Anesthesia for diagnostic bronchoscopic procedures

Diagnostic bronchoscopic procedures are performed every day by both pulmonologists and thoracic surgeons. Diagnostic bronchoscopy is indicated for airway exam, bronchioalveolar lavage, biopsy of airway lesions, autofluorescence bronchoscopy, and narrow band imaging. Most of the diagnostic procedures are performed in an outpatient setting under moderate (conscious) sedation in conjunction with local anesthesia to numb the airway. Moderate sedation is commonly provided by a trained sedation nurse under the supervision of the bronchoscopist and has become a well-accepted method of providing anesthesia for diagnostic bronchoscopy. The short duration of diagnostic bronchoscopy procedures makes moderate sedation a suitable method of anesthesia [1]. In recent years more prolonged sophisticated diagnostic bronchoscopic procedures have emerged. These include endobronchial ultrasound with fine-needle aspiration (EBUS-FNA) [2], staging of lung cancer, and electromagnetic navigation (EMN) with biopsy of peripheral lung lesions. These procedures require a longer duration and a quiet field for precise targeting of the mediastinal lymph nodes or lung lesions without injury to surrounding large vessels or breach of the pleura. As a result there is increasing demand for general anesthesia under the care of anesthesiologists for advanced diagnostic bronchoscopic procedures. The demand for the advanced diagnostic bronchoscopic procedures is increasing as these procedures provide a minimally invasive approach. Although it seems intuitive to perform general anesthesia for airway procedures in the operating room, the current practice is that most of these procedures are performed in interventional bronchoscopy suites that have been modified to mimic an operating room (Figure 30.1) These suites are commonly found in large academic centers with high volumes of patients needing advanced diagnostic bronchoscopic procedures on a daily basis. Several factors have caused the shift of performing such airway procedures to outside the operating room. These include the high safety profile of EBUS-FNA, the increased cost of performing procedures in the operating room, inability to obtain operating room block time on short notice for the pulmonologists, and the cumbersome process of moving the equipment required to perform the procedures to the operating room. The interventional bronchoscopy suites are designed with both safety and excellence in mind [3]. The American Society of Anesthesiology guidelines on establishing out of the operating room anesthesia support have to be implemented during the design of such interventional bronchoscopic suites [4].