Advances in interventional pulmonology

Supraglottic airway versus endotracheal tube during interventional pulmonary procedures - a retrospective study

Background

As the field of interventional pulmonology (IP) expands, anesthesia services are increasingly being utilized when complex procedures of longer duration are performed on sicker patients with high risk co-morbidities and lung pathology. Yet, evidence on the optimal anesthetic management for these patients remains lacking. Our aim was to characterize the airway management and, secondarily anesthetic maintenance patterns used for IP procedures at our institution.

Methods

From 2894 identified encounters, charts of 783 patients undergoing an IP procedure with general anesthesia over a 5-year period, employing an endotracheal tube (ETT) or a supraglottic airway (SGA) for airway maintenance, were identified and reviewed after exclusions. Patients posted for a concurrent thoracic surgical procedure and those already intubated at presentation were excluded. Baseline patient demographics, procedure, proceduralist type, anesthesia maintenance modality, neuromuscular blocking drug (NMBD) use, and airway management characteristics were extracted and analyzed.

Results

Inhaled general anesthesia with an ETT for airway maintenance was most commonly employed; however, SGAs were used in one-third of patients with a very low conversion rate (0.4%), and their use was associated with a significant reduction in NMBD use.

Conclusions

In this large series of patients receiving general anesthesia for IP procedures, inhaled anesthetic agents and ETTs were favored. However, in appropriately selected patients, SGA use was effective for airway maintenance and allowed for a reduction in NMBD use, which may have implications in this patient population who may have an increased risk for pulmonary complications and warrants further investigation.

New trends in interventional pulmonology

PURPOSE OF REVIEW

As the field of interventional pulmonology continues to expand and develop at a rapid pace, anesthesiologists are increasingly called upon to provide well tolerated anesthetic care during these procedures. These patients may not be candidates for surgical treatment and often have multiple comorbidities. It is important for anesthesiologists to familiarize themselves with these procedures and their associated risks and complications.

RECENT FINDINGS

The scope of the interventional pulmonologist's practice is varied and includes both diagnostic and therapeutic procedures. Bronchial thermoplasty is now offered as endoscopic treatment of severe asthma. Endobronchial lung volume reduction procedures are currently undergoing clinical trials and may become more commonplace. Interventional pulmonologists are performing medical thoracoscopy for the treatment and diagnosis of pleural disorders. Interventional radiologists are performing complex pulmonary procedures, often requiring anesthesia.

SUMMARY

The review summarizes the procedures now commonly performed by interventional pulmonologists and interventional radiologists. It discusses the anesthetic considerations for and common complications of these procedures to prepare anesthesiologists to safely care for these patients. Investigational techniques are also described.

Anaesthesia Management During Interventional Bronchoscopic Procedures: Laryngeal Mask Airway or Rigid Bronchoscope

OBJECTIVE

Interventional bronchoscopy procedures are novel and effective modes of diagnosing and treating airway lesions. Airway management and ventilation are a major concern, especially when considering the fire hazard of ventilating during endobronchial thermal therapies. The aim of this study was to evaluate the usage of laryngeal mask airway (LMA) compared to rigid bronchoscopy for the ventilation of patients undergoing diagnostic or therapeutic interventional bronchoscopy procedures.

METHODS

During this prospective randomised clinical trial study, patients were randomly allocated to two groups for ventilation: LMA and rigid bronchoscopy. Vital signs, including blood pressure, heart rate and percentage of blood O2 saturation before and during the procedure, degree of sore throat after recovery and physician's satisfaction, were recorded.

RESULTS

A total of 83 patients, including 45 in the "LMA" and 38 in the "rigid" groups, were enrolled in this study. Their mean age was 51±17 years, and 59 (71%) were male. There was a statically significant difference between "rigid" and "LMA" categories regarding the decrease in O2 during the procedure in proportion to baseline figures (p=0.028). Haemodynamic parameters were better maintained using LMA compared to rigid bronchoscopy.

CONCLUSION

Laryngeal mask ventilation maintains better oxygenation and haemodynamic stability and ensures physicians' and patients' satisfaction regarding ease of use, airway access and fewer complications compared to rigid bronchoscopy. Therefore, LMA can be introduced as a reliable alternative for ventilation during interventional airway procedures.

Advances in interventional pulmonology

Interventional pulmonology (IP) remains a rapidly expanding and evolving subspecialty focused on the diagnosis and treatment of complex diseases of the thorax. As the field continues to push the leading edge of medical technology, new procedures allow for novel minimally invasive approaches to old diseases including asthma, chronic obstructive pulmonary disease and metastatic or primary lung malignancy. In addition to technologic advances, IP has matured into a defined subspecialty, requiring formal training necessary to perform the advanced procedures. This need for advanced training has led to the need for standardization of training and the institution of a subspecialty board examination. In this review, we will discuss the dynamic field of IP as well as novel technologies being investigated or employed in the treatment of thoracic disease.