Hensley's Practical Approach to Cardiothoracic Anesthesia


26. Anesthetic Management for Interventional Pulmonology Procedures

B. Endobronchial Ultrasound Bronchoscopy 1. Procedure: Flexible bronchoscopy is performed via a bronchoscope with an ultrasound probe that is used to visualize central structures within the tracheobronchial walls, medi astinum, and lungs. 2. Anesthesia: General anesthesia with an ETT or SGA, with or without paralysis. TIVA is usually preferred, given the presence of air leak around the bronchoscopy adapter. If the pa tient cannot accommodate an 8.0 or larger ETT, a smaller (7.0) ETT is sufficient for flexible bronchoscopy with a subsequent switch to SGA for the endobronchial ultrasound (EBUS) portion of the procedure. 3. Additional considerations: Typically performed with transbronchial needle aspiration to access mediastinal lymph nodes for sampling. Higher paratracheal nodes can only be ac cessed with an SGA in place, while lower nodes remain accessible with an ETT. 4. Complications: Same as flexible bronchoscopy, plus airway bleeding and tension pneumo thorax from the biopsy needle C. Navigational Bronchoscopy 1. Procedure: Electromagnetic navigation with real-time CT images is used to create a three-dimensional (3D) map of the lungs . Following high-resolution CT acquisition, a 3D image of the patient’s chest is generated, and lesion targets are identified. A virtual pathway through the endobronchial tree is planned. Flexible bronchoscopy is performed, and a navi gational catheter is introduced through the working channel to the target area; real-time lo cation is shown on intraprocedural CT, and the catheter is adjusted by the physician. Once it is locked in place, a standard endoscopic tool is introduced to obtain a sample. 2. Anesthesia: General with an ETT with paralysis 3. Additional considerations: The locator board and sensors must be correctly placed, and nothing with metal in close proximity. Accuracy is limited by lack of visualization during sample acquisition. Cough or patient motion must be avoided to prevent losing the target area. 4. Complications: Same as EBUS CLINICAL PEARL General anesthesia with endotracheal intubation and paralysis is most commonly used to avoid motion, which interferes with the mapping and finally the accuracy of tissue sampling. CLINICAL PEARL Vocal cord trauma is more common with EBUS due to the 45° location of the light source.

D. Robotic-Assisted Bronchoscopy 1. Procedure

a. Electromagnetic navigation: The Monarch system relies on electromagnetic guid ance, requiring reference sensors around the patient to triangulate the lesion location and thus requires registration. This allows for continuous visualization, which is re quired to extend a telescopic “mother-daughter” catheter controlled by a joystick. 1

Copyright © 2024 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. b. Shape sensing: The ION system is based on shape-sensing technology. Once the target lesion is identified, the camera is removed and a uniform catheter controlled by a track ball and scroll wheel is used. A 3D reconstruction from a dedicated detailed CT also requires registration before the start. 1,10

2. Indications and advantages: This technique allows for endobronchial navigation into lung periphery (Figure 26.3) with catheter stabilization to maximize precision and diag nostic yield.

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