nerve damage, which was not attributable to use of this method.

CONCLUSION

On the basis of our results so far, the method described is feasible and provides a safe method of nerve location during surgery. Laryngeal nerve stimulation is likely to become an integral part of thyroid surgery.

The use of the laryngeal mask airway in children with subglottic stenosis

Patients with tracheal stenosis have a high incidence of difficult or failed tracheal intubation. Airway management with the laryngeal mask airway during fibreoptic laryngoscopy was used in two children with acquired subglottic stenosis during spontaneous breathing. The laryngeal mask airway may be superior to tracheal intubation or use of a face mask during anaesthesia management in severe subglottic stenosis. Ventilation may be improved and the use of a laryngeal mask airway can reduce or eliminate some of the problems associated with the other methods of airway management, such as further damage to stenotic tissue and gastric distention.

Bronchoscopy with bronchoalveolar lavage via the laryngeal mask airway in high-risk hypoxemic immunosuppressed patients

OBJECTIVE

Fiberoptic bronchoscopy (FOB) and bronchoalveolar lavage (BAL) are major tools in the diagnosis of pulmonary complications in immunocompromised patients. Nevertheless, severe hypoxemia is an accepted contraindication to FOB in nonintubated patients. The purpose of this study was to evaluate the feasibility and safety of laryngeal mask airway (LMA)-supported FOB with BAL in immunosuppressed patients with suspected pneumonia and severe hypoxemia.

DESIGN

Prospective, clinical investigation.

SETTING

Medical intensive care unit of a university hospital.

PATIENTS

Forty-six immunosuppressed patients admitted to our intensive care unit with suspected pneumonia and Pao2/Fio2 < or = 125.

INTERVENTIONS

After the administration of 0.3 mg x kg(-1) of etomidate, the patients were ventilated manually while receiving 1.0 Fio2. After the administration of 2.5 mg x kg(-1) of propofol, followed by an infusion of 9.1 +/- 2.3 mg x kg(-1) x hr(-1) of propofol, the LMA (size 3 or 4) was placed and connected to a bag-valve unit to allow manual ventilation with 1.0 Fio2. The FOB was introduced through a T-adapter attached to the LMA, and BAL was carried out with 150 mL of sterile 0.9% saline solution by sequential instillation and aspiration of 50-mL aliquots.

MEASUREMENTS AND MAIN RESULTS

Three patients developed transient laryngospasm during passage of the bronchoscope via the LMA, which resolved with deepening of anesthesia. Changes in mean blood pressure, heart rate, Pao2/Fio2, and Paco2 values induced by the procedure did not reach significance. Seven patients (15%) presented hypotension (mean blood pressure, <60 mm Hg) maintained for 120 +/- 40 secs, which required plasma expanders in three cases. Oxygen desaturation to <90% occurred in six patients (13%) during BAL. Nevertheless, the lowest Sao2 during the procedure was significantly higher than the initial Sao2 (94% +/- 4% vs. 90% +/- 2%). No patient required tracheal intubation during the 8 hrs after the procedure. BAL had an overall diagnostic yield of 65%. Because of the results obtained by using the BAL analysis, treatment was modified in 33 (72%) cases.

CONCLUSION

Application of the LMA appears to be a safe and effective alternative to intubation for accomplishing FOB with BAL in immunosuppressed patients with suspected pneumonia and severe hypoxemia.

Comparative evaluation of TIVA with propofol-fentanyl and thiopental-sevoflurane anesthesia using laryngeal mask airway for diagnostic bronchoscopy

PURPOSE

Diagnostic bronchoscopy is performed under general anesthesia in our hospital. This study was designed to determine whether total intravenous anesthesia (TIVA) with propofol-fentanyl provides more stable hemodynamics using a laryngeal mask airway (LMA) for diagnostic bronchoscopy than thiopental-sevoflurane anesthesia.

METHODS

Sixty patients scheduled for diagnostic bronchoscopy were randomly assigned to two groups. TIVA with propofol-fentanyl was induced with intravenous fentanyl 2 μg·kg^-1 and propofol 2 mg·kg^-1 and maintained with continuous infusion of propofol with fentanyl. Thiopental-sevoflurane anesthesia was induced with thiopental 5 mg·kg^-1 and maintained with N₂O/O₂/sevoflurane. Insertion of the LMA was facilitated with vecuronium 0.1 mg·kg^-1 i.v. in both groups. Ventilation was controlled, and administration of propofol and sevoflurane was continued until the end of the procedure. The LMA was removed when the patient was able to open his or her mouth.

RESULTS

During TIVA, the mean arterial pressure and rate pressure product decreased significantly from induction until 20 min after the start of the procedure, and they were maintained at around 70 mmHg and 7000, respectively, during the procedure. There were no significant differences in heart rate,[Formula: see text] and[Formula: see text]. In thiopental-sevoflurane anesthesia, the mean arterial pressure and rate pressure product decreased significantly after induction and increased significantly from insertion of the LMA until removal of the LMA. Heart rate increased significantly after insertion of the LMA, insertion of the bronchoscope, and removal of the LMA. There were no significant differences in[Formula: see text] and[Formula: see text].

CONCLUSION

TIVA with propofol-fentanyl in conjunction with an LMA performs better than thiopental-sevoflurane anesthesia for diagnostic bronchoscopy because of its superior maintenance of cardiovascular stability.

The laryngeal mask airway: a new technique for fiberoptic guided vocal cord biopsy

STUDY OBJECTIVE

To describe a new technique for vocal cord biopsy involving placement of a laryngeal mask airway (LMA) during general anesthesia and fiberoptic guided biopsy. To report our early experience with this technique.

DESIGN

Descriptive study.

SETTING

Teaching hospital.

PATIENTS

10 patients undergoing vocal cord biopsy for minor laryngeal pathology and with no evidence of infraglottic airway obstruction.

INTERVENTIONS

Patients were premedicated 1 hour preoperatively with pethidine 1 mg/kg and atropine 0.01 mg/kg. Following preoxygenation, anesthesia was induced with propofol 2.5 mg/kg and fentanyl 1 mg/kg. Once airway control was established with a facemask, vecuronium 0.1 mg was given and anesthesia established with oxygen (O2) and nitrous oxide mixture and isoflurane 1% to 2%. Gentle direct laryngoscopy was then performed to inspect the pharyngeal structures and the LMA was then inserted in the standard manner by highly experienced LMA users. A fiberoptic scope was passed via a self-sealing mount down the shaft of the LMA to the level of the vocal cords. The vocal cords were then sprayed with local anesthetic and the biopsy taken.

MEASUREMENTS AND MAIN RESULTS

The age and weight range were 29 to 57 years and 65 to 85 kg, respectively. All patients were smokers or recent ex-smokers. LMA insertion was readily achieved in all patients, and an excellent view of the vocal cords was obtained. There were no problems with ventilation or obtaining tissue samples, and O2 saturation remained greater than 95% throughout the perioperative period. Tissue samples were adequate in all patients. Hypertension and other adverse cardiac events did not occur during the procedure, which lasted 10 to 20 minutes. There were no problems during emergence from anesthesia, and all patients were discharged home on the same day.

CONCLUSIONS

The technique has potential advantages over suspension microlaryngoscopy in that it is relatively noninvasive, it allows good airway control with adequate views of the vocal cords, and it facilitates a smooth recovery.

Use of LMA for awake intubation for caesarean section

PURPOSE

This case report describes the use of a Laryngeal Mask Airway in a morbidly obese parturient with the H.E.L.L.P. syndrome. An urgent Caesarean section was required because of vaginal bleeding and fetal distress.

CLINICAL FEATURES

The patient was a 32 year old G3, T1, P1, L1 who presented with epigastric pain, headache, vomiting, and diarrhoea. She was hypertensive (180/110 mmHg) and thrombocytopaenic (18 x 10(-9). L-1). Examination of the airway revealed a short neck, receded jaw, full dentition, large breasts and she was considered to be a potential intubation problem. The patient required an awake intubation using a technique that minimized hypertension, aspiration risk, airway trauma, and hypoxia. A laryngeal mask was used to facilitate tracheal intubation, and the patient tolerated the procedure with no adverse outcome.

CONCLUSION

The LMA has a place to facilitate potentially difficult awake tracheal intubation with the pregnant patient.

Bronchoscopic airway evaluation facilitated by the laryngeal mask airway in pediatric patients

The laryngeal mask airway (LMA) was introduced for clinical use in 1988. It represents a new concept in airway management. Its role has been described as filling the gap between tracheal intubation and the anesthesia face mask. It is inserted without direct visualization into the hypopharynx and when properly positioned forms a low pressure seal around the laryngeal inlet, allowing spontaneous as well as gentle positive pressure ventilation. Since its introduction, its indications and applications in anesthesia practice have increased. Although initially used as a means of delivering anesthesia and obviating the need for holding a mask on the patient, its position directly over the laryngeal inlet makes it a useful guide during flexible bronchoscopy. We report our experience in six pediatric patients and describe an anesthetic technique for bronchoscopy using the LMA for general anesthesia with spontaneous ventilation.

Current concepts in airway management for cardiopulmonary resuscitation

OBJECTIVE

To describe the methods of maintaining airway patency for oxygenation during cardiopulmonary resuscitation (CPR) that do not require expertise in mask ventilation or endotracheal intubation by direct laryngoscopy.

DESIGN

A review of rescue breathing and newer methods of providing airway patency is provided.

RESULTS

Airway patency during CPR is often difficult to achieve. Mask ventilation predisposes to hypoventilation and aspiration pneumonitis. Endotracheal intubation by direct laryngoscopy is the preferred method of maintaining airway patency for CPR. Alternative techniques for airway management include endotracheal intubation by lighted stylet, esophageal tracheal Combitube, laryngeal mask airway, and transtracheal ventilation. These methods are recommended by the American Heart Association and the American Society of Anesthesiologists. They have been approved by the Food and Drug Administration for maintenance of airway patency; they are easy to learn, effective, and applicable to CPR. Advantages and disadvantages of each technique may indicate or contraindicate one method over another in specific circumstances.

CONCLUSION

When CPR is compromised by airway obstruction that remains unresponsive to traditional techniques, using alternative methods is appropriate. The techniques selected must be based on individual familiarity and expertise.

The airway endoscopy mask: useful device for fibreoptic evaluation and intubation of the paediatric airway

A mask is presented which allows the administration of 100% oxygen, inhalational anaesthetics, continuous positive airway pressure and intermittent positive pressure ventilation during diagnostic airway endoscopy and difficult intubation with a fibreoptic bronchoscope in paediatric patients. The mask is particularly useful in small or critically ill patients. It may also have its place in teaching situations.

A new diagnostic approach to congenital stridor using a laryngeal mask airway and rigid endoscope

Neonates with symptoms of stridor from birth, present a difficult diagnostic problem. We have demonstrated that by the use of a laryngeal mask airway in an anaesthetized baby breathing spontaneously, we are able to reach a diagnosis. This is accomplished by the introduction of a rigid fibre-optic endoscope through a Portex swivel connector and visualizing the glottis and larynx.

The laryngeal mask airway: its features, effects and role

The laryngeal mask airway was designed as a new concept in airway management and has been gaining a firm position in anaesthetic practice. Numerous articles and letters about the device have been published in the last decade, but few large controlled trials have been performed. Despite widespread use, the definitive role of the laryngeal mask has yet to be established. In some situations, such as after failed tracheal intubation or in anaesthesia for patients undergoing laparoscopic or oral surgery, its use is controversial. There are a number of unresolved issues, for example the effect of the laryngeal mask on regurgitation and whether or not cricoid pressure prevents placement of the mask. We review the techniques of insertion, details of misplacement, and complications associated with the use of the laryngeal mask. We discuss the features and physiological effects of the device, including the changes in intra-cuff pressure during anaesthesia and effects on blood pressure, heart rate and intra-ocular pressure. We then attempt to clarify the role of the laryngeal mask in airway management during anaesthesia, based on the current knowledge, by discussing the advantages and disadvantages as well as the indications and contraindications of its use. Lastly we describe the use of the laryngeal mask in circumstances other than airway maintenance during anaesthesia: fibreoptic bronchoscopy, tracheal intubation through the mask and its use in cardiopulmonary resuscitation.

Prospective survey of the use of the laryngeal mask airway in 2359 patients

Patients undergoing anaesthesia in which the laryngeal mask airway was used were prospectively audited over a 6-month period. A simple record sheet was completed at the time of anaesthetic administration and 2359 completed forms were analysed to assess problems encountered with its use. It was used successfully in 2350 patients (99.61%); of these, 1399 patients (59%) breathed spontaneously through the airway and 960 patients (41%) underwent intermittent positive pressure ventilation of the lungs. Two patients (0.08%) were reported to have regurgitated during the use of the laryngeal mask airway, but no serious sequelae associated with its use were encountered.

Flexible fibreoptic bronchoscopy via the laryngeal mask

The efficacy of flexible fibreoptic bronchoscopy through the laryngeal mask was investigated in 20 patients under total intravenous anaesthesia with propofol, fentanyl, atropine and suxamethonium. Mask size 4 was used for men and size 3 for women. Ventilation was performed with oxygen in air, FIO2 0.6. The ventilatory pressures were median 18 (9-40) cmH2O (1.8 (0.9-3.9) kPa) before the bronchoscope was inserted. When the tip of the bronchoscope was above the vocal cords the ventilatory pressures increased to 22 (10-43) mmHg (2.2 (1.0-4.2) kPa) (P < 0.001), and when the tip was situated at the mid-tracheal level there was a further increase to 24 (12-50) mmHg (2.4 (1.2-4.9) kPa) (P < 0.001). Maximal gas leakages were median 1 (0-2) l/min-1. PEEP at the mid-tracheal level was 3 (0-7) cmH2O (0.3(0-0.7) kPa). When 15 min of the procedure had elapsed, PaO2 was 232 (112-350) mmHg (30.9 (14.9-46.6) kPa) and PaCO2 39 (33-46) mmHg (5.2(4.4-6.1) kPa). The lowest oxygen saturation was median 98 (96-100)% and the highest end-tidal CO2 34 (24-41) mmHg (4.5(3.2-5.5) kPa). It was easy to examine the laryngeal opening and a good assessment of vocal cord function was allowed when muscle relaxation ceased. We conclude that flexible fibreoptic bronchoscopy through the laryngeal mask is a safe technique provided that total intravenous anaesthesia is used. It is a valuable alternative to flexible bronchoscopy performed with topical anaesthesia.

A potential new technique for awake fibreoptic bronchoscopy--use of the laryngeal mask airway

OBJECTIVE

To assess the potential use of the laryngeal mask airway (LMA) for awake diagnostic fibreoptic bronchoscopy.

DESIGN

A prospective study of 50 patients presenting for awake diagnostic bronchoscopy. All patients were premedicated with pethidine and atropine. The LMA was inserted under topical anaesthesia with sedation and the quality of the subsequent laryngoscopy and bronchoscopy was assessed for both patient and bronchoscopist.

SETTING AND PATIENTS

All patients over the age of 18 years who presented to Cairns Base Hospital for diagnostic bronchoscopy were asked to participate in the study.

MAIN OUTCOME MEASURES

The main factors determining the suitability of the technique were insertion rate, ease of the laryngoscopy and bronchoscopy, oxygen saturation and patient acceptance.

RESULTS

The LMA was inserted successfully in all patients and the bronchoscopy subsequently performed. The first time insertion rate was 72%. The mean oxygen saturation during the procedure was 98% and patients tolerated the technique.

CONCLUSIONS

The potential advantages of the LMA are that it is simple to insert, avoids nasal trauma and facilitates direct laryngoscopy. It allows respiration to be monitored and oxygen to be administered. The technique may have a role to play in patients whose respiratory function is in a critical condition, but confirmation of this awaits comparative trials. A period of training is recommended in anaesthetised patients before the LMA is used for awake diagnostic bronchoscopy.