Jet Ventilation during Rigid Bronchoscopy in Adults: A Focused Review

A multi-centre prospective random control study of superimposed high-frequency jet ventilation and conventional jet ventilation for interventional bronchoscopy

Introduction: Superimposed high-frequency jet ventilation (SHFJV) is a new type of jet ventilation that simultaneously uses high- and low-frequency types of jet ventilation. We compared SHFJV with the conventional high-frequency jet ventilation (CHFJV) in interventional bronchoscopy in terms of safety and effectiveness. Methods: A multi-centre prospective random single-blind clinical trial was conducted by three interventional bronchoscopy centres. Patients who underwent diagnostic or therapeutic bronchoscopy under general anaesthesia were admitted and divided into two groups: SHFJV group (trial group) and CHFJV group (control group). PaO2 and PaCO2 were recorded before anaesthesia and during and after the procedure. SpO2 and etCO2 were recorded every 10 min throughout the procedure. Patients were observed until 24 h post-bronchoscopy. Results: Sixty patients were included in the study. Twenty-nine were in the trial group, and 31 were in the control group. Both groups had no significant differences in demographic data. In the control group, the PaO2 measured in the operation was higher than that in the trial group (p = 0.023). The values of etCO2 in the control group were more dispersed than those of the trial group. When the procedure time was over 90 minutes, the etCO2 in the control group significantly increased (p = 0.01), while the etCO2 in trial group remained stable (p = 0.594). There were more patients with PaCO2 ≥ 50 mmHg during the procedure in the control group than in the trial group (p = 0.042). Conclusion: SHFJV is effective and safe in interventional bronchoscopy. It may provide more effective and stabilised ventilation than CHFJV in cases with long procedure times.

The Impact of Tracheal Stenosis on Distal Airway Pressure with Jet Ventilation

OBJECTIVE

This study investigates the effects of tracheal stenosis on distal airway pressure during low-frequency jet ventilation (LFJV) in tracheal stenosis resection procedures, focusing on variables like stenosis size, depth, scope type, and inlet pressure.

METHODS

A 3D-printed human airway model was employed, featuring inserted tracheal stenoses of varied sizes and depths. Distal airway pressure was measured with 16 pressure transducers, and data were processed via MATLAB. The study varied stenosis size, depth, scope type, and inlet pressure during five sequential jet bursts under LFJV.

RESULTS

Using a subglottiscope resulted in significantly reduced distal airway pressure compared to a laryngoscope. Interestingly, neither stenosis size nor depth significantly influenced distal airway pressure. However, increased distance between the scope and stenosis raised normalized pressure. A linear rise in normalized distal airway pressure was noted with increased inlet pressure, regardless of stenosis dimensions.

CONCLUSION

In this model, scope type and inlet pressure were noted to be significant determinants of distal airway pressure, while stenosis size and depth were not. The distance between the scope and the stenosis did influence distal pressures. These findings may have clinical implications for managing airway pressures in patients undergoing LFJV, potentially reducing the risk of ventilator-induced lung injury.

LEVEL OF EVIDENCE

NA (Basic Research) Laryngoscope, 134:2300-2305, 2024.

Supraglottic Jet Oxygenation and Ventilation to Minimize Hypoxia in Patients Receiving Flexible Bronchoscopy Under Deep Sedation: A 3-Arm Randomized Controlled Trial

BACKGROUND

Hypoxia often occurs due to shared airway and anesthetic sedation-induced hypoventilation in patients receiving flexible bronchoscopy (FB) under deep sedation. Previous evidence has shown that supraglottic jet oxygenation and ventilation (SJOV) via Wei nasal jet tube (WNJ) reduces the incidence of hypoxia during FB. This study aimed to investigate the extent to which SJOV via WNJ could decrease the incidence of hypoxia in patients under deep sedation as compared to oxygen supplementation via WNJ alone or nasal catheter (NC) for oxygen supplementation during FB.

METHODS

This was a single-center 3-arm randomized controlled trial (RCT). Adult patients scheduled to undergo FB were randomly assigned to 3 groups: NC (oxygen supplementation via NC), low-pressure low-flow (LPLF) (low-pressure oxygen supplementation via WNJ alone), or SJOV (high-pressure oxygen supplementation via WNJ). The primary outcome was hypoxia (defined as peripheral saturation of oxygen [Sp o2 ] <90% lasting more than 5 seconds) during FB. Secondary outcomes included subclinical respiratory depression or severe hypoxia, and rescue interventions specifically performed for hypoxia treatment. Other evaluated outcomes were sore throat, xerostomia, nasal bleeding, and SJOV-related barotraumatic events.

RESULTS

One hundred and thirty-two randomized patients were included in 3 interventions (n = 44 in each), and all were included in the final analysis under intention to treat. Hypoxia occurred in 4 of 44 patients (9.1%) allocated to SJOV, compared to 38 of 44 patients (86%) allocated to NC, with a relative risk (RR) for hypoxia, 0.11; 98% confidence interval (CI), 0.02-0.51; P < .001; or to 27 of 44 patients (61%) allocated to LPLF, with RR for hypoxia, 0.15; 95% CI, 0.04-0.61; P < .001, respectively. The percentage of subclinical respiratory depression was also significantly diminished in patients with SJOV (39%) compared with patients with NC (100%) or patients with LPLF (96%), both P < .001. In SJOV, no severe hypoxia event occurred. More remedial interventions for hypoxia were needed in the patients with NC. Higher risk of xerostomia was observed in patients with SJOV. No severe adverse event was observed throughout the study.

CONCLUSIONS

SJOV via WNJ effectively reduces the incidence of hypoxia during FB under deep sedation.

Current Practices Supporting Rigid Bronchoscopy-An International Survey

BACKGROUND

There are no guidelines for anesthesia or staff support needed during rigid bronchoscopy (RB). Identifying current practice patterns for RB pertinent to anesthesia, multidisciplinary teams, and algorithms of intra and post-procedural care may inform best practice recommendations.

METHODS

Thirty-three-question survey created obtaining practice patterns for RB, disseminated via email to the members of the American Association of Bronchology and Interventional Pulmonology and the American College of Chest Physicians Interventional Chest Diagnostic Procedures Network.

RESULTS

One hundred seventy-five clinicians participated. Presence of a dedicated interventional pulmonology (IP) suite correlated with having a dedicated multidisciplinary RB team ( P =0.0001) and predicted higher likelihood of implementing team-based algorithms for managing complications (39.4% vs. 23.5%, P =0.024). A dedicated anesthesiology team was associated with the increased use of high-frequency jet ventilation ( P =0.0033), higher likelihood of laryngeal mask airway use post-RB extubation ( P =0.0249), and perceived lower rates of postprocedural anesthesia adverse effects ( P =0.0170). Although total intravenous anesthesia was the most used technique during RB (94.29%), significant variability in the modes of ventilation and administration of muscle relaxants was reported. Higher comfort levels in performing RB are reported for both anesthesiologists ( P =0.0074) and interventional pulmonologists ( P =0.05) with the presence of dedicated anesthesia and RB supportive teams, respectively.

CONCLUSION

Interventional bronchoscopists value dedicated services supporting RB. Multidisciplinary dedicated RB teams are more likely to implement protocols guiding management of intraprocedural complications. There are no preferred modes of ventilation during RB. These findings may guide future research on RB practices.

A Novel Low-Cost Technique to Allow for Jet Ventilation

BACKGROUND/OBJECTIVE

Traditional jet ventilation requires the use of a catheter that is inserted either through an endotracheal tube or laryngoscope. Specially designed laryngoscopes with a built-in luer lock adapter to which the high-pressure tubing may be attached exist but are not always available. We present our experience with an adapter which allows connection of the high-pressure tubing to the suction side port of suitable laryngoscopes that is easily assembled using readily available materials in the operating room.

METHOD

We designed a jet ventilator adapter using a high-pressure jet ventilation tubing assembly and a 3-way stopcock extension set which we have used for the past 13 years. A retrospective case series of all adult patients who underwent direct laryngoscopy and/or bronchoscopy using this jet ventilation adapter between January 2017 and August 2021 was performed.

RESULT

A total of 100 consecutive patients underwent laryngoscopy and bronchoscopy using jet ventilation between January 2017 and August 2021 was identified. The mean age was 56.3 years, and the mean BMI was 31.2. The most common diagnoses were idiopathic subglottic/tracheal stenosis (46.4%), acquired tracheal stenosis (34.1%), and acquired subglottic stenosis (14.8%). The median duration of the surgical procedure was 53 minutes with an interquartile range of 23. The CO₂ laser was used in all cases. There was no disconnection of the adapter, episodes of postoperative respiratory compromise, or extraluminal air on chest radiography for any of our cases. Oxygen saturations remained above 90% intraoperatively for all cases.

CONCLUSION

Our simple jet ventilator adapter connects the jet ventilator to the suction side port of suitable laryngoscopes and eliminates the need for a jet ventilation catheter or specialized laryngoscope at a minimal cost.

Concomitant Intubation with Minimal Cuffed Tube and Rigid Bronchoscopy for Severe Tracheo-Carinal Obstruction

BACKGROUND

Our aim was to report on the use of an innovative technique for airway management utilizing a small diameter, short-cuffed, long orotracheal tube for assisting operative rigid bronchoscopy in critical airway obstruction.

METHODS

We retrospectively reviewed the clinical data of 36 patients with life-threatening critical airway stenosis submitted for rigid bronchoscopy between January 2008 and July 2021. The supporting ventilatory tube, part of the Translaryngeal Tracheostomy KIT (Fantoni method), was utilized in tandem with the rigid bronchoscope during endoscopic airway reopening.

RESULTS

Indications for collateral intubation were either tumors of the trachea with near-total airway obstruction (13), or tumors of the main carina with total obstruction of one main bronchus and possible contralateral involvement (23). Preliminary dilation was necessary before tube placement in only 2/13 patients with tracheal-obstructing tumors (15.4%). No postoperative complications were reported. There was one case of an intraoperative cuff tear, with no further technical problems.

CONCLUSIONS

In our experience, this innovative method proved to be safe, allowing for continuous airway control. It enabled anesthesia inhalation, use of neuromuscular blockage and reliable end-tidal CO2 monitoring, along with protection of the distal airway from blood flooding. The shorter time of the procedure was due to the lack of need for pauses to ventilate the patient.

Ventilation challenge in rigid bronchoscopy: Laser tube as an alternative management in patients with lung cancer and central airway obstruction

INTRODUCTION

Central airway tumors involving the trachea and main-stem bronchi are a common cause of airway obstruction and a significant cause of mortality among the patients of thoracic diseases with respiratory failure. Debulking in rigid bronchoscopy is quick, safe, and effective. It can be complex and hard in patients with severe bronchial or tracheal obstruction and/or with intraluminal bleeding tumors because of inadequate distal airway control. We have used laser tube as a new technique of ventilation for severe central airway obstruction.

MATERIALS AND METHODS

Forty-six patients with severe airway obstruction undergoing rigid bronchoscopy from September 2020 to June 2022 at the Thoracic Surgery Department of the University L. Vanvitelli of Naples underwent placement of laser tube.

RESULTS

In all patients who underwent rigid bronchoscopy with the use of the laser tube, a reduction of obstruction of more than 50% was obtained and in all patients no hypoxia (saturation < 88%), nor hypercapnia, nor significant bleeding were reported.

DISCUSSION

The results of this study suggest that rigid bronchoscopic debulking with the use of laser tube is a safe and effective technique in the management of central airway obstruction.

CONCLUSIONS

The use of the laser tube allows the monitoring of gas exchange, which controls hypoxemia. Thanks to the double cuff put distally to the tracheal obstruction or in the contralateral bronchus to the obstructed one, the laser tube prevents the flooding of blood from debulking below the stenosis. Rigid bronchoscopy with laser tube will expand its use in the future.

Clinical study of multifunctional laryngeal mask in airway interventional therapy

OBJECTIVE

This study is conducted to evaluate the efficacy and safety of using multifunctional intubation laryngeal masks with normal frequency jet ventilation in airway interventional therapy.

METHODS

A total of 200 patients receiving airway interventional therapy were enrolled in this retrospective study and were divided into 2 groups (group M and group P) by doctors in our hospital to compare the effect of different laryngeal masks. Group M used common laryngeal masks and an anesthesia machine for positive pressure ventilation while group P took multifunctional intubation laryngeal masks and used a jet ventilator for normal frequency jet ventilation. The patients' mean arterial pressure, heart rate, arterial oxygen partial pressure (PaO2) and arterial carbon dioxide partial pressure (PaCO2), and the operation time, recovery score and the patients' and doctors' satisfaction levels were compared between the 2 groups.

RESULTS

Both groups were hemodynamically stable, and their PaO2 levels were significantly higher before the operation than that during and after the operation (P < .05). Compared with group M, the PaCO2 level of group P was more stable both during and after the operation, and this difference was statistically significant (P < .05). There was no statistically significant difference in terms of the 2 group's operating time, recovery score, and patients' satisfaction levels (P > .05). However, the satisfaction levels of doctors in group P were higher than that in group M, and this difference was statistically significant (P < .05).

CONCLUSION

As statistics show, the intraoperative hemodynamics and PaO2 and PaCO2 levels were stable, and patients, surgeons and anesthesia operators were satisfied. Therefore, it is feasible to apply multifunctional intubation laryngeal masks with normal frequency jet ventilation in airway interventional therapy and it is a safe and ideal way to ensure ventilation.

Successful extracorporeal membrane oxygenation in a patient with central airway obstruction due to an endotracheal mass

Extracorporeal membrane oxygenation (ECMO) assists blood circulation and gas exchange via a heart–lung machine. ECMO is used mainly in intensive care units as bridging therapy until heart and respiratory failure can be addressed or until transplantation can be performed. ECMO is sometimes used during surgery under general anaesthesia, depending on the patient’s underlying diseases and the nature of the operation. If the oxygen supply and carbon dioxide removal capacity are limited, venovenous (VV)-ECMO can be helpful. Here, we describe the use of VV-ECMO for surgical resection of an endotracheal mass through rigid bronchoscopy in a patient who developed decompensating dyspnoea due to central airway obstruction (CAO).

Self-Expandable Metal Stent in the Management of Malignant Airway Disorders

Background

Self-expanding metallic stent (SEMS) is a palliative therapy for patients with malignant central airway obstruction (CAO) or tracheoesophageal fistula (TEF). Despite this, many patients experience death shortly after SEMS placement.

Aims

We aimed to investigate the effect of SEMS on the palliative treatment between malignant CAO and malignant TEF patients and investigate the associated prognostic factors of the 3-month survival.

Methods

We performed a single-center, retrospective study of malignant CAO or TEF patients receiving SEMS placement. Clinical data were collected using the standardized data abstraction forms. Data were analyzed using SPSS 22.0. A two-sided P-value &lt;0.05 was statistically significant.

Results

106 malignant patients (82 CAO and 24 TEF) receiving SEMS placement were included. The body mass index (BMI), hemoglobin levels, and albumin levels in the malignant TEF group were lower than in the malignant CAO group (all P &lt; 0.05). The procalcitonin levels, C-reactive protein levels, and the proportion of inflammatory lesions were higher in the malignant TEF group than in the malignant CAO group (all P &lt; 0.05). The proportion of symptomatic improvement after the SEMS placement was 97.6% in the malignant CAO group, whereas 50.0% in the malignant TEF group, with a significant difference (P = 0.000). Three months after SEMS placement, the survival rate at was 67.0%, significantly lower in the malignant TEF group than in the malignant CAO group (45.8% vs. 73.2%, P = 0.013). Multivariate analysis revealed that BMI [odds ratio (OR) = 1.841, 95% certificated interval (CI) (1.155-2.935), P = 0.010] and neutrophil percentage [OR = 0.936, 95% CI (0.883–0.993), P = 0.027] were the independent risk factors for patients who survived three months after SEMS placement.

Conclusions

We observed symptom improvement in malignant CAO and TEF patients after SEMS placement. The survival rate in malignant TEF patients after SEMS placement was low, probably due to aspiration pneumonitis and malnutrition. Therefore, we recommend more aggressive treatment modalities in patients with malignant TEF, such as strong antibiotics, nutrition support, and strategic ventilation. More studies are needed to investigate the prognostic factors in patients with malignant airway disorders receiving SEMS placement.

Parameters of high-frequency jet ventilation using a mechanical lung model

High frequency jet ventilationis a mechanical lung ventilation method which uses a relatively high flow usually through an open system. This work examined the effect of high-frequency jet ventilation on respiratory parameters of an intubated patient simulated using a high-frequency jet ventilator attached to a ventilation monitor for measurements of ventilation parameters. The series of experiments altered specific parameters each time (respiratory rate, inspiratory-expiratory (I:E) ratio, and inspiratory pressure), under different lung compliances. A reduction of minute ventilation was observed alongside a rise in respiratory rate, with low airway pressures over the entire range of lung compliances. In addition, an I:E ratio of 2:1 to 1:1; and the tidal and minute volumes were directly related to the inspiratory pressure over all compliance settings. To conclude, the respiratory mechanics in high-frequency jet ventilation are very different from those of conventional rate ventilation in a lung model. Further studies on patients and/or a biological model are needed to investigate pCO2 and end-tidal carbon-dioxide during high-frequency jet ventilation.

Anesthesia for interventional pulmonology

PURPOSE OF REVIEW

Anesthesia for pulmonological interventions is a demanding challenge. This article discusses recent innovations and the implications for periinterventional anesthetic management.

RECENT FINDINGS

Interventional pulmonology is a rapidly expanding specialty with very complex diagnostic and therapeutic approaches that include oncological staging, treatment of obstructive and restrictive lung diseases, recanalization of endobronchial obstructions, and retrieval of foreign bodies. With the development of advanced diagnostic and therapeutic interventions, the application is extended to critically ill patients. Current evidence focusing on the anesthetic techniques is presented here.

SUMMARY

The development of new pulmonological methods requires a tailored anesthesiological approach. Their specific impact must be taken into account to ensure patient safety, goal-oriented outcome diagnostics and -quality, successful interventions, and patient comfort.

Humidified rapid-insufflation ventilatory exchange is a means of oxygenation during rigid bronchoscopy: A case series

Humidified rapid-insufflation ventilatory exchange (HRIVE) is an option for maintenance of oxygenation. This technique allows for oxygenation while the patient is apnoeic due to continuous positive airway pressure and gas exchange through flow-dependent dead space flushing. There is no study about the usage of HRIVE during rigid bronchoscopy. This retrospective study looked at rigid bronchoscopy cases utilizing HRIVE. Data points assessing adequacy of oxygenation and ventilation were recorded at time points: oxygen saturation (SpO2), partial pressure of oxygen (PaO2) and partial pressure of carbon dioxide (PaCO2). Our nine cases had an average baseline SpO2 of 99.26%, 95.56% at 10 min into HRIVE and 95.27% at the end of HRIVE. The average baseline PaO2 was 309.01 mmHg, 124.99 mmHg at 10 min into HRIVE and 128.17 mmHg at the end of HRIVE. The average baseline PaCO2 was 43.26 mmHg, 68.76 mmHg at 10 min into HRIVE and 75.52 mmHg at the end of HRIVE. The average pre-HRIVE end-tidal CO2 (ETCO2) was 38.56 mmHg and the average post-HRIVE ETCO2 was 61.22 mmHg. The average baseline pH was 7.36, 7.22 at 10 min into HRIVE and 7.19 at the end of HRIVE. In this small cohort study, HRIVE was able to maintain adequate oxygenation via the rigid bronchoscope in a select group of patients. Hypercapnia and respiratory acidosis did result after 10 min, which may predispose certain patient populations to complications. HRIVE potentially offers an additional option of oxygenation via the rigid bronchoscope.

Apnoeic oxygenation using transnasal humidified rapid-insufflation ventilatory exchange during rigid bronchoscopy: a report of four cases

General anaesthesia with a muscle relaxant is usually performed for rigid bronchoscopy (RB), but ventilation is challenging due to large amounts of leakage. Optiflow™ supplies 100% humidified, warmed oxygen at a rate of up to 70 l/min and this high flow rate may overcome the leakage problem. This case report describes four patients that were scheduled for RB. The lung lesions were all located below the carina, so a bronchial tube was inserted under general anaesthesia. Once a large amount of leakage was confirmed by manual ventilation, Optiflow™ was connected to the bronchial tube (flow rate, 70 l/min). All of the ports of the bronchoscopy were left open to prevent the risk of outlet obstruction. Oxygenation was well maintained with stable vital signs throughout the procedures, which took up to 34 min without airway intervention. There were no occurrences of cardiac arrhythmia or changes in the electrocardiograms. Respiratory acidosis recovered after emergence, which was confirmed by arterial blood gas analysis in all cases. Apnoeic oxygenation using Optiflow™ was applied successfully during RB. Applying Optiflow™ could make cases of difficult ventilation during RB much easier for the anaesthetist. Larger studies need to demonstrate the efficacy and safety of this technique.

Hypercapnia in COPD Patients Undergoing Endobronchial Ultrasound under Local Anaesthesia and Analgosedation: A Prospective Controlled Study Using Continuous Transcutaneous Capnometry

BACKGROUND

Flexible bronchoscopy (FB) in analgosedation causes alveolar hypoventilation and hypercapnia, the more so if patients suffer from COPD. Nonetheless, neither is capnometry part of standard monitoring nor is there evidence on how long patients should be monitored after sedation.

OBJECTIVES

We investigated the impact of COPD on hypercapnia during FB with endobronchial ultrasound (EBUS) in sedation and how the periprocedural monitoring should be adapted.

METHODS

Two cohorts of consecutive patients - with advanced and without COPD - with the indication for FB with EBUS-guided transbronchial needle aspiration in analgosedation received continuous transcutaneous capnometry (ptcCO2) before, during, and for 60 min after the sedation with midazolam and alfentanil.

MAIN RESULTS

Forty-six patients with advanced COPD and 44 without COPD were included. The mean examination time was 26 ± 9 min. Patients with advanced COPD had a higher peak ptcCO2 (53.7 ± 7.1 vs. 46.8 ± 4.8 mm Hg, p < 0.001) and mean ptcCO2 (49.5 ± 6.8 vs. 44.0 ± 4.4 mm Hg, p < 0.001). Thirty-six percent of all patients reached the maximum hypercapnia after FB in the recovery room (8 ± 11 min). Patients with COPD needed more time to recover to normocapnia (22 ± 24 vs. 7 ± 11 min, p < 0.001). They needed a nasopharyngeal tube more often (28 vs. 11%, p < 0.001). All patients recovered from hypercapnia within 60 min after FB. No intermittent ventilation manoeuvres were needed.

CONCLUSION

A relevant proportion of patients reached their peak-pCO2 after the end of intervention. We recommend using capnometry at least for patients with known COPD. Flexible EBUS in analgosedation can be safely performed in patients with advanced COPD. For patients with advanced COPD, a postprocedural observation time of 60 min was sufficient.

High frequency jet ventilation through mask contributes to oxygen therapy among patients undergoing bronchoscopic intervention under deep sedation

Background

High frequency jet ventilation (HFJV) is an open ventilating technique to maintain ventilation for emergency or difficult airway. However, whether jet ventilation or conventional oxygen therapy (COT) is more effective and safe in maintaining adequate oxygenation, is unclear among patients with airway stenosis during bronchoscopic intervention (BI) under deep sedation.

Methods

A prospective randomized cohort study was conducted to compare COT (high flow oxygen) with normal frequency jet ventilation (NFJV) and HFJV in oxygen supplementation during BI under deep sedation from March 2020 to August 2020. Patients receiving BI under deep sedation were randomly divided into 3 parallel groups of 50 patients each: the COT group (fractional inspired oxygen (FiO₂) of 1.0, 12 L/min), the NFJV group (FiO₂ of 1.0, driving pressure of 0.1 MPa, and respiratory rate (RR) 15 bpm) and the HFJV Group (FiO₂ of 1.0, driving pressure of 0.1 MPa, and RR of 1200 bpm). Pulse oxygen saturation (SpO₂), mean arterial blood pressure and heart rate were recorded during the whole procedure. Arterial blood gas was examined and recorded 15 min after the procedure was initiated. The procedure duration, dose of anesthetics, and adverse events during BI in the three groups were also recorded.

Results

A total of 161 patients were enrolled, with 11 patients excluded. The clinical characteristics were similar among the three groups. PaO₂ of the COT and NFJV groups was significantly lower than that of the HFJV group (P < 0.001). PaO₂ was significantly correlated with ventilation mode (P < 0.001), body mass index (BMI) (P = 0.019) and procedure duration (P = 0.001). Multiple linear regression showed that only BMI and procedure duration were independent influencing factors of arterial blood gas PaO₂ (P = 0.040 and P = 0.002, respectively). The location of airway lesions and the severity of airway stenosis were not statistically correlated with PaCO₂ and PaO₂.

Conclusions

HFJV could effectively and safely improve intra-operative PaO₂ among patients with airway stenosis during BI in deep sedation, and it did not increase the intra-operative PaCO₂ and the risk of hypercapnia. PaO₂ was correlated with ventilation mode, BMI and procedure duration. Only BMI and procedure duration were independent influencing factors of arterial blood gas PaO₂. PaCO₂ was not correlated with any preoperative factor.

Trial registration

Chinese Clinical Trial Registry. Registration number, ChiCTR2000031110, registered on March 22, 2020.

Multi-Institutional Analysis of Outcomes in Supraglottic Jet Ventilation with a Team-Based Approach

OBJECTIVES/HYPOTHESIS

To evaluate the safety and complications of endoscopic airway surgery using supraglottic jet ventilation with a team-based approach.

STUDY DESIGN

Retrospective cohort study.

METHODS

Subjects at two academic institutions diagnosed with laryngotracheal stenosis who underwent endoscopic airway surgery with jet ventilation between January 2008 and December 2018 were identified. Patient characteristics (age, gender, race, follow-up duration) and comorbidities were extracted from the electronic health record. Records were reviewed for treatment approach, intraoperative data, and complications (intraoperative, acute postoperative, and delayed postoperative).

RESULTS

Eight hundred and ninety-four patient encounters from 371 patients were identified. Intraoperative complications (unplanned tracheotomy, profound or severe hypoxic events, barotrauma, laryngospasm) occurred in fewer than 1% of patient encounters. Acute postoperative complications (postoperative recovery unit [PACU] rapid response, PACU intubation, return to the emergency department [ED] within 24 hours of surgery) were rare, occurring in fewer than 3% of patient encounters. Delayed postoperative complications (return to the ED or admission for respiratory complaints within 30 days of surgery) occurred in fewer than 1% of patient encounters. Diabetes mellitus, active smoking, and history of previous tracheotomy were independently associated with intraoperative, acute, and delayed complications.

CONCLUSIONS

Employing a team-based approach, jet ventilation during endoscopic airway surgery demonstrates a low rate of complications and provides for safe and successful surgery.

LEVEL OF EVIDENCE

Level 4 Laryngoscope, 2021.

High-Frequency Jet Ventilation for a Patient With Tracheomediastinal Fistula, Tension Pneumomediastinum, and Pneumothorax: A Case Report

Tracheomediastinal fistula (TMF) is an uncommon condition and carries a high mortality. We report the anesthetic management of a patient with TMF using stent insertion via rigid bronchoscopy. The TMF was a complication of double-lumen endotracheal tube insertion resulting in a tension pneumomediastinum. Initial intraoperative attempts to ventilate the lungs and overcome the air leak with high gas flow of 45 L/min via the side port of the bronchoscope resulted in a pneumothorax. This case report demonstrates that high-frequency jet ventilation can minimize the air leak and avoid barotrauma during anesthesia for TMF repair.

Ultrasound-guided superior laryngeal nerve block assists in anesthesia for bronchoscopic surgical procedure: A case report of anesthesia for rigid bronchoscopy

INTRODUCTION

Evolving techniques in the field of therapeutic bronchoscopy have led to the return of rigid bronchoscopy in the treatment of complex central airway disease. Rigid bronchoscopy is typically performed under general anesthesia because of the strong stimulation caused by metal instruments. Anesthesia for rigid bronchoscopy is challenging to administer because anesthesiologists and interventionists share the same working channel: the airway. Previously reviewed anesthetic methods are used primarily for short procedures. Balanced anesthesia with ultrasound-guided superior laryngeal nerve (SLN) block and total intravenous anesthesia might provide anesthesia for a prolonged procedure and facilitate patient recovery.

PATIENT CONCERNS

A patient with obstructed endobronchial stent was referred for therapeutic rigid bronchoscopy, which requires deeper anesthesia than flexible bronchoscopy. There were concerns of the stronger stimulation of the rigid bronchoscopy, lengthy duration of the procedure, higher risk of hypoxemia, and the difficulty of mechanical ventilation weaning after anesthesia due to the patients co-morbidities.

DIAGNOSIS

A 66-year-old female patient presented with a history of breast cancer with lung metastases. Right main bronchus obstruction due to external compression of lung metastases was relieved through insertion of an endobronchial stent, but obstructive granulation developed after 4 months. Presence of the malfunctioning stent caused severe cough and discomfort. Removal of the stent by using a flexible bronchoscope was attempted twice but failed.

INTERVENTIONS

Regional anesthesia of the upper airway through ultrasound-guided SLN block combined with intratracheal 2% lidocaine spray was performed to assist in total intravenous anesthesia (TIVA) during rigid bronchoscopy.

OUTCOMES

The patient maintained steady spontaneous breathing throughout the procedure without laryngospasm, bucking, or desaturation. Emergence from anesthesia was smooth and rapid after propofol infusion was discontinued. The surgery lasted 2.5 hours without discontinuity, and no perioperative pulmonary or cardiovascular complications were noted.

CONCLUSION

Ultrasound-guided SLN block is a simple technique with a high success rate and low complication rate. Application of SLN block to assist TIVA provides sufficient anesthesia for lengthened therapeutic rigid bronchoscopy without interruption and facilitates patient recovery.

Preemptive veno-venous ECMO support in a patient with anticipated difficult airway: A case report

This report presents a case of endotracheal metastasis in which elective veno-venous extracorporeal membrane oxygenation (VV ECMO) was used to undergo tracheal laser-surgery prior to establishment of a definitive airway. Specifically, we describe the respiratory and airway management in an adult patient from the preclinical phase throughout elective preoperative ECMO implantation to postoperative ECMO weaning and decannulation in the Intensive Care Unit. This case report lends further supports to the idea that the extracorporeal membrane oxygenation could be electively used to provide safe environment for surgery in situations where the standard maneuvers of sustaining adequate gas exchange are anticipated to fail.

An Alternative Method for Airway Management With Combined Tracheal Intubation and Rigid Bronchoscope

An innovative technique for airway management, using a small-diameter, short-cuffed orotracheal tube for assisting rigid bronchoscopy in critical airway obstruction is reported. The device, part of the translaryngeal tracheostomy kit, "Fantoni method" (DAR TLT, Covidien, Minneapolis, MN), was placed beyond the stenosis and used in combination with the rigid bronchoscope. This procedure improves safety during the management of critical tracheal stenoses because the airway is constantly under the anesthesiologist's control. Consequently, inhalation anesthesia is feasible, use of neuromuscular blockade is possible, end-tidal carbon dioxide monitoring is reliable, and the distal airway is protected from blood and debris soilage during tumor debulking. Surgery is faster because it is uninterrupted.

Interventional Pulmonology

Bronchoscopy presents a unique challenge and need for collaboration between anesthesia providers and bronchoscopists. The approach to topical anesthesia, analgesia, and sedation must be customized based on complexity, duration, and setting. The bronchoscopy team must work together in each phase of the procedure to ensure patient safety and allow completion of a quality bronchoscopy. Airway access may change depending on the type of procedure planned and must be discussed before each case. Intraprocedural difficulties with ventilation, airway pressure, and sedation may arise that must be addressed together. This review highlights an approach to these common challenges.

Recovery process and determinants of adverse event occurrence in bronchoscopic procedures performed under general anaesthesia

OBJECTIVE

Regarding the fact that rigid bronchoscopy is generally performed under general anaesthesia and this patient subgroup is remarkably morbid, encountering procedure and/or anaesthesia related complications are highly likely. Here, we aimed to assess factors influencing recovery and detect possible determinants of adverse event occurrence during these operations performed in a tertiary referral centre.

METHODS

Eighty-one consecutive ASA I-IV patients were recruited for this investigation. In the operating theatre after induction of anaesthesia and advancement of the device, maintenance was provided with total intravenous anaesthesia. Neuromuscular blockage was invariably administered, and patients were ventilated manually. In addition to preoperative demographic and procedural characteristics, perioperative hemodynamic variables, recovery times and observed adverse events were noted.

RESULTS

Basic demographic properties, ASA and Mallampati scores, and procedure specific variables as lesion localization, lesion and procedure type were comparable among groups assembled with reference to event occurrence. Patients who had experienced adverse event had higher heart rates. Recovery times were comparable between Event (-) and Event (+) groups. Relationship of recovery process were individually tested with all variables and only lesion type was detected to have an effect on respiration and extubation times. Among all parameters only procedural time seemed to be associated with adverse event occurrence (mins, 22.9 ± 11.9 vs 41.6 ± 28.8, P < .001).

CONCLUSION

Recovery times related with return of spontaneous respiration were significantly lower in procedures performed for treatment of tumoral diseases in this study and procedure length was determined to be the ultimate factor which had an impact on adverse event occurrence.

Biphasic Cuirass Ventilation During Anesthesia for Tracheobronchial Stent Insertion or Removal by a Rigid Bronchoscope: A Case Report

Airway management and ventilation during a tracheobronchial stenting procedure are challenging given that mandatory positive pressure ventilation cannot be fully achieved while using a rigid bronchoscope due to leakage from the scope tip. Biphasic cuirass ventilation is a negative pressure ventilation method using an external cuirass fitted to the anterior chest, which could assist in spontaneous breathing and ventilation support. We report 3 successful anesthesia cases in which we could maintain adequate ventilation and oxygenation, supported by biphasic cuirass ventilation, in patients undergoing tracheobronchial stent placement or removal procedures using rigid bronchoscopy.

Anesthesia for interventional pulmonology procedures: a review of advanced diagnostic and therapeutic bronchoscopy

PURPOSE

Interventional pulmonology is a growing subspecialty of pulmonary medicine with flexible and rigid bronchoscopies increasingly used by interventional pulmonologists for advanced diagnostic and therapeutic purposes. This review discusses different technical aspects of anesthesia for interventional pulmonary procedures with an emphasis placed on pharmacologic combinations, airway management, ventilation techniques, and common complications.

SOURCE

Relevant medical literature was identified by searching the PubMed and Google Scholar databases for publications on different anesthesia topics applicable to interventional pulmonary procedures. Cited literature included case reports, original research articles, review articles, meta-analyses, guidelines, and official society statements.

PRINCIPAL FINDINGS

Interventional pulmonology is a rapidly growing area of medicine. Anesthesiologists need to be familiar with different considerations required for every procedure, particularly as airway access is a shared responsibility with pulmonologists. Depending on the individual case characteristics, a different selection of airway method, ventilation mode, and pharmacologic combination may be required. Most commonly, airways are managed with supraglottic devices or endotracheal tubes. Nevertheless, patients with central airway obstruction or tracheal stenosis may require rigid bronchoscopy and jet ventilation. Although anesthetic approaches may vary depending on factors such as the length, complexity, and acuity of the procedure, the majority of patients are anesthetized using a total intravenous anesthetic technique.

CONCLUSIONS

It is fundamental for the anesthesia provider to be updated on interventional pulmonology procedures in this rapidly growing area of medicine.