High-risk bronchoscopy

Fiberoptic bronchoscopy may be performed in patients with acute respiratory distress after thoracic surgical procedures as a measure to avoid intubation and subsequent positive-pressure ventilation in a patient with mucous impaction or as a method of intubating in a patient with a difficult airway. We describe the indications, the technique, and the potential complications.     

Paediatric bronchoscopy

Anaesthesia for paediatric bronchoscopy requires special equipmentand a sound knowledge of the anatomy, physiology and pathologyof the paediatric airway, which determine key differences betweenpaediatric and adult bronchoscopy. Whenever possible it shouldbe performed in a tertiary referral centre. There must be excellentcommunication between the anaesthetist and the endoscopist toensure that adequate oxygenation is maintained via the sharedairway.     

Flexible fiberoptic bronchoscopy

The flexible fiberoptic bronchoscope has become an invaluable diagnostic and therapeutic instrument in the management of pulmonary disease. Advantages over the conventional rigid bronchoscope include airway examination to the subsegmental level, increased accuracy of diagnosis in pulmonary malignancy, patient comfort, ease of bedside examination, and atraumatic aspiration of postoperative secretions. Disadvantages include cost, inability to remove foreign bodies, and lack of a satisfactory technique for infant endoscopy. The extended range of diagnostic and therapeutic capabilities of the flexible bronchoscope makes it an important instrument for the thoracic surgeon.     

Laser bronchoscopy.

Because the lung cancer epidemic shows no signs of abating, little doubt exists that the need for interventional bronchoscopists will persist for many years to come. The Nd:YAG laser and the rigid bronchoscope remain crucial weapons in the fight against lung cancer. With more than 4000 published interventions pertaining to it, this combination is ideal for treating central airways obstruction. The safety and efficacy of laser bronchoscopy has been well established, and the reported incidence of complications is impressively low. If complications were to arise, a skilled bronchoscopist can manage them easily by using the beneficial attributes of the rigid bronchoscope. Many complications can be avoided by implementing the established safety procedures and techniques. A solid understanding of laser physics and tissue interactions is a necessity to anyone performing laser surgery. The team approach, relying on communication among the bronchoscopist, anesthesiologist, laser technician, and nurses, leads to a safer and more successful procedure. It is important to remember, however, that this is typically a palliative procedure, and therefore the focus should be on alleviating symptoms and improving quality of life. Unfortunately, because not every patient is a candidate for laser bronchoscopy, there are specific characteristics of endobronchial lesions that make them more or less amenable to resection. Each year a promising new technology is being developed, such as argon plasma coagulation, cryotherapy, and endobronchial electrosurgery. Although it is unclear what role these technologies will have, prospective controlled studies must be done to help clarify this question. The future may lay in combining these various technologies along with Nd:YAG laser bronchoscopy to maximize the therapeutic, palliative, and possibly even curative effect. As the experience of the medical community with Nd:YAG laser bronchoscopy continues to grow and as more health-care professionals are made aware of its therapeutic capability, fewer patients with cancer will need to suffer and die from the complications of airway obstruction.     

Video-assisted interventional bronchoscopy

Background: Major airway obstruction due to benign or malignant etiology is not uncommon and is always distressing. Intraluminal stenting has been shown to be a safe and effective approach for symptomatic relief in selected patients based on the European and North American experience. Methods: We reviewed our experience in Hong Kong on airway stenting over a 19-month period. Results: From February 1994 to August 1995, 33 silicone stents (Dumon stent, Cometh, Marseille, France) were placed in 23 patients (20 males, three females with mean age 61.4 years, range from 26 to 81). Eighteen stents were placed in the trachea, nine in the left main stem, five in the right main stem, and one Y-stent over the carina. Twelve patients had esophageal carcinoma involving the airway, seven had bronchial carcinoma, one had metastatic carcinoma, and three had benign strictures (of which two were due to tuberculosis). There was no procedural related mortality. Stent migration occurred in four patients (17%) and required stent change. Symptoms were improved in all patients as documented by the visual analogue scale. Conclusion: Our experience represents the ``stentable' diseases seen in Hong Kong, where carcinoma of the esophagus (and tuberculosis) remains prevalent. We conclude that intraluminal stenting remains a safe and effective approach in selected patients with critical airway stenosis. Complications, however, do exist and should be realized by the operator, the patients, and their families. Received: 4 September 1996/Accepted: 3 August 1996     

Anaesthesia for bronchoscopy

The control module of the Nuffield (A-P) Anaesthetic Ventilator was found to be an efficient means of automatically controlling the ventilation of the lungs through a bronchoscope during a series of laboratory experiments. The relationships between lung characteristics (compliance and airway resistance) and the driving flow rate through various injectors on the final oxygen concentrations and tidal volumes delivered were determined. A 14 gauge injector provided the largest tidal volumes with the least entrainment of air.     

Awareness during bronchoscopy.

The purpose of the study was to assess the incidence of awareness during bronchoscopy and to evaluate the effectiveness of auditory random noise in preventing awareness. All patients were unpremedicated and underwent elective bronchoscopy under thiopentone-suxamethonium anaesthesia. Half the patients received auditory random noise preoperatively. Patients were interviewed postoperatively and the incidence of awareness and dreaming assessed. Eleven patients described awareness, of whom three had received random noise. No relation with awareness could be shown with the age and sex of the patient, nor was awareness related to the dosage of thiopentone. Awareness was associated with a short time interval between removal of the bronchoscope and response to command. Awareness is still an important problem in anaesthesia and the use of random noise stimulation to block auditory input of relevance to the patient merits further investigation.     

Improved oxygenation during bronchoscopy

A method for the continuous administration of oxygen during fiberoptic bronchoscopy is described. The procedure has proved effective in elevating marginal intraoperative arterial oxygen tensions to safe levels in most patients.