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  • Diagnostic bronchoscopy is now usually performed using flexible equipment, whereas therapeutic bronchoscopy may be conducted with both flexible and rigid equipment. A thorough appreciation of both is essential for safe anesthetic management in the bronchoscopy suite.
  • Unexpected massive bleeding is always possible during cervical mediastinoscopy, and thus anesthesiologists should be prepared to administer large volume resuscitation at a moment's notice.
  • Right radial artery cannulation is preferred in order to alert the surgeon to innominate artery compression with risk of cerebral ischemia.

A 75-year-old male presented with a three-month history of cough. He has been treated with two courses of antibiotic therapy after which a chest radiograph revealed a suspicious left upper lobe lesion. He is now referred for staging bronchoscopy and mediastinoscopy following a computed tomography (CT) scan, which confirmed the 3.5 × 3 cm mass, and also showed enlarged subaortic lymph nodes. He has hypertension and chronic obstructive pulmonary disease due to a 40-pack year smoking history. Medications include furosemide and aspirin.

Vital signs: BP 175/85, HR 72, room air SpO2 95%. Laboratory examination is normal except for a BUN of 25, creatinine of 1.8 and potassium of 3.2. His CXR is notable for the left upper lobe mass and mild centrilobular emphysema.

With the growing use of computed tomographic (CT) scanning, pulmonary lesions are being diagnosed with increasing frequency. In fact, incidental lesions found on chest x-ray (CXR) or CT have become the most common manifestation of lung cancer.1 A lesion larger than 3 cm in diameter is considered a mass, and as such has a greater likelihood of being malignant.1 A single pulmonary lesion that is less than 3 cm in diameter, completely surrounded by pulmonary parenchyma, and is not associated with atelectasis or adenopathy is defined as a solitary pulmonary nodule (SPN).1 While as many as one-third of SPNs represent primary malignancies, and nearly one quarter may be solitary metastases, the differential diagnosis of an SPN is broad and includes vascular diseases, infections, inflammatory conditions, congenital abnormalities and benign tumors.1

In managing patients with suspected lung cancer, the goals are to determine an accurate histological diagnosis and stage the disease, if the lesion is malignant. This information is critical, not only to predict resectability, but also to avoid unnecessary surgery and provide the patient with prognostic information. Flexible fiberoptic bronchoscopy (FOB) and mediastinoscopy are the standard methods used for staging non-small cell lung cancer (NSCLC), the most prevalent type of lung cancer.

Flexible fiberoptic bronchoscopy (FOB) is utilized extensively in the initial evaluation of patients suspected of having lung carcinoma. FOB enables direct visualization of the bronchial mucosa down to the level of the segmental and proximal subsegmental bronchi. At these levels direct visually guided biopsy is possible. FOB also enables endobronchial brushing and bronchoalveolar lavage (BAL) of disease beyond direct visualization.

Since its introduction into clinical practice in the ...

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