Sedation and anesthesia for interventionist bronchoscopy Marcelo Gervilla

Sedation and anesthesia for interventionist bronchoscopy Marcelo Gervilla Gregório - SP

But… What is non-interventionist bronchoscopy? O que é broncoscopia nãointervencionista?

non-interventionist bronchoscopy is …

non-interventionist bronchoscopy is … Virtual bronchoscopy

All the others are interventionist bronchoscopy Significant haemorrhage (>50 ml) occurred in 1. 6– 4. 4% of patients with diffuse lung disease from whom transbronchial biopsy specimens were taken. Br J Dis Chest 1981; 75: 258– 62.

General Anesthesia and Levels of Sedation/Analgesia American Society of Anesthesiologists. ASA Standards, Guidelines and Statements, October 2007

preference possible not recommended PROCEDURE SEDATION MILD Dynamic assessment of the airways Bronchoscopy to take species (BAL BTB) EBUS Brachytherapy Tumor desobstruction / Placement of stents Stenosis dilatation Removal of foreign bodies Emphysema treatment / Thermoplasty MOD ANESTHESIA DEEP

Anesthetic and access approaches utilized 1. 2. 3. Support on a ventilator laryngeal mask airway access by flexible bronchoscopy, procteted by block bit Full support on a ventilator with endotracheal tube airway access by flexible bronchoscopy, procteted by block bit Rigid bronchoscopic intubation with IV sedation and spontaneous breathing partially supported by ventilation through the rigidbronchoscope (combined techniques rigid Chest 2006; 129; 518 -526

preference possible not recommended ANESTHESIA PROCEDURE Bronchoscopy to take species (BAL BTB) EBUS Tumor desobstruction Stenosis dilatation Removal of foreign bodies Thermoplasty / Emphysema treatment Placement of stents laryngeal mask endotracheal tube rigidbronchoscope

Ventilation through the rigidbronchoscope • • Spontaneous assisted ventilation, Controlled ventilation with Venturi Jet High-frequency ventilation Closedcircuit

combined techniques: flexible through rigid

only flexible through laryngeal mask

ANESTHETICS QUESTIONS ABOUT COPD AND ASTHMATICS PATIENTS IS IT NEW? ? ?

1917 Syme WS. Br Med J. 1917 Jun 30; 1(2948): 868 -869

KIT FOR TREATMENT COCAINE ADRENALIN SILVER NITRATE

Bronchoscopy in lung function n n Bronchoscopic procedures have been shown to cause a decrease in lung volumes in normal individuals. Topical anesthetics and/or systemic sedation may enhance the mechanic effects of the bronchoscope, leading to decrease both in FEV 1 and FVC Am J Respir Crit Care Med 2005; 172: 807– 816

Safety of bronchoscopy in asthmatic n n The fall in FEV 1 in association with bronchoscopy was inversely related to PC 20. Most adverse events were associated with BAL Chetta A. Chest 1992; 101: 1563– 1568

COPD n X ASTHMA Bronchoscopy is thought to be safer in patients with COPD than with asthma because of lower levels of bronchial hyperresponsiveness.

COPD n X ASTHMA Bronchoscopy is thought to be safer in patients with COPD than with asthma because of lower levels of bronchial hyperresponsiveness. COPD & ASTHMA

Major complications n n n Need for noninvasive ventilation Need for invasive ventilation Hemoptysis Hemodynamic instability requiring vasoactive drugs Pneumothorax Death Chest 2007; 131; 765 -772

Major complications n n n Need for noninvasive ventilation Need for invasive ventilation Hemoptysis prevented or treated by rigid bronchoscope !!!!!! Chest 2007; 131; 765 -772

Anaesthetic Protocol for Rigid Bronchoskopie – Thoraxklinik Heidelberg n n Pre-medication: Midazolam 7. 5 mg Atropin 0. 5 mg PO (or 2 mg IV) PO In the Endoscopy suite: Initially spontaneously breathing (with O 2 maskheld in front of patient) followed by assisted ventilation with 100% O 2

Anaesthetic Protocol for Rigid Bronchoskopie – Thoraxklinik Heidelberg IV Anaesthetics: Propofol 1. 0 -1. 5 mg/kg BW Rocuronium 5 mg Succinylcholin 1. 0 mg/kg BW Remifentanyl 0. 1 ug n IV IV Followed by intubation with rigid bronchoscope or if not possible with endotracheal tube size 8. 5/ 9. 0 or laryngeal mask size 4/5 (both suitable for flexible bronchoscopy only).

Anaesthetic Protocol for Rigid Bronchoskopie – Thoraxklinik Heidelberg Jet ventilation: 70 kg adult patient: Jet-frequency 100/min Pressure 1. 5 -2. 0 bar (= 23 -28 l/min) n Children (depending on age and weight): Jet-frequency 150/min Pressure 0. 5 – 1. 0 bar (16 l/min) If HFJV not available, ventilate manually with 100% O 2 via side-port on rigid bronchoscope (Storz) n

Conclusion n n All bronchoscopist must be trained and fit for both techniques: rigid & flexible sedation & general anesthesia The practice of combined methods is an excellent choice for developing a respiratory endoscopy center offering greater safety to patients and efficiency of methods

Lessons I’ve learned with Dr. Becker Life is like bronchoscopy… Full of risks, but once you have to live it Get the best you can of it !!!