Anaes · Thoracic anaesthesia
Anaesthesia for bronchoscopy and shared airway surgery
Also known as Rigid bronchoscopy · Flexible bronchoscopy anaesthesia · Shared airway · Jet ventilation · Airway surgery
Shared-airway anaesthesia for flexible and rigid bronchoscopy and interventional airway surgery: oxygenation strategies, TIVA, jet ventilation, laser/fire safety, and massive haemoptysis drills.
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Red flags
- Shared airway: continuous negotiation of oxygenation versus surgical access.
- Rigid bronchoscopy needs deep anaesthesia, muscle relaxation, and a ventilation plan (ventilating bronchoscope, jet, intermittent apnoea).
- Airway fire triad: fuel, oxidiser, ignition — lowest safe FiO2, no N2O with laser.
- Massive haemoptysis: isolate bleeding lung, large-bore suction, surgical/IR help.
- Have a failed oxygenation plan before starting (DAS mindset).
Meet the patient
A 64-year-old smoker arrives with three weeks of worsening stridor and intermittent haemoptysis. CT shows a vascular tracheal tumour narrowing the airway to six millimetres. The ENT surgeon wants rigid bronchoscopy with laser debulking — a procedure where the FiO2 that keeps the patient pink is the FiO2 that turns the airway into a blowtorch.[4]
The two questions that decide the case are the two that decide every shared-airway operation: how will I oxygenate through an open airway? and what is my rescue if oxygenation fails? Answer both before induction — never after the patient turns blue.[1]
References9ShowHide
- [1]Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth, 2015.PMID 26556848
- [2]Brassard CL, Lohser J, Donati F, Bussières JS. Step-by-step clinical management of one-lung ventilation: continuing professional development. Can J Anaesth, 2014.PMID 25389025
- [3]Karzai W, Schwarzkopf K. Hypoxemia during one-lung ventilation: prediction, prevention, and treatment. Anesthesiology, 2009.PMID 19417615
- [4]Pathak V, Welsby I, Mahmood K, et al. Ventilation and anesthetic approaches for rigid bronchoscopy. Ann Am Thorac Soc, 2014.PMID 24635585
- [5]Apfelbaum JL, Caplan RA, Barker SJ, et al. Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology, 2013.PMID 23287706
- [6]Abu-Ghanem S, Cochran J. The Use of Oxygen/Air Blender during Transoral Laser Microsurgery with Supraglottic Manual Jet Ventilation: A Safe Approach. Case Rep Anesthesiol, 2023.PMID 37701679
- [7]Jaquet Y, Monnier P, Van Melle G, et al. Complications of different ventilation strategies in endoscopic laryngeal surgery: a 10-year review. Anesthesiology, 2006.PMID 16394690
- [8]Toh TW, Goh JHF, Lie SA, et al. Clinical Approach to Massive Hemoptysis: Perioperative Focus on Causes and Management. J Cardiothorac Vasc Anesth, 2024.PMID 38964992
- [9]Wu FL, Razzaghi A, Souney PF. Seizure after lidocaine for bronchoscopy: case report and review of the use of lidocaine in airway anesthesia. Pharmacotherapy, 1993.PMID 8437971