Anaesthesia for

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• Anaesthesia for
• Foreign body Bronchus
• Laryngeal Papilloma

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Bronchoscopy

• Indication
• Foreign body evaluation/management
• Stridor
• Evaluation of laryngo tracheal pathology
• Management of airway mass

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Goals during bronchoscopy

• Control of the airway
• Prevent or decrease airway and adrenergic
  reflexes
• Immobile surgical field
• Amnesia
• Smooth emergence and safe extubation

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Flexible VS Rigid Bronchoscopy

• Selection depends on physician expertise
• Rigid bronchoscopy preferred technique
• Better ventilation and visualization,
  suctioning, and control of bleeding
• Flexible bronchoscopy- nonradiopaque peripheral
  FB
• lack of airway control ventilatory capacity
• Limited suction and instrumentation

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Foreign body bronchus

• Most common 1-3 yrs
• 95 - right main bronchus
• 5 - trachea
• Laryngeal FB with complete obstruction is rare
• Types FB Organic - seeds, nuts
• Inorganic - coins,
  needles, pins

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• Clinical presentation
• H/o aspiration choking
• Bronchus
• Cough, Wheezing
• Tracheal or Laryngeal
• Cough, Dyspnea, Stridor, Cyanosis
• Secondary late symptoms

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• Examination should focus
• Location
• Degree of obstruction
• Gas exchange
• Secondary pathological changes

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Differential diagnosis

• Reactive airway disease
• Pneumonia, Empyema, croup,
• Tracheo bronchial tumor
• Tracheo bronchomalacia
• psychogenic cough

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Anaesthetic management

• Pts condition determines the timing of
  bronchoscopy
• Depends on Level, Degree Duration.
• Induction
• Inhalational
  IV
• FB with stridor
  peripheral FB
• Laryngeal FB

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Sevoflurane or Halothane?

• Sevoflurane Halothane
• More pleasant More soluble
• Rapid induction Slower elimination
  airway manipulation
• ? Minute ventilation Smooth post
  anesthetic period
• ? Diaphragmatic contractility
• Post op delirium ACNA 2001, Br
  J Anes 76767-771,1996

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• Total intravenous technique
• Propofol
• Bolus 2-3 mg/kg - 200 - 400mcg/kg/min
• Steady level of anaesthesia regardless of
  ventilation and perfusion mismatch
• Less airway irritability and emergence delirium

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• Analgesia
• Fentanyl 1-2 mcg/kg
• Remifentanil 0.2-0.5 mcg/kg/min
• Topical analgesia lidocaine 3 4 mg/kg
• Muscle relaxant
• Succinylcholine
• Mivacurium, atracurium and vecuronium

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Spontaneous VS controlled ventilation
Spontaneous

• Disadvantage
• Increased CO2
• Hard to GUARANTEE no movement
• Prolonged emergence

• Advantage
• Better ventilation
• Suspected Foreign body
• NMB partially compromised airway in to complete
  obstruction

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Controlled
ventilation

• Advantage
• Patient immobility
• More rapid emergence
• Better for hypercarbia

• Disadvantage
• Force the FB deeper

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• Kosloske. AM Am J Dis Child. 198213610924-7
• Ronald S. Anesth Analg 2000911389-91
• Verghese. ACNA 2001
• Pawar DK. Paediatr Anaesth 200010333

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• Techniques for ventilation
• Conventional ventilation
• Apnoeic oxygenation
• High frequency jet ventilator

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Monitoring

• Standard monitoring
• Clinical vigilance is key
• Communication between the endocopist and
  anaesthesiologist is important
• Endtidal CO2 unreliable

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Intraoperarive complication

• Acute airway obstruction
• Laryngo spasm and laryngeal edema
• Pneumomediastinum
• Pneumothorax
• Massive hemoptysis

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• Tracheal intubation
• Tracheobronchial suction
• Lung expansion
• For oxygenation and ventilation
  auscultation
• Airway edema
• Dexamethasone (0.4 to 1 mg/kg )
• Racemic epinephrine (0.5ml -2.25)
• Monitor in the PACU

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Laryngeal papillomatosis

• Recurrent Respiratory Papillomatosis (RRP)
• HPV-6 and HPV-11
• More common in children than adults
• Course of RRP is unpredictable
• Larynx is the most common site

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• Hoarseness is the most common
• Choking episodes
• Cough, Dyspnea Inspiratory wheeze
• Stridor
• Respiratory distress

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• Diagnosis
• Laryngoscopy or Bronchoscopy
• Imaging Studies
• X-ray
• CT scan

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• No curative treatment
• Medical Surgical
• Interferon alfa-2a Forceps
• Acyclovir Ultrasonic
  microdebrider
• Indole 3-carbinol Laser

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• Check previous medical records
• Premedication
• Quite anxious PAC help allay fears
• Sedative should be used very carefully
• Glycopyrolate, Dexamethasone

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• Perioperative care
• The degree of obstruction to airflow
• Type and location of the papilloma
• Plan before the case
• Alternative Tracheostomy should be ready
• ACNA
  2001

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• Induction
• Prexygenation
• Maintain spontaneous ventilation until the
  airway is examined and controlled ventilation
  possible.
• Intubation - keep small size ETT ( 2.5 mm),
  Conventional ventilation
• Muscle relaxant
• Analgesia

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• Laser-safe tracheal tube conventional
  ventilation (46)
• Jet ventilation (26)
• Apneic technique (16)
• Spontaneous ventilation (12)
• Tracheostomy ?

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Basic safety guidelines for endoscopic procedure

• Evaluate the airway, and know the airway disease
• Sedate carefully
• Select the anesthesia technique that best matches
  up to patient, the disease, and the surgical
  procedure
• Always give priority to oxygenation and
  ventilation

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• Use and monitor muscle relaxants appropriately
• Suppress airway reflexes
• Perform extubation in an awake patient whenever
  possible.

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