Download Anesthesia for adult rigid bronchoscopy

(Acta Anaesth. Belg., 2014, 65, 95-103)
Anesthesia for adult rigid bronchoscopy
A.-S. Dincq (*), M. Gourdin (*), E. Collard (*), S. Ocak (**), J.-P.
C. Dahlqvist (**), D. Lacrosse (*) and L. Putz (*)
Abstract : Rigid bronchoscopy under general anesthesia
enables performing diagnostic and/or therapeutic procedures in the tracheobronchial tree. This technique is characterized by specific technical problems, insofar as the
anesthesiologist and the operators share the same space,
namely the airway. Several potential complications
(hemorrhage inside the airway, threat to ventilation …)
may arise. These challenges render the ability to use the
variable available techniques essential, as well as knowledge of the complications they could entail, and the ability to rapidly solve them. General anesthesia is usually
total intravenous anesthesia, using short acting agents.
Ventilation can be spontaneous, but more often insured
using high-frequency jet ventilation. The hospital infrastructure and staff must have the expertise to perform this
particular procedure, in order to limit the complication
rate.
Key words : Anesthesia ; bronchoscopy ; adult.
d’Odémont
(**),
Specific equipment
A rigid bronchoscope, such as the Efer-Dumon
bronchoscope (Fig. 1), consists of a metal tube fitted
on a base. The base includes first a wide axial entrance to introduce the optic device or introduce
specific instruments such as clips, dilation balloons,
or stents. The optic device can be a rigid one, which
can be used to view the operative field directly or
through an integrated video system, or can be a flexible bronchoscope. The flexible bronchoscope allows reaching more distal lesions. Second, the base
contains an oblique lateral entrance, through which
a laser fiber, an argon plasma coagulation probe, or
a suction cannula can be passed. The third orifice of
the base is a lateral entrance that is specifically devoted to ventilation.
Introduction
Indications of rigid bronchoscopy
Rigid bronchoscopy (RB), initially performed
under local anesthesia, was first described in 1898
by Killian (1). Today, general anesthesia and appropriate ventilation method are recommended. RB
offers a wide range of diagnostic and therapeutic
options for the upper airway. Some procedures even
allow avoiding conventional surgery such as thoracoscopy. The anesthetic management during rigid
bronchoscopy is challenging. It necessitates the
management of the airway of fragile patients, often
presenting with an American Society of Anesthesiologists (ASA) physical status III or IV, and an already critically compromised airway. Here we propose to review the specific RB perioperative
management. Given the possible occurrence of
acute complications such as obstruction of the airway, bleeding, or pneumothorax, and the need for
manipulating specific devices and techniques, such
as High Frequency Jet Ventilation (HFJV) or extracorporeal circulation, this specialized activity must
be performed in hospital environments that gather
the needed equipment and expertise. This is the
only way to ensure patient safety.
The main indication for rigid bronchoscopy is
the diagnostic and treatment of intra- and/or extraluminal obstruction of the airway. The stenosis can
be located in the trachea, the carina, or the primary
or intermediate bronchial tubes. Lesions that provoke the obstruction can be malignant or benign tumors, or foreign bodies. In the event of an acute
tracheal obstruction by a malignant pathology, such
as primary bronchogenic carcinoma or bronchial
metastases, rigid bronchoscopy enables palliative
obstruction relief of the main airway, and can be
temporarily life-saving (2, 3). In some patients, it
Anne-Sophie Dincq, M.D. ; Maximilien Gourdin, M.D.,
Ph.D. ; Edith Collard, M.D. ; Sebahat Ocak, M.D., Ph.D. ;
Jean-Paul d’Odémont, M.D. ; Caroline Dahlqvist, M.D. ;
Dominique Lacrosse, M.D. ; Laurie Putz, M.D.
(*) Anesthesia Department, (**) Department of Pneumology,
Centre Hospitalier Universitaire de Dinant Godinne asbl,
5530 Yvoir, Belgium.
Correspondence address : Anne-Sophie Dincq, Department
of Anesthesia, Centre Hospitalier Universitaire de Dinant
Godinne, 5530 Yvoir.
E-mail : [email protected]
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Fig. 1.
will serve as a stabilization procedure before surgery.
Benign pathologies usually involve iatrogenic
stenosis (including post-intubation fibrosis, and
post-transplant stenosis), amyloid or granulomatous
infiltration, or extrinsic compression (e.g. tumors of
the mediastinum). Other types of indications include intra-luminal tracheo-bronchial repair of sealing defects, including esophageal-airway or broncho-pleural fistulas, stabilization of malacic
segments, treatment of infectious complications
(e.g. papillomatosis, or tuberculosis), hemorrhage,
reduction of pulmonary volume by means of oneway endo-bronchial valves, or biopsies and cryotherapy.
Foreign body aspiration deserves special attention. In adults, flexible bronchoscopy may be used
for diagnosis and extraction. Non-asphyxiating foreign bodies may often be removed under conscious
sedation. In case of asphyxia or flexible bronchoscopy failure, RB remains the gold standard. RB operators who wish to perform foreign body extraction body with flexible bronchoscopy must be
trained in both techniques (4). The foreign body is
usually removed using forceps, snares, and/or
baskets (5). Asphyxiation due to foreign body’s
­
­migration is one of the procedural risks.
Contraindications
Contraindications are rare when the procedure
is managed by experienced anesthesiologists and
competent operating room staff (6). Relative contraindications include uncontrolled coagulopathy,
extreme ventilation and oxygenation demands, and
tracheal obstruction (7).
Treatment techniques
Most of diagnostic procedures are performed
using a flexible bronchoscope under local anesthesia or deep sedation and laryngeal mask control of
the airway. The rigid bronchoscope allows performing therapeutic acts with immediate or delayed
­effects. Those therapeutic acts include, for example,
cryo-therapy, bronchial brachytherapy, or dynamic
phototherapy (8). Here, we will consider the techniques that produce immediate therapeutic results.
Rigid bronchoscope
Owing to its beveled end, and using rotary progression, the rigid bronchoscope can be used for
mechanical resection. In that case, its tip can be
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used to “drill” through large tumors. In case of lifethreating airway obstruction, it allows restoring
­efficient ventilation rapidly. Large suction catheters
can aspirate blood or remove tissue debris easier
than during flexible bronchoscopy.
jet of ionised argon, and has shallow penetration
(1-3 mm). It ensures superficial coagulation without
affecting the underlying tissues.
Balloon dilation
Stents can be used to restore and maintain the
proximal airway permeability when compromised
by various types of intrinsic or extrinsic obstructions. They also help sealing the airway walls in
case of eso-tracheal fistulae, dehiscence of bronchial suture after lung transplant, or tracheobronchomalacia. Type of stents may vary according to their
physical properties, shape, size, and material composition. They can be made of silicone, or metal,
they can be uncovered, partially or totally covered.
Others are hybrid, or even biodegradable (11).
­Silicone stents are chosen for benign pathologies as
they are intended to be removed with ease. Uncovered or partially covered metallic stents are primarily used for palliative indications, given the difficulty of removing them. When subsequent tracheal
intubation is needed, it must be performed under
­fiberscope monitoring. Otherwise, supra-glottic
­devices, such as laryngeal masks, are an alternative.
Balloon dilation is performed using a balloon
catheter that is attached to a stylet and pushed
through the stenosis. Sterile saline filling of the
­balloon during 30 to 120 seconds and applying a
1-5 mmHg pressure can be monitored using flexible
bronchoscope or X-ray. The maneuver can be repeated in case of persistent stenosis. The results are
immediate, but often transient. This technique is
very stimulating for the patient, mainly causing
coughing. It may also prevent the below dilation
zone from being ventilated. The sequential introduction of progressively enlarging dilators can be
combined with balloon dilation.
Laser
Lasers are of various types. Their wavelength
(λ) conditions the vaporization and coagulation effects. The neodymium, or yttrium aluminum garnet
(Nd :YAG) laser (λ = 1064 nm) reaches tissues at a
3-5 mm depth, and provides adequate photocoagulation, as compared to the carbon dioxide (CO2)
­laser (λ = 10600 nm). This last laser can be used to
achieve superficial tissue penetration (0.1-0.5 mm),
but has low hemostasis power. It is mainly used
mainly during ear, nose and throat surgery. Recently, the thallium laser (λ = 1.9 nm) has become
­available. Its energy is totally absorbed by the tissue
surface, making it more precise than the Nd:YAG
laser (9). In 83-93% of cases, the Nd:YAG laser has
proved being efficient at relieving endo-bronchial
obstructions of pulmonary cancer origin (10).
High-frequency thermo-coagulation
The energy produced by an electrical current
can be used for coagulation, similarly to the
­coagulation obtained with the Nd:YAG laser. This
technique is less expensive, but requires frequent
cleaning of the probe.
Argon plasma coagulation
Argon plasma coagulation is a monopolar
electrosurgical technique that delivers energy,
­without coming into contact with tissues. It uses a
Stents
Anesthetic management
Rigid bronchoscopy under general anesthesia
is safe and effective (12-14). However, a discussion
between the operator and the anesthesiologist must
take place prior to the procedure, in order to precisely define the actions to be undertaken and their
sequence, and to anticipate any complications that
could jeopardize the vital prognosis of the patient.
Rigid bronchoscopy must be performed in the
­operating room. A radioscope must be available,
and the patient installed on a radioscopy-compatible
tray (15). The ability to perform urgent thoracotomy is also mandatory (16). Ideally, vascular embolization and extracorporeal circulation techniques
should be readily available. A video screen is useful
for allowing visualization of the procedure by the
entire team, and enabling them readily responding
to events.
Preoperative assessment
The pre-anesthesia consultation must be
adapted to the technique, the status of the patient
and the degree of emergency. Patients are frequently of ASA III-IV physical status (15). They suffer
from critical diseases, and present variable degrees
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of dyspnea or respiratory distress. When patients
present repeatedly, it is important to consult previous medical reports describing the anesthetic strategy (ventilation, intubation), and the encountered
difficulties. However, and noteworthy, the incidence of difficult laryngoscopy is not higher than
the incidence of the normal population (12).
Several tests can be performed to precise the
nature and location of the airway obstruction, and
guide therapeutic management. A conventional Xray of the thorax cannot determine with precision
the size, location and extent of the pathology (12).
If an oro-tracheal intubation is planned, a thoracic
scanner, possibly with biplanar or even three-dimensional reconstruction, or nuclear magnetic resonance may be considered (17, 18) to provide information on the diameter of the tube to be inserted,
the distance of introduction into the trachea, or
eventual unfeasibility of the procedure (15). A fiberscope can be used to describe the lesion, its localization, or macroscopic aspect. Functional respiratory testing estimates the impact of the pathology
on the respiratory dynamics, and the reversibility of
this impact. Flow curve or flow rate volume analysis allows differentiating between intra or extra-thoracic, and fixed or variable obstruction of the airway. Blood gases analysis performed when the
patient is breathing ambient air is useful for evaluating the primary state of the patient in terms of hypoxemia and hypercarbia. These are factors that can
predict complications during and after the procedure (16).
Premedication
Sedative premedication must be used with
caution, as it can cause hypoventilation and aggravate airway obstruction. Medications reducing saliva and bronchial tree secretions are useful. Scopolamine is the most potent in that respect.
Anticholinergic agents also reduce the vagotonic
effects of remifentanil. Oral clonidine, at a dose of 4
to 4.5 µg/Kg, with a maximum of 300 µg, and given
an hour and a half before the procedure is encouraged, particularly for patients at coronary risk (19).
Bronchodilators are still given in the perioperative
period in order to condition and improve lung function. Except for emergencies, fasting is in line with
any procedure requiring general anesthesia.
Intraoperative care
Standard equipment and monitoring, in line
with the Helsinki Declaration on patient safety (20),
et al.
should include electrocardiography, pulse oximetry,
non-invasive blood pressure monitoring, and muscle relaxation monitoring. Expired fraction of CO2
monitoring is often compromised, owing to ventilation methods. The alternatives are transcutaneous
CO2 measurement, intermittent blood sample drawing and analysis through an eventual arterial line,
aspiration of CO2 through the injector of HFJV after
having provoked apnea (21), capnography after a
few low-frequency respiratory cycles (10-12/min)
during HFJV (22), or direct measurement using a
new-generation HFJV device. Monitoring depth of
anesthesia is useful, to the extent that as interventional RB is considered to be at risk of explicit intraoperative awareness (23, 24).
Total intravenous anesthesia (TIVA) is usually
the first choice, to the extent that as closing breathing circuit leaks around the bronchoscope is generally impossible. In addition, periods of apnea are
needed to perform specific parts of the procedure.
Short acting intravenous agents are recommended.
The best approach to administer propofol is a Target
Control Infusion (TCI) mode. Remifentanil, which
as has demonstrated superiority to alfentanil in
terms of blood pressure stability (25), can be given
through a continuous intravenous infusion, at a dose
of 0.1-0.3 µg/Kg/min (13), or as a 1 µg/Kg bolus in
one minute, followed by a 0.5 µg/Kg/min infusion
for maintenance (26). Infusion rates should be adjusted according to heart rate and blood pressure.
As soon as the patient lose consciousness and manual ventilation is possible, neuromuscular transmission monitoring should be calibrated and started. A
bolus of rocuronium at a dose of 0.3-0.5 mg/Kg can
be administered to facilitate the insertion of the rigid bronchoscope. Local anesthesia of the glottis, using, for example, 4 ml of 4% lidocaïne, can be performed before rigid bronchoscope insertion.
Maintaining a deep muscle relaxation, corresponding to a post-­tetanic count of 1-5, ensures strict immobilization, vocal cord adduction, and prevention
of patient coughing during the procedure.
During induction, the operator should be at the
patient’s head, so that an emergency rigid bronchoscopy can be performed to control the airway, if
needed (27). A risky situation is the presence of an
anterior mediastinal mass (28), which could result
in a major cardiovascular collapse at the moment of
induction or simply when the patient is placed in the
supine position, because of tracheal obstruction.
Deep sedation with spontaneous breathing can
be used as an alternative to general anesthesia.
However, hypoventilation may occur, as well as
laryngospasm, or slight relaxation of laryngeal
­
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­ uscles, leading to difficulties in introducing the
rigid bronchoscope, and causing genuine discomfort
or danger when working (coughing, movements).
Others techniques have been proposed. A flexible fiberscope can be introduced through a laryngeal mask (LMA). In this case, the fiberscope is an
obstacle to ventilation. Rigid bronchoscopy remains
the safest means of enabling efficient oxygenation
and concomitant instrumentation.
After positioning the patient with the neck extended or flexed on a head rest (7), the operator inserts the rigid bronchoscope into the trachea. If the
patient has fragile teeth, a tooth guard is recommended (29). Ventilation starts only after confirmation of tracheal location of the rigid bronchoscope.
This confirmation can be obtained through the use
of a rigid optic device, or a flexible fiberscope.
The presence of the rigid bronchoscope in the
airway imposes specific ventilation methods. HFJV
is the most widely accepted alternative ventilation
method in the context of interventional rigid bronchoscopy (30), creating high-quality and safe working conditions for the operator and the patient (13).
The injector catheter can be placed within the side
arm of the bronchoscope. The tidal volume received
by the patient is the sum of the injected volume and
the Venturi effect-generated additional volume.
HFJV occurs through an open circuit that allows all
technical manipulations in the airway. The inspired
oxygen fraction selected on the ventilator is not the
one encountered in the patient’s airway. The reason
is that injected gases are diluted by the surrounding
gas at the distal extremity of the catheter. This dilution is majored in the setting of RB, insofar as the
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admixture of oxygen-air within the system is proximal. The HFJV advantages include the delivery of
small respiratory volumes, often smaller than the
dead space, limited movements of the diaphragm,
the creation of a positive end expiratory pressure,
which improves oxygenation by reducing the alveoli shunt, and the expulsion of laser-generated smoke.
However, the airflow can send fragments of neoplastic tissue, and/or viral particles into the tracheobronchial tree. The main risk of HFJV is pulmonary
barotrauma, which occurs when expiration of the
injected gas is impaired by upper airway obstruction. To reduce this risk, it is important to use a device dedicated to measure end-expiratory pressure
(Fig. 2) (31).
Expiration is a priori not compromised because it occurs through the lumen of the bronchoscope and its surroundings (30). However, if the lumen is full of instruments or occupied by a piece of
tissue, or if the tip of the bronchoscope is against the
tumor, expiration can be compromised. A difficulty
in case of bronchial tumors is the lateralization of
the bronchoscope. In that case, only one lung is ventilated. If adequate ventilation cannot be achieved,
the bronchoscope must be drawn back above the
­carina, to ensure bilateral lung ventilation. Another
option consists in inserting a small catheter along
the tumor to permit intermittent deflating of the
­pulmonary portion under the obstruction. Manual
ventilation or mechanical ventilation can be
achieved using the lateral arm of the bronchoscope
after occlusion of the other entrances. In extreme
situations, veno-venous extracorporeal membrane
oxygenation can be envisaged. This must be planned
Fig. 2.
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before the procedure. It prevents the consequences
of airway collapse when there is a serious risk of
complete obstruction of the airway, such as in case
of anterior mediastinal mass, or before withdrawing
certain types of metallic stents (32, 33).
lowed by a period of hospitalization, lasting 24 to
48 hours.
Postoperative care
Complication rate ranges between 0.4 and 1%.
The ageing population and the learning curve of
new technologies increase the occurrence of complications. Patient selection, comorbidities, and the
expertise and resources of the center are decisive
factors that influence the final outcome. In that respect, the American College of Chest Physicians
recommends performing at least 20 supervised procedures before performing the procedure alone (7).
It is also essential that the entire team have in-depth
knowledge of these complications to ensure optimal
patient safety.
Recovery is often more challenging than induction of anesthesia. Five to ten% of patients requiring active interventions at this stage (15). Deep
muscle relaxation, which ensures excellent operating conditions during the entire procedure, must be
completely reversed before recovery. Sugammadex,
at a dose of 4 mg/Kg, reverses deep rocuroniuminduced muscle relaxation within a few minutes. It
provides the opportunity to maintain deep blockade
of the neuromuscular junction until the end of the
procedure, while ensuring fast, predictable, and safe
reversal at the time of bronchoscope removal (34,
35). At that time, manual ventilation is restarted.
The permeability of the airways can be temporarily
reduced by the manipulation-induced edema. If the
airway has been traumatized during the withdrawal
of the bronchoscope, or if manual ventilation proves
precarious, there should be no hesitation to temporarily intubate the patient under fiberscope control.
The post-intervention monitoring of rigid
bronchoscopies must occur in the recovery room. In
case of complications or special procedures, such as
those involving extracorporeal oxygenation, monitoring should be undertaken in an intensive care
unit. The most serious potential complication is an
acute occlusion of the airway. This may occur, for
example, after movement of a stent. Such an event
provokes acute respiratory distress. The possibility
of an immediate re-intervention must always be
considered. There should be no hesitation to perform immediate flexible bronchoscopy to diagnose
the obstruction origin (36). An chest X-ray can assess the re-inflation of a lung or segment that had
initially collapsed, to confirm the location of a stent,
or detect a pneumomediastinum or a pneumo­
thorax (16, 36).
Pain is essentially laryngeal, and is due to repeated repositioning of the bronchoscope. It usually
responds to World Health Organisation Analgesic
Ladder level I analgesics, that is paracetamol and
non-steroidal anti-inflammatory medications. Corticotherapy for anti-inflammatory purposes can be
considered in the event of a local inflammatory
state, repeated intubations, or long procedure. However, their efficacy after laser use has not been proven after laser resection (37). The procedures are fol-
Complications
General complications
Hypoxia due to ventilation inefficiency, intrabronchial hemorrhage, congestion resulting from
bronchial secretions or tissue fragments, and even
barotrauma can be remedied by increasing the Fi02,
ventilation optimization, repositioning of the bronchoscope, cessation of HFJV and temporary manual
ventilation, secretion aspiration, removal of tumor
fragments, control of hemorrhages, or pneumothorax drainage. Hypercarbia is frequent, but has generally few repercussions. Hemodynamic instability
may be managed using vasoactive medications.
Laryngospasm and bronchospasm are fairly rare
­
complications (0.64%) (38).
Technical complications
Some complications are specifically related to
the use of the bronchoscope. Repeated manipulations can cause dental or gingival lesions, as well as
lesions to the vocal cords, the piriform sinus, the
trachea, and, more frequently, the pars membrane,
which is the thinnest. Any maneuvers within the
bronchial tubes must be careful, particularly when
close to the left primary bronchus, owing to its natural curve (39).
Other complications are related to dilatation
balloons. Bleeding, tearing of the tracheal wall, and
hypoxemia, at the moment of balloon inflation, are
the most frequent (40).
Laser-induced complications have a low incidence. The complication rate of Nd :YAG laser is
lower than 5% (41, 42), and the mortality rate is
evaluated to range between 0.3% and 0.5% (40).
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This complication rate is influenced by the condition of the patient, the location of the tumor lesion,
the type of endoscopy, failure to observe the rules
on the use of the laser [monitoring of Nd :YAG laser energy, exposures of 0.5 to 1 second at a maximum power of 45 W, poor functioning of the fiber
cooling system), the experience of the surgeon, and
the cooperation among the team members (43).
These complications include the following : hemorrhage can be controlled by laser cauterization, local
compression using the tip of the bronchoscope or a
Fogarty catheter, and adrenaline plugging or instillation. Continuous aspiration can be applied through
the lateral arm of the rigid bronchoscope, to clean
the work field. Should a serious hemorrhage occur,
that is of more than 250 ml (43), an emergency thoracotomy may be necessary (16). Selective intubation to protect the healthy lung should occur before
such a risky procedure, that may prove to be fatal to
the patient (44). Endo-bronchial fire incidence is
approximately 0.1% (45). This incidence is reduced
by removing endotracheal tubes, unsheathed flexible fiberscopes, and all inflammable objects from
the laser field, as well as by working with a lower
than 40% inspired oxygen fraction to prevent the
acceleration of combustion (31) . Should a fire occur, the following attitude is recommended. The
rigid bronchoscope and/or probe should be first
withdrawn directly, and the surgical field watered.
Ventilation should then be stopped, and the source
of oxygen disconnected. Novel intubation should
occur to control the airway and allow manual ventilation. The rigid bronchoscope should be reinserted
to assess the damage, and steroids, bronchodilators,
and antibiotics administered. The patient should be
admitted to the intensive care unit for assessment
and evaluation of the need for a gastrostomy.
Air embolism may result from a communication between the airway and a vein. Early signs are
low arterial blood pressure and arrhythmia. In case
of direct communication between the airway and an
artery, arrhythmia and convulsions occur, followed
by coma. In case of any suspicion of air embolism,
the patient must be placed in the Trendelenburg
­position, inspired oxygen fraction should be set at
100%, vasopressor support should be considered, as
well as hyperbaric oxygen therapy (46).
Smoke and tissue particles might be inhaled by
the staff and the patient, causing human papillomavirus contamination and neoplastic dissemination.
Smoke can also cause pulmonary edema. Therefore,
continuous aspiration is essential.
Various other complications have been described, including pneumothorax after bronchial
perforation, non-cardiogenic pulmonary edema,
bronchospasm, pneumonia, and broncho-pleural
fistula.
Complications linked to high-frequency thermo-coagulation, which is a thermal method similarly to laser, are endo-bronchial fire, hemorrhage
(2.5%), perforations of the airway, and, in theory,
air embolism (47). Argon plasma coagulation has
lower risk of hemorrhage, and tissue perforation. Ignition of the airway, or argon gaseous embolisms
are possible (48, 49).
The immediate complications of stents (50) include partial or total obstruction of the airway. This
can occur in case of wrong position of the device at
the time of release. Migration is the main issue of
silicone stents, although the risk can be lowered by
the presence of lugs on the external wall. The retention of secretions necessitates the use of mucolytic
agents or aspiration with a fiberscope. Delayed
complications include halitosis. With uncovered or
partially covered metallic stents, the tumor invades
the mesh (13). This complication has recently led
operators using fully covered metallic stents, which
are also easier to remove. Obstruction of the tips by
granulomas affects all types of stents, the incidence
of that event being 16% for silicone stents (51) and
30% for metallic stents (52). Fractures are occasionally reported with metallic stents (53). Cases of
fatal or non-fatal hemoptysis (54) have been reported following vessel erosion. The complications are
more frequent when the indication is a benign pathology, given the longer survival time.
Conclusions
The number of therapeutic techniques performed by means of rigid bronchoscopy is multiplying rapidly, presenting to anesthesiologists new
challenges for managing those patients with serious
comorbidities. In this context, our literature review
highlights anesthetic specificities. An in-depth
knowledge of the various endoscopic techniques is
essential to be able to promptly address occasionally serious complications, ranging from hypoxia to
cardiovascular collapse. Interventional rigid bronchoscopies should be performed in institutions
with adequate infrastructure and trained dedicated
staff.
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