Hensley's Practical Approach to Cardiothoracic Anesthesia

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IV. Thoracic Anesthesia

FIGURE 26.4 Endobronchial valves. (A) Deployed endobronchial valve. (B) Rigid bronchoscopy view of bronchi be fore endobronchial valve deployment. (C) Rigid bronchoscopy view of bronchi following endobronchial valve deploy ment, as indicated by the arrows. (Images courtesy of Dr Alessia Pedoto.)

D. Bronchial Thermoplasty 1. Compatible with flexible bronchoscopy

2. Procedure: Radiofrequency energy is applied directly to large airway mucosa, to decrease airway smooth muscle mass and contractility, as well as neuroendocrine cells and auto nomic fibers. 22 3. Indications: Nonpharmacologic treatment of severe, refractory asthma 4. Complications: Worsening of respiratory symptoms E. Laser Debulking 1. Compatible with flexible and rigid bronchoscopy 2. Procedure: Lasers of various wavelengths (eg, CO 2 , Nd-YAG, argon plasma) are used to burn away tissue. CO 2 lasers have limited tissue penetration and are useful for superficial airway lesions; Nd-YAG lasers are higher energy and are useful for tumor ablation. 25 All lasers require the use of very low Fio 2 (typically < 30%) to reduce the risk of airway fire. 3. Indications: Debulking of malignant and benign endobronchial, carinal, or tracheal airway tumors; treatment of various upper airway stenoses 23 4. Complications: Hemorrhage, tracheobronchial perforation, gas embolism, airway fire, hypoxemia, hypercarbia, pneumothorax, pneumomediastinum, tracheoesophageal fistula, eye injury 24 F. Cryoablation 1. Compatible with flexible, navigational, robotic, and rigid bronchoscopy 2. Procedure: Argon gas expansion rapidly cools the probe tip to <− 140 °C to freeze the target. Cycles of freezing and thawing cause cell necrosis. 3. Indications/advantages: Indicated for tumor ablation and nerve ablation (pain therapy). Compared to other ablative techniques, such as microwave ablation and radiofrequency ab lation, cryoablation is less painful and preserves tissue architecture, making it preferred for sensitive areas such as the pleura or areas where structural integrity is critical, such as the large airways and diaphragm. It has the lowest complication rate of currently available ablative techniques. 25 Since there are no Fio 2 limitations, this technique is indicated for patients on O 2 . 4. Complications: Hemoptysis, hemorrhage, pleural effusions, pneumothorax, prolonged air leak, bronchopleural fistula, arrhythmias, bronchospasm

CLINICAL PEARL Low F io 2 is necessary to prevent airway fire during laser use.

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