Bronchoscopy
Anesthesia type GA vs. MAC
Airway ETT (use > 8.0 tube) / LMA
Lines and access PIV x 1
Monitors Standard
Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative


A bronchoscopy is a procedure that involves examining the tracheobronchial tree for diagnostic and/or therapeutic purposes. The bronchoscope can either be flexible or rigid. Flexible bronchoscopes, which are more commonly used, have multiple ports that allow the proceduralist to visualize, suction, irrigate, and take biopsies. Spontaneous ventilation can be maintained when using a flexible bronchoscope, which affords the possibility of doing this procedure on an awake patient (although a flexible scope can also be introduced via an LMA/ETT). A rigid bronchoscope has a larger working channel, which allows for the introduction of larger instruments for grasping, sampling, or retrieving samples or foreign objects.

Preoperative management

Patient evaluation

System Considerations
Neurologic
Cardiovascular In patients with CAD, the adrenergic response during airway manipulation could precipitate myocardial ischemia. Breakthrough sympathetic responses can be managed with beta blockers or short acting narcotics.
Respiratory High incidence of COPD and respiratory disease. Stridor at rest could suggest airway narrowing.
Gastrointestinal
Hematologic Patients with malignancy may have anemia or coagulopathy
Renal
Endocrine
Other Careful assessment of teeth and documentation of any loose or missing teeth. Inform patients that dental trauma may occur from surgical instrumentation.

Labs and studies

Operating room setup

  • Have bronchoscopy swivel adapter (allows bronchoscope to be inserted through ETT/LMA)

Patient preparation and premedication

  • Glycopyrolate to dry the airway
  • Albuterol if wheezing noted pre-operatively
  • Avoid sedative premedication in elderly or patients with upper airway obstruction
  • Patients with significant respiratory disease may need specialized ventilation techniques, such as jet ventilation, apnea intermittent ventilation, high-flow nasal cannula
  • A plan (and backup plan) for securing the airway should be discussed with surgeon prior to induction, particularly if airway is compromised

Regional and neuraxial techniques

Intraoperative management

Monitoring and access

Induction and airway management

  • If doing a GA, can use ETT or LMA
    • Need large ETT (8.0 or greater) to accommodate bronchoscope
    • Succinylcholine or intermediate acting NDMR
    • LTA lidocaine
  • If doing a MAC, have supplies ready to secure aware if needed

Positioning

  • Supine

Maintenance and surgical considerations

  • Consider TIVA with propofol/remifentanyl
    • Avoid inhalation agents given the potential for large leaks
  • Minimal use of narcotics given brevity of case
  • Decadron

Emergence

Postoperative management

Disposition

Pain management

Potential complications

  • Bleeding from biopsy sites
  • Laryngospasm
  • Breathing difficulties
  • Sore throat

Procedure variants

Flexible bronchoscopy Rigid bronchoscopy
Unique considerations
Position Supine Supine
Surgical time 10-30 mins 10-30 mins
EBL Minimal Minimal
Postoperative disposition PACU PACU
Potential complications

References