Feasibility and safety of general anesthesia for bronchial thermoplasty: a description of early 10 treatments

Anesthesia for Bronchoscopy-An Update

The field of interventional pulmonology has grown immensely and is increasingly recognized as a subspecialty. The new procedures introduced in the last decade pose unique challenges, and anesthesiologists need to readapt to their specific demands. In this review, we extensively discuss the pathophysiology, technical aspects, preprocedural preparation, anesthetic management, and postprocedural challenges of many new procedures such as navigational bronchoscopy, endobronchial valve deployment, and bronchial thermoplasty. Majority of these procedures are performed under general anesthesia with an endotracheal tube. Total intravenous anesthesia with rocuronium as a muscle relaxant seems to be the standard US practice. The easy availability and proven safety and efficacy of sugammadex as a reversal agent of rocuronium has decreased the need for high-dose remifentanil as an agent to avoid muscle relaxants. Additional research is available with regard to the utility of nebulized lidocaine and is discussed. Finally, two newer drugs administered for conscious sedation (typically without the need of an anesthesiologist) are likely to gain popularity in the future. Remimazolam is a new short-acting benzodiazepine with a relatively faster offset of clinical effects. Dexmedetomidine, a selective adrenergic agonist, is increasingly employed in bronchoscopy as a sedative during bronchoscopic procedures.

Complications of bronchial thermoplasty using laryngeal mask: case series

Severe asthma affects more than 250 million people and represents high healthcare costs. Bronchial thermoplasty is a relatively new technique in interventional pulmonology for managing this condition. The procedure is done under general anesthesia and the patients are mostly ASA II and III; therefore, the anesthesia plan must be safe. The purpose of the article is to describe the anesthetic technique used (general anesthesia and laryngeal mask) and the immediate and early complications of the procedure. Four patients were included, each undergoing three sessions. The complications during and immediately after the procedure, as well as the early complications (up to seven days post-procedure) that could have required hospital management were discussed. In three of the sessions at least one acute bronchospasm event presented, but only one patient required hospital admission for more than 24 hours. Experience suggests that thermoplasty may be safely conducted under general anesthesia and laryngeal mask.

Anesthetic considerations for bronchial thermoplasty in patients of severe asthma: A case series

The role of anesthesiologist in nonoperating room procedures including pulmonary interventions is expanding. Bronchial thermoplasty (BT) is a minimally invasive bronchoscopic intervention for patients with severe asthma refractory to conventional pharmacotherapy. It involves the application of controlled radiofrequency thermal energy to large- and medium-sized airways. We report our experience for perioperative anesthetic management of patients scheduled for BT. Three patients with severe asthma were planned for BT under general anesthesia. After standard monitoring and intravenous cannula insertion, anesthesia was induced with propofol, fentanyl, and rocuronium after preoxygenation and maintained with propofol target-controlled infusion. The ventilation was controlled mechanically with I-gel used for airway management. The oxygen concentration was titrated to 40% or less at the time of thermal activation delivery. The procedure was performed using a thin bronchoscope inserted through the I-gel working port of the catheter mount. The procedures lasted for around 1 h. After completion of the procedure, the residual neuromuscular blockade was reversed, and I-gel was removed. BT requires three separate procedure sessions performed 2-3 weeks apart, and each session sequentially targets right lower lobe, left lower lobe, and bilateral upper lobes. The challenge involved in BT is due to the airway sharing between anesthesiologists and pulmonologists and anesthesia in a nonoperating room setting in patient with uncontrolled severe asthma. A meticulous preoperative evaluation, perioperative anesthetic plan, and periprocedural monitoring can reduce the complications.

Bronchial thermoplasty for severe asthma: A position statement of the Indian chest society

Bronchial thermoplasty (BT) is an interventional bronchoscopic treatment for severe asthma. There is a need to define patient selection criteria to guide clinicians in offering the appropriate treatment options to patients with severe asthma.

METHODOLOGY

An expert group formed this statement under the aegis of the Indian Chest Society. We performed a systematic search of the MEDLINE and EMBASE databases to extract evidence on patient selection and the technical performance of BT.

RESULTS

The experts agreed that the appropriate selection of patients is crucial and proposed identification of the asthma phenotype, a screening algorithm, and inclusion/exclusion criteria for BT. In the presence of atypical clinical or chest radiograph features, there should be a low threshold for obtaining a thoracic computed tomography scan before BT. The patient should not have had an asthma exacerbation in the preceding two weeks from the day of the procedure. A 5-day course of glucocorticoid should be administered, beginning three days before the procedure day, and continued until the day following the procedure. General Anesthesia (total intravenous anesthesia with a neuromuscular blocker) provides ideal conditions for performing BT. A thin bronchoscope with a 2.0 mm working channel is preferable. An attempt should be made to deliver the maximum radiofrequency activations. Middle lobe treatment is not recommended. Following the procedure, overnight observation in the hospital, and a follow-up visit, a week following each treatment session, is desirable.

CONCLUSION

This position statement provides practical guidance regarding patient selection and the technical performance of BT for severe asthma.