Liao Yu-Chen, Wu Wei-Ciao, Hsieh Ming-Hui, Chang Chuen-Chau, Tsai Hsiao-Chien
Department of Anesthesiology.
Division of Thoracic Surgery, Department of Surgery, Taipei Medical University Hospital.
Medicine (Baltimore). 2020 Jul 2;99(27):e20916. doi: 10.1097/MD.0000000000020916.
Evolving techniques in the field of therapeutic bronchoscopy have led to the return of rigid bronchoscopy in the treatment of complex central airway disease. Rigid bronchoscopy is typically performed under general anesthesia because of the strong stimulation caused by metal instruments. Anesthesia for rigid bronchoscopy is challenging to administer because anesthesiologists and interventionists share the same working channel: the airway. Previously reviewed anesthetic methods are used primarily for short procedures. Balanced anesthesia with ultrasound-guided superior laryngeal nerve (SLN) block and total intravenous anesthesia might provide anesthesia for a prolonged procedure and facilitate patient recovery.
A patient with obstructed endobronchial stent was referred for therapeutic rigid bronchoscopy, which requires deeper anesthesia than flexible bronchoscopy. There were concerns of the stronger stimulation of the rigid bronchoscopy, lengthy duration of the procedure, higher risk of hypoxemia, and the difficulty of mechanical ventilation weaning after anesthesia due to the patients co-morbidities.
A 66-year-old female patient presented with a history of breast cancer with lung metastases. Right main bronchus obstruction due to external compression of lung metastases was relieved through insertion of an endobronchial stent, but obstructive granulation developed after 4 months. Presence of the malfunctioning stent caused severe cough and discomfort. Removal of the stent by using a flexible bronchoscope was attempted twice but failed.
Regional anesthesia of the upper airway through ultrasound-guided SLN block combined with intratracheal 2% lidocaine spray was performed to assist in total intravenous anesthesia (TIVA) during rigid bronchoscopy.
The patient maintained steady spontaneous breathing throughout the procedure without laryngospasm, bucking, or desaturation. Emergence from anesthesia was smooth and rapid after propofol infusion was discontinued. The surgery lasted 2.5 hours without discontinuity, and no perioperative pulmonary or cardiovascular complications were noted.
Ultrasound-guided SLN block is a simple technique with a high success rate and low complication rate. Application of SLN block to assist TIVA provides sufficient anesthesia for lengthened therapeutic rigid bronchoscopy without interruption and facilitates patient recovery.
治疗性支气管镜领域不断发展的技术使得硬质支气管镜在复杂中央气道疾病的治疗中得以回归。由于金属器械会引起强烈刺激，硬质支气管镜检查通常在全身麻醉下进行。硬质支气管镜麻醉给药具有挑战性，因为麻醉医生和介入医生共用同一个工作通道：气道。之前所回顾的麻醉方法主要用于短时间手术。超声引导下喉上神经（SLN）阻滞联合全静脉麻醉的平衡麻醉可能为长时间手术提供麻醉并促进患者恢复。
一名支气管内支架阻塞的患者被转诊接受治疗性硬质支气管镜检查，该检查所需麻醉深度比软性支气管镜检查更深。人们担心硬质支气管镜检查刺激更强、手术时间长、低氧血症风险高，以及由于患者合并症导致麻醉后机械通气脱机困难。
一名66岁女性患者，有乳腺癌伴肺转移病史。因肺转移瘤外部压迫导致右主支气管阻塞，通过插入支气管内支架得以缓解，但4个月后出现阻塞性肉芽组织。支架功能障碍导致严重咳嗽和不适。尝试用软性支气管镜取出支架两次，但均失败。
在硬质支气管镜检查期间，通过超声引导下SLN阻滞对上呼吸道进行区域麻醉，并联合气管内喷洒2%利多卡因，以辅助全静脉麻醉（TIVA）。
患者在整个手术过程中保持稳定的自主呼吸，未出现喉痉挛、呛咳或血氧饱和度下降。停用丙泊酚输注后，麻醉苏醒平稳且迅速。手术持续2.5小时，无间断，未观察到围手术期肺部或心血管并发症。
超声引导下SLN阻滞是一种成功率高、并发症发生率低的简单技术。应用SLN阻滞辅助TIVA可为延长的治疗性硬质支气管镜检查提供充分且不间断的麻醉，并促进患者恢复。
