Chapter 11

1. Therapeutic bronchoscopy is most commonly employed to treat patients with central airways obstruction due to malignant disease.

2. Rigid bronchoscopy provides definitive control of the airway permitting the use of general anesthesia to maximize patient comfort.

3. Patients can undergo bronchoscopy with transbronchial biopsy without stopping aspirin therapy, but clopidogrel should be stopped 5 days prior to the procedure.

4. As with any shared airway case, close communication between operator and anesthesiologist is vital for maximum patient safety.

The patient is a 47-year-old female with stage 4 adenocarcinoma involving the left lung. A prior stent was placed in the left mainstem bronchus due to tumor invasion of the proximal airway. Now, the tumor has invaded the stent to the point where complete airway obstruction is imminent. She is referred for stent exchange and tumor debulking.

She has a history of 100 pack-years of smoking but no other medical problems. She is oxygen dependent at home on 2L/min nasal cannula.

Medications are alprazolam and albuterol. Vital signs: BP 110/80, HR 82, room air SpO2 85%. Laboratory examination is notable only for a WBC of 11.5.

Therapeutic bronchoscopy, previously practiced primarily by thoracic surgeons, is becoming more commonly performed by pulmonologists who receive specialized training in the performance of airway surgical techniques for the treatment of central airways obstruction. Performing these procedures involves the use of the rigid bronchoscope, which requires careful coordination of care between the anesthesia team and the proceduralist. Several issues around the use of rigid bronchoscopy can often lead the anesthesiologist into unfamiliar territory, including release of the airway into the hands of the proceduralist, turning the head of the patient away from the anesthesiologist during the procedure, and often ceding control of ventilation to the procedural team. Good communication regarding procedural planning, ventilatory strategy, and anesthesia management are critical to optimize patient safety and provide for a successful procedure.

Therapeutic bronchoscopy is most commonly employed to treat patients with central airways obstruction (CAO) due to benign or malignant etiology. While the incidence of CAO is unknown, it is a commonly encountered clinical problem present in 20% to 30% of patients with primary lung cancer1 and 7% to 18% of patients post-lung transplantation.2 Additional common causes of CAO include tracheal stenosis, either post-tracheostomy or idiopathic, tracheomalacia, and foreign body aspiration.1 While many of the techniques that will be described in this section are amenable to use with the flexible bronchoscope, rigid bronchoscopy provides definitive control of the airway permitting the use of general anesthesia to maximize patient comfort (Table 11–1).3 In addition, the rigid bronchoscope becomes a conduit for use of a variety of tools and suction devices to perform minimally invasive airway surgery. The bronchoscope itself can become a therapeutic tool useful for dilation of airway stenoses, and "coring out" of airway tumor providing rapid relief of central airway obstruction.3

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