Hensley's Practical Approach to Cardiothoracic Anesthesia

26 Anesthetic Management for Interventional Pulmonology Procedures

Julia Scarpa and Alessia Pedoto

I. Introduction 589 A. Indications 589 B. Alternatives 589 II. Anesthetic Approaches 589

V. Therapeutic Techniques 597 A. Airway Dilation 597 B. Airway Stent Placement (and Removal) 597

A. Local: Airway Topicalization 589 B. Sedation: Monitored Anesthesia Care 591 C. General Anesthesia 591

C. Endobronchial Valves 597 D. Bronchial Thermoplasty 598 E. Laser Debulking 598 F. Cryoablation 598 G. Whole Lung Bronchopulmonary Lavage 599 H. Foreign Body Removal 600

III. Procedural Approaches 591 A. Flexible Bronchoscopy 591 B. Endobronchial Ultrasound Bronchoscopy 593

VI. Preoperative Assessment for Interventional Pulmonology Procedures 600 VII. Management of Interventional Pulmonology–Specific

C. Navigational Bronchoscopy 593 D. Robotic-Assisted Bronchoscopy 593 E. Rigid Bronchoscopy 595 F. Pleuroscopy 595 A. Bronchoalveolar Lavage 596 B. Transbronchial Needle Aspiration 596 C. Spray Cryotherapy 596 D. Transbronchial Lung Cryobiopsy 596

Intraprocedural Complications 600 A. Airway Irritability 600 B. Airway Loss 600 C. Airway Bleeding 600 D. Airway Fire 601 E. Pneumothorax 601 F. Failure to Extubate 601

IV. Diagnostic Techniques 596

KEY POINTS 1. Interventional pulmonology (IP) techniques are rapidly and increasingly being used to diagnose, stage, and treat a large variety of lung and airway diseases. 2. These procedures are commonly done in an IP lab that may be some distance from the operating rooms. In addition to the acuity of the pulmonary patients cared for in the IP suite, the distance to the operating room and other surgical and interventional collaborators further necessitates good planning and communication among all the IP team members. Fortunately, serious complications in the IP suite are not frequent, but when they do occur, they can be life-threatening. It is imperative that rescue protocols are in place in case of major complications. 3. Most of the IP cases where an anesthesiologist is involved are done under general anesthesia, with an endotracheal tube or a supraglottic airway device in place. 4. Interventional procedures may require the use of jet ventilation and total intravenous anesthesia (TIVA). Airway bleeding, airway obstruction, bronchospasm, and pneumothorax are the most com mon perioperative complications requiring immediate management. 5. Many of these procedures are done as outpatients; therefore, the anesthetic should be tailored to expedite discharge. 6. Good regional anesthesia is essential for the success of pleural procedures done with sedation. Neuraxial and peripheral nerve blocks have been successfully used .

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