Hensley's Practical Approach to Cardiothoracic Anesthesia


26. Anesthetic Management for Interventional Pulmonology Procedures

CLINICAL PEARL Bleeding can be significant at the site of biopsy and is usually tamponaded via bronchial blocker.

V. Therapeutic Techniques A. Airway Dilation

1. Compatible with flexible and rigid bronchoscopy 2. Procedure: Serial dilatations may occur either with a balloon passed distally to the ob struction and inflated to dilate the stenosed airway or via rigid bronchoscopes of increasing size. It can be performed in combination with debulking techniques to maximize airway recanalization, depending on the etiology of disease. Due to the short-lived results, this procedure is usually combined with stent placement. 3. Indications: Benign or malignant airway stenosis 4. Complications: Airway injury, pneumothorax, pneumomediastinum, hemorrhage 19 B. Airway Stent Placement (and Removal) 1. Compatible with rigid bronchoscopy. Some stents can also be placed using flexible bron choscopy with fluoroscopy confirmation. 20 2. Procedure: Various types and shapes of stents are available, depending on the location and etiology of the diseased airway. Retrievability and repositioning of the stent depend on the stent material. 21 3. Indications: Benign and malignant central airway stenosis, obstructions, and fistulae 4. Additional anesthetic considerations: The more central the diseased conducting airway, the more complex the anesthetic management. For very severe tracheal obstruction, standby veno-venous extracorporeal membrane oxygenation (ECMO) should be available. Jet ven tilation is commonly used with rigid bronchoscopy. Stent removal may be complicated by bleeding and difficulty with ventilation if performed for stents placed months or years prior. 5. Complications: Acute airway obstruction, hypoxia, hypercarbia, stent migration or ero sion into surrounding structures, in-stent stenosis or plugging, airway or vascular injury CLINICAL PEARL Carinal stents are difficult to place and tend to dislodge, impairing ventilation. Ventilation may also be difficult during placement and can be facilitated via Jet. 2. Procedure: Bronchoscopic lung volume reduction can be achieved by the placement of one-way valves in bronchi, leading to the most emphysematous portions of the lung to limit air entry and allow air expulsion. Unidirectional endobronchial valves can be used to treat air leaks after lung surgery (Figure 26.4). 3. Indications: Severe chronic obstructive pulmonary disease (COPD) with hyperinflation, persistent postoperative air leak 4. Complications: Pneumothorax, pneumonia, respiratory failure, COPD exacerbation, valve migration, and erosion into surrounding structures C. Endobronchial Valves 1. Compatible with flexible bronchoscopy

Copyright © 2024 Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. CLINICAL PEARL Pneumothorax can occur on induction in patients with severe COPD and should be in the differential diagnosis of refractory hypotension. Tension pneumothorax may occur with positive-pressure ventila tion in the presence of an air leak.

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