Welcome back to the Deep Dive. Today we're shifting gears a
little. We are moving away from General
Medical curiosities and stepping directly into the line of fire.
If you're listening to this, chances are you aren't just
looking for some cocktail party trivia about lungs.
No, not today. You're likely an anesthesia
resident, maybe staring down the barrel of the Goudreaux
University in the anesthesiology exams or the DNB final theory,
and you need to know this topic cold.
That is absolutely right. Today isn't about casual
learning, it's about survival. There's Fival.
I like that. It is.
It's about walking into that exam hall, facing a senior MD
faculty member who's been managing airwaves for 30 years,
and knowing exactly what to say when they hand you a
bronchoscope and ask, how do you keep this patient alive?
The stakes are definitely high. Yeah.
So here's a premise for today's deep dive.
We're treating this strictly as a simulated Viva and theory prep
session. Exactly.
I'm going to play the role of the inquisitive, you know,
slightly stressed resident. Let's just call me the learner.
I've read the books, I've skimmed through Miller and
Morgan. I've looked at Kaushik
Jothanat's notes, but I really need to synthesize it all into
something coherent. And I'll play the role of the
examiner or maybe your senior mentor.
My job is to strip away all the fluff.
We're going to take that whole stack of sources, your standard
texts, the review notes, question bank patterns and
convert them into high yield pass grade answers.
OK. So our mission statement for
today is simple. Convert these complex airway
procedures, specifically bronchoscopy and endobronchial
ultrasound or EBUS, into structured answers that are
going to score marks. That's the goal.
And we're focusing heavily on this shared airway concept
because that really seems to be the pivot point for everything
in this topic. It is the absolute core.
Look, if you understand the shared airway, you pass.
If you don't respect it, you fail.
And that's true in the exam and more importantly, in the
operating room. Right, let's do it.
Let's. Get started part A introduction
and exam framing. OK, Section 1, I'm sitting in
the exam. I get a short note or a Viva
question. I have to start with
definitions. I can't just say looking into
the lungs, Yeah. Don't do that.
How do we define bronchoscopy in a way that sounds professional?
Precision is key. So bronchoscopy is defined as
the visualization of the tracheobronchial tree.
Simple as that. OK, but to show you really know
your stuff you have to immediately follow up.
You say it allows for three distinct activities, inspection,
diagnostic sampling and therapeutic intervention.
Inspection, diagnosis, therapy. Got it.
Simple structure. Now what about EBUS?
That's endobronchial ultrasound. That seems to be the buzzword in
all the recent papers and exams it.
Is and for good reason. EBUS is a technique that
combines bronchoscopy with ultrasound imaging.
Now, why does an examiner care about this?
Because standard bronchoscopy only sees the inside surface of
the airway. You know the mucosal.
Layer the lining. Exactly.
EBUS let's you visualize structures adjacent to the
bronchial wall. We're not just looking at the
tunnel anymore, We are literally looking through the wall at
parabronchial lesions. And this is the most important
part mediastinal lymph nodes. So if I were to put it simply,
regular bronchoscopy sees the tunnel, but Ebus sees what's
buried in the dirt outside the tunnel.
That is a very fair analogy. Yeah.
And for exam relevance, you have to nail the Y.
Bronchoscopy identifies endobronchial abnormalities,
tumors, foreign bodies, bleeding sites, right?
EBUS is now the gold standard for staging lung cancer.
It allows for transbronchial needle aspiration, TBNA of those
mediastinal nodes without having to cut the patient open for a
media stenoscopy. It's a huge deal.
OK, that makes perfect sense. And that brings us to the
concept, what you called the crucial concept, the shared
airway. Why is this the biggest hurdle?
Because it represents A fundamental physiological
conflict. It's a turf war.
A turf war, Okay. As the anesthesiologist, your
job is to use the airway to keep the patient alive by delivering
oxygen and removing CO2. Right, my one job.
Your one job. Meanwhile, the pulmonologist or
the surgeon needs that exact same airway to do their job.
To pass a scope, take a biopsy, or remove a foreign body.
You are competing for the same anatomical real estate.
Competition for the airway. Use that exact phrase in an
exam. If you say this procedure
necessitates absolute coordination due to the inherent
competition for the airway, you have already scored points.
The bronchoscope itself is an obstruction.
It increases resistance to airflow.
It's a physiological stress test you're imposing on the patient.
OK. So before we really get into the
weeds of how we manage that, what are the common question
patterns we need to be ready for what's going to be on the test?
In the Gujarat University or DNB pattern, you'll see short notes
things like anesthetic management of rigid bronchoscopy
or jet ventilation. The classic 5 markers.
Exactly your bread and butter questions.
Then for the long 10 to 15 mark answers, you have to expect a
clinical scenario. The absolute classic is describe
the anesthetic challenges and management of a child with a
foreign body in the bronchus. Oh yeah.
We definitely need to role play that one.
Later we will. And then in the Viva, it's hands
on. They'll hand you a scope, ask
you to identify it. Is this rigid or flexible?
Or they'll hit you with a crisis.
The sats are dropping, the patient is spasming.
What do you do? Right now?
You need to have that algorithm ready to go.
OK. Let's move to Part B, then.
Bronchoscopy. You've marked this as absolutely
essential. It is.
We have two main players here, flexible and rigid.
Yeah, I admit I sometimes get confused about when exactly we
use which. Aside from the obvious fact that
one is stiff, how do I differentiate them for the
examiner? You differentiate them based on
three things, structure, utility, and the anesthetic
requirement. OK, so flexible fiber optic
bronchoscopy. It's pliable, it's maneuverable.
It has a much smaller diameter. The key exam differentiator is
that it can often be done under topical anesthesia or just light
sedation. Right, the patient can be awake
Ish. Exactly.
And you use it for diagnosis and for reaching the distal Airways,
the really small bronchi where a big metal tube just can't go.
And the rigid bronchoscope. Think of it as a weapon.
Seriously. It's a hollow, straight metal
tube. It's non yielding.
Morgan's textbook is crystal clear on this.
Rigid bronchoscopy is traditionally the technique of
choice for three main things. Yeah, what are they?
Tracheal obstruction, massive hemoptysis, and foreign body
removal. Foreign bodies, bleeding,
obstruction, rigid. Correct.
And the exam differentiator for the rigid scope is that it
almost always requires general anesthesia, GA, and usually with
muscle relaxation. You cannot shove a wide metal
pipe down a conscious person's throat.
It's just not going to happen. OK, so to summarize it for an
examiner, I'd say flexible is for diagnosis, distal reach, and
patient comfort. Rigid is for intervention,
proximal control, foreign bodies, and massive bleeding.
That is a perfect summary. Nail that and you're golden on
that question. Let's talk indications in
Section 3. We've listed a few, but let's be
thorough. If I have to list out diagnostic
indications, what am I saying? So you're drawing from your
sources. Like Koushik Jothanath's notes
for the Oxford Handbook, your diagnostic list is about
investigating symptoms. Things like an unexplained
cough, hemoptysis, a new wheeze or stridor.
OK, the common stuff. The common stuff.
Then there's suspected neoplasms.
You're hunting for cancer. Collection of microbiological
specimens? That's your Bal.
The broncho Viola lavage for infections.
And don't forget assessment of the vocal cords for palsies.
You see this a lot before a big thyroid surgery or after a
prolonged intubation. OK.
And therapeutic. This feels like where the real
high stakes anesthesia work happens.
It is. This is where it gets serious.
Foreign body removal is the big one, especially in Pediatrics.
The peanut and the Blancos. The peanut, the Lego, you name
it. Then removal of tenacious
secretions or mucus plugs, often in ICU patients who just can't
clear their own chest. Laser resection of tumors to
open up the airway, which is incredibly high risk for an
airway fire. Oh wow.
Tracheal dilation for stenosis and stent placement to keep a
collapsed airway open. So from my perspective as the
anesthetist, how do I group these in my head?
You group them by risk. It's risk stratification.
Diagnostic usually implies a shorter, less stimulating
procedure where sedation might be enough.
Therapeutic, like digging out a foreign body or lasering A tumor
implies a high risk of obstruction of losing the
airway. And it almost always mandates
general anaesthesia to ensure the patient is perfectly still
while there are sharp instruments or lasers in their
lungs. Right, that makes total sense.
OK, let's get into the Physiology in Section 4.
You called this exam gold. So what has actually happened to
the patient's body when we stick a scope down their airway?
It's a cascade of bad things for gas exchange.
It really is. First, the shared airway problem
we talked about effectively means obstruction.
The scope itself reduces the cross-sectional area of the
airway, right? And you have to remember Quizo's
law resistance is inversely proportional to the radius to
the 4th power. A small decrease in radius leads
to a huge increase in resistance.
It's like trying to breathe through a coffee stirrer while
you're running. Exactly.
And that leads directly to the second major challenge, hypoxia.
OK, you get hypoventilation because of that insane
resistance. You get VQ mismatch because of
atelectasis, parts of the lung just collapse.
And don't forget suctioning. This is a key point for exams.
What about suctioning? When the surgeon or the
pulmonologist suctions blood or mucus, they are also suctioning
away your oxygen and your lung volume.
They are actively de recruiting the lungs.
That's a great point. They're literally vacuuming the
air out of the patient's lungs. They are and 3rd hypercapnia.
The CO2 builds up because of that hypoventilation or because
of periods of apnea, especially during rigid bronchoscopy where
you might have to stop ventilating completely for a
minute to let them work. And what about the body's own
reaction? The reflexes?
Oh. The airway irritation is
profound. The airway is one of the most
sensitive parts of the body. Any instrumentation causes an
intense sympathetic stimulation, tachycardia, hypertension.
Right, the fight or flight response.
A massive 1 and it triggers protective reflexes, coughing,
laryngosasm, bronchospasm. If you are doing this procedure
and your anesthesia is too light, the vocal cords will slam
shut and then you're in real trouble.
O The anesthetic goal is this this balancing act.
We have to blunt those reflexes so they don't cough or spasm,
but we have to keep them breathing or ventilated enough
to stop them from turning blue. You have just perfectly
described the art of bronchoscopy anesthesia.
You are walking a tightrope between too light, where they
spasm and fight you, and too deep, where they stop breathing
entirely and their blood pressure crashes.
That's the challenge. That segues perfectly into Part
C, anesthetic management. This is the real meat of the
answer, right? Absolutely.
So before we even induce, we need to assess the patient.
Section 5 preoperative assessment.
What are we looking for that's specific to this procedure?
So your standard airway evaluation is a given.
Melamotty, neck movement, thyro, mental distance, all of that.
But Miller's textbook really emphasizes that you must look
for specific pathology related to the procedure.
Is there stridor? If a patient has strider at
rest, their airway is already critical.
You have to be incredibly careful.
Is the trachea deviated on the chest X-ray?
And you have to look at the scans.
You must look at the CT scan. Is there a big mediastinal mass
compressing the airway? Is it an extrinsic compression?
Because if there is extrinsic compression and we paralyze
them. The airway might collapse
completely. It's called dynamic airway
collapse. The muscles holding the airway
open relax, the positive pressure in the chest is lost
and the mass just crushes the trachea flat.
That's a cannot intubate, cannot ventilate nightmare.
The ultimate nightmare. So you have to know the nature
of the obstruction before you start.
Is it fixed or is it dynamic? OK, so beyond the anatomy of the
airway, what about the lungs themselves of a parent chemo?
Respiratory reserve is absolutely key.
Many of these patients have underlying COPD or asthma,
right? The sources, like the
perioperative asthma guidelines, emphasize optimization.
You want them on their bronchodilators.
You want them to have had their steroids, metal medisolone or
hydrocortisone on board if they're reactive.
What about smoking? And smoking cessation, though,
you know, practically for an urgent scope, you're almost
never going to get the 4 to 8 weeks lead time that's required
for real meaningful benefit. But you should mention it.
And other comorbidities. Cardiac status is huge.
Remember that massive sympathetic surge I mentioned?
Yeah, the tachycardia and hypertension.
If your patient has ischemic heart disease, that tachycardia
and hypertension during the scoping can cause a myocardial
infarction right there on the table.
You need to identify patients who cannot tolerate that stress
or who can't tolerate the inevitable periods of apnea or
hypoventilation. OK.
Now for the big decision, the one that seems to trip people
up, Section six, choice of anesthesia.
Is it topical with sedation or is it general anesthesia?
How do I make this decision for the examiner?
You frame it as a risk benefit analysis based on the patient,
the procedure, and the operator. Topical anesthesia with sedation
is primarily for diagnostic flexible bronchoscopy.
In a cooperative patient. You use a spray as you go
technique with lidocaine, or you nebulize it beforehand.
The beauty of this is that it preserves spontaneous
respiration, which is inherently safer if the airway is already
precarious. And GA when is that the answer?
GA is mandatory for rigid bronchoscopy, full stop.
No exceptions. No exceptions.
It's also the standard of care for pediatric patients.
They will not cooperate uncooperative adults any complex
therapeutic procedure like stenting or laser, and usually
for lengthy EB West procedures. I see Kaushik Jothanaths notes
list advantages and disadvantages.
What's the headline there? For GA, the advantage is you
have a totally controlled airway, you have immobility, you
have complete control over oxygenation and ventilation.
And the downside? The disadvantages are the
hemodynamic fluctuations from the drugs and a longer recovery
time. Sedation, on the other hand,
keeps them breathing on their own, but if they cough or move
at the wrong time, the surgeon can't work or worse, perforates
the airway. So if the examiner puts me on
the spot and asks when do I say GA is mandatory?
You give them a firm clear list. Foreign body removal, all
pediatric patients, massive hemoptysis, and all rigid
bronchoscopy do not waver on those 4.
OK, got it. Let's talk about the plumbing
Section 7 airway management techniques.
We've got a few options here. We do for flexible bronchoscopy.
You can go nasal or oral. The nasal route is quite common
for awake fiber optic procedures.
Right? But you must tell the examiner
you'll use vasoconstrictors first.
Something like phenilephrine or xylometasoline spray in the
nose. You have to prevent epistaxis.
A Nosebleed ruins the view before you even start the
procedure. That's a great practical point.
What about the LMA? I've seen that used a lot.
The LMA is a fantastic tool for this.
Miller's describes it as a conduit.
It's a brilliant description. Why conduit?
You place the LMA, the patient is breathing through it, and you
simply pass the flexible scope through the Lma's channel.
It's much wider than an endotracheal tube of a similar
size, so there's less resistance to breathing around the stove.
And you can see the chords better.
Exactly, it sits above the vocal cords so you can visually all
the subglottic structures perfectly, and it's excellent
for maintaining spontaneous respiration while keeping the
upper airway patent. OK.
And for rigid bronchoscopy, what's the airway there?
For rigid bronchoscopy, the scope is the airway.
No, that metal tube becomes your endotracheal tube.
You attach your ventilation circuit to a special side port
on the scope. But, and this is a huge but,
when the surgeon opens the back of the scope to insert forceps
or a suction catheter. The circuit is open to the room.
The whole circuit is open. You lose all your pressure, all
your tidal volume, it just vents out.
So you're only really ventilating when they close that
little back window. Correct.
It's an intermittent ventilation technique.
You're constantly communicating, ventilating, ventilating.
OK, they're opening, suctioning. OK.
They're closed ventilating again or use jet ventilation, but
we'll get to that. OK, let's talk drugs.
Section 8, sedation and drug considerations.
What's our ideal cocktail? The goals are simple.
You want anxiolysis, amnesia and profound cough suppression, and
you need to maintain hemodynamic stability.
So benzodiazepines like mirazolem are standard for
anxiolysis. You know, maybe .05 to .15
mileageocruises for opioids. Fentanyl is very common, but
remifentanyl is the real superstar here, especially for
the exam. OK, why remifentanyl?
I know it's expensive, but why is it the preferred exam answer?
Because of its unique pharmacokinetics, it has a very,
very short context sensitive half life.
It's not metabolized by the liver or kidneys.
It's broken down by plasma estrasis all over the body.
So it's gone almost instantly. Almost instantly you can run a
high dose infusion to completely knockout the cough reflex during
the most stimulating parts of the procedure, and then you turn
it off and the patient is waking up and breathing spontaneously
within minutes. For a stimulating procedure like
rigid bronchoscopy where you need a rapid wake up to check
airway reflexes, it is absolutely ideal.
What about Propofol? Propofol is your workhorse.
It's standard for induction and maintenance, usually as a taiva,
a total intravenous anesthesia infusion.
Whytiva over an inhalational gas?
Because the circuit is open to the room so often, right?
If you were using SEVA fluorine, most of it would just leak out,
polluting the OR and not keeping the patient asleep.
TFLY gives you consistent depth regardless of circuit leaks.
And I see dexmitotomidine mentioned in the Yow and Artuzio
source, Yeah, Where does that fit in?
Dexmitotomidine is a great choice for what's called
cooperative sedation. It provides sedation and some
analgesia without causing significant respiratory
depression. It's great if you want the
patient awake enough to follow commands, but comfortable and
not caulking. And one last thing, don't forget
the anti cialagogue. You must not forget it.
Glycopyrrolite is your friend. You have to dry up the
ecretions. If the lens of the scope is
constantly being covered by mucus, the rocedure fails.
A dry airway is a hay airway for the bronchoscopist.
Right. Moving to Section 9, oxygenation
and ventilation strategies, We've touched on the side port
ventilation for the rigid scope, but what is this concept of
apneic oxygenation? Morgan explains this very well.
It's a fascinating physiological principle.
It relies on the mass movement of oxygen from the alveoli into
the blood. So you insufflate oxygen,
usually veer a small catheter deep into the airway.
Even if the patient isn't taking a breath, if they're apneic, the
oxygen in their lungs is still being rapidly absorbed into the
bloodstream. This creates a pressure
gradient, a sort of vacuum, a sub atmospheric pressure in the
alveoli that literally pulls more oxygen down the trachea
from your source. So you're getting oxygenation,
but the CO2 doesn't leave. That's the catch exactly.
You get oxygenation without ventilation.
The CO2 has no way out, so it accumulates, leading to a
progressive respiratory acidosis.
You're limited by time, usually only 10 to 20 minutes before the
patient's pH drops dangerously low.
Got it. And now for the big buzzword,
jet ventilation. Ah yes, jet ventilation uses
something called a Sanders injector.
It's a device that shoots a high pressure jet of pure oxygen down
the scope. So you're just blasting oxygen
in? You are, and as that high
pressure jet shoots forward, it entrains room air from the side
port. That's the Venturi effect, which
increases the total volume delivered to the patient.
What's the danger? It sounds risky.
The danger is Barrow trauma, massive Barrow trauma.
You are blasting high pressure into the lungs.
If that air has no way to get out, let's say because of a ball
valve obstruction from a tumor or the scope is wedged too
tightly in the trachea, you will blow a pneumothorax or a
pneumomedia Steinem. It's a catastrophic
complication. So what is the absolute number
one rule? Rule #1 of jet ventilation
always ensure an egress path for the gas.
If air goes in, air must be able to come out.
Always ensure an egress path. Yeah, I'm tattooing that on my
brain. Let's shift gears now to Part D,
endobronchial ultrasound, or EBUS.
This seems to be more and more common in exams.
It's essential now it's largely replacing surgical media
stenoscopy, so you have to know it.
OK, Section 10, Principles and types, what is it fundamentally?
Fundamentally, EBUS involves an ultrasound probe that's been
incorporated into the tip of a flexible bronchoscope.
It allows us to, as we said, see through the bronchial wall.
And there are two types, radial and convex.
That's right, the radial probe gives you a 360° view, which is
good for looking at peripheral lesions or small pulmonary
nodules. But the convex probe is the one
we use most for staging. It gives a linear view which is
what allows for the needle aspiration, the TB and a.
You can see the needle in real time on the ultrasound as it
enters the lymph node. So why do we as anesthetists
care so much? Isn't it just another
bronchoscopy from our end? No, it's very different.
It's a hybrid procedure with a unique set of challenges.
It has the invasiveness and risk of a deep biopsy combined with
the significant airway obstruction of a large.
Scope. So Section 11 indications, you
said it's mainly for cancer staging.
Primarily the number one indication is staging of non
small cell lung cancer. They're looking for spread of
cancer to the mediastinal lymph nodes.
If those nodes are positive, the patient might not be a candidate
for surgical resection. The result of this one test can
determine the patient's entire treatment plan.
It's a high stakes procedure. OK, This is why Section 12 calls
it Exam Gold. What are the specific anesthetic
challenges in Ebos that are different from a regular scope?
OK, first duration. An EBS procedure is generally
much longer than a quick look. See bronchoscopy.
They have to systematically map out all the lymph node stations
and then carefully sample each one.
So more time under anesthesia, more risk.
Exactly. Second, the scope size.
EBOS scopes are bulkier. They're almost 7mm in diameter.
If you put that scope through a standard size 7.5 or 8 point O
endotracheal tube, you are blocking a huge percentage of
the lumen airway resistance goes right through.
The roof and someone mentioned a balloon.
Right, this is critical. To get a good ultrasound image,
the operator has to inflate a small saline filled balloon at
the tip of the scope, pressing it against the airway wall.
So that creates a complete obstruction of that bronchus
while they're scanning A. Complete 100% obstruction.
So if they are in the right main brontus and they inflate that
balloon, you are now effectively doing one lung ventilation.
Wow. But without a double lumen tube
or a bronchial blocker. Precisely so if the patient has
poor respiratory reserve to begin with, they will desaturate
instantly. And the kicker, I'm guessing, is
immobility. That's the absolute kicker.
The pulmonologist is passing a sharp needle through the
bronchial wall into a lymph node that is often sitting right next
to the pulmonary artery or the aorta if the patient coughs or
moves at that exact moment. That's a disaster.
You puncture a major vessel. It's a catastrophe, a massive
bleed in the mediastinum. So while you can technically do
these procedures under deep sedation for exams and often in
real world practice, for safety, general anesthesia is strongly
preferred. You need that absolute guarantee
of immobility. OK, so that leads to Section 13
techniques for EBUS. If GA is the way to go, what's
the airway? Divisive choice?
This is a great discussion point for an exam.
Miller's actually suggests that an LMA can be a better choice
here. An LMA.
Why not a definitive ET. Because the LMA, A superglottic
airway, sits above the glottis. This allows you to pass the
large ebus scope through the vocal cords, and you still have
the entire tracheal lumen to ventilate around the scope.
It can offer lower resistance than trying to cram that big
scope down a relatively narrow endotracheal tube.
I see, but I imagine some people still prefer an ECT.
Oh absolutely. Many anesthetist prefer a large
bore endotracheal tube tube like a size 8.5 or even a nine point
O to ensure a definitive secured airway, especially if there's a
high risk of bleeding. Both are valid options and you
should be able to discuss the pros and cons of each.
OK, that's a key point. Let's move to Part E
complications and safety. This is another really high
yield area, Section 14. What can go wrong?
The most common thing to go wrong by far is hypoxia
desaturation due to all the reasons we've already discussed,
obstruction, suctioning, VQ mismatch.
After that. Bronchospasm and laryngospasm,
especially if the anesthesia is too light for the degree of
stimulation. What about bleeding?
Bleeding is a major concern, especially after a biopsy or a
TBNA. Miller's notes that it's usually
self limiting, just a bit of oozing, but it can be massive
and life threatening. And pneumothorax.
That's a real risk with any transbronchial biopsy.
If the needle goes too far, it punctures the pleura and the
lung collapses. Or, of course, barotrauma from
jet ventilation. And arrhythmias.
Very common, usually due to that huge sympathetic surge or from
hypoxia. You can also get profound
bradycardia if there's strong vagal stimulation deep in the
airway. OK, Section 15, Management of
complications. Let's do this rapid fire Viva
style. I'm in the middle of the case.
The pulse oximeter alarm is going off.
Sats are dropping to 85. What is the first thing I do?
You stop everything, you tell the operator stop the procedure,
then you ask them to withdraw the scope to the mid trachea, or
if necessary, remove it entirely.
Get the obstruction out. Get the obstruction out, then
you administer 100% oxygen and you gently assist ventilation
with the bag. You cannot ventilate effectively
with that huge scope still blocking the airway.
OK, new scenario. They just took a biopsy and now
there's bright red blood filling the airway, bleeding.
First suction, then you can instill cold saline through the
scope to cause vasoconstriction. You can also give topical
epinephrine solution A1 in 10,000 or ONE in 20,000 solution
down the scope. And if it's massive?
If it's massive, the operator can wedge the tip of the
bronchoscope into the bleeding bronchus to tamponate it.
This also protects the healthy lung from being flooded with
blood and you should immediately turn the patient so the bleeding
side is down. Right, good.
Lung up. Yeah.
OK, last one. I hear a wheeze and I can't
ventilate bronchospasm. First, deep in the anesthesia,
increase your propofol or your volatile agent.
Civil fluorine is a potent bronchodilator.
At the same time give bronchodilator cellbutamol puffs
right into the circuit. So if the examiner asked me,
what is your primary safety rule during any of these
complications? Your answer is safety first.
I would immediately stop the procedure, withdraw the scope
and secure the airway and ventilation.
You never try to fix the problem through the disaster while the
scope is still obstructing everything.
OK Part F Post procedure care Section 16 Monitoring the
procedures done. The patient is waking up.
What are we watching for? Like a hawk.
You're watching for the return of their airway reflexes.
They absolutely must have them back before discharge to prevent
aspiration, especially if you used a lot of topical anesthesia
on their vocal cords. They need to be able to protect
their own airway. What about hemodynamics?
You're watching for any delayed bleeding, which can manifest as
tachycardia or hypertension. And oxygenation you.
Have to watch for a delayed pneumothorax.
It doesn't always show up immediately.
If they did a biopsy, a post procedure chest X-ray is often
very prudent. At the very least, you need
close observation for any signs of respiratory distress,
desaturation, or subcutaneous emphysema.
Section 17. What are the discharge criteria?
When is it safe for them to go home?
You use the standard pads, the post anesthetic discharge
scoring system. They have to be awake elite with
stable vitals. But specifically for an airway
procedure exam answer, you add three more things.
OK, ensure no stride or ensure no active hemoptysis and ensure
they have the ability to swallow water without coughing or
choking. Perfect.
All right, Part G, This is where we bring it all together for the
exam. Section 18, flexible versus
rigid bronchoscopy. This is a classic comparison.
Let's build that mental table for the examiner.
Let's do it. It's all about direct
comparison. Indication flexible is for
diagnosis and looking at peripheral lesions.
Rigid is for foreign bodies, massive bleeds and central
obstructions. Got it.
Row 2. Anesthetic.
Flexible usually uses sedation, Rigid always uses GA.
Row 3 ventilation. Flexible you're looking at
spontaneous breathing or ventilation via an LMA.
For rigid, it's either the sidearm port or jet ventilation.
And finally, complications. Flexible has a much lower risk
of airway trauma. Rigid has a higher risk of
dental damage, lip injury, and laryngeal trauma from insertion.
OK. That's clear.
Now Section 19, bronchoscopy versus EBS, how do we compare
those? EBS is a specific high tech
subset of flexible bronchoscopy. The purpose is different staging
for EBS versus general diagnosis or therapy for standard
bronchoscopy. And the airway management
reflects. That it does.
EBS leans very heavily towards general anesthesia with an LMA
or a large ETT. Why?
Because you need that absolute immobility and you have to
manage the airway obstruction from the larger scope.
A standard flexible bronchoscopy, on the other hand,
leans much more towards sedation.
Perfect section 20 common exam questions and Viva traps.
We mentioned the foreign body child.
Let's really role play this. The examiner asked me.
I have a three-year old who has inhaled a peanut.
It's in the right vein bronchus. How do you induce anesthesia?
Is the ultimate trap. Do not say rapid sequence
induction. Do not say I would paralyze the
child. You will fail on the spot.
So what's the right answer? The correct safe answer is
inhalational induction with civil slurane maintaining
spontaneous ventilation. Why is paralysis so incredibly
dangerous here? Because the negative pressure
generated by spontaneous breathing actually helps to keep
the airway open around the foreign body.
If you paralyze them, all the airway muscles relax, the
mediastinum can shift, and that peanut might dislodge and move,
turning a partial obstruction into a complete can't ventilate
obstruction. You maintain spontaneous
ventilation until the surgeon has the rigid scope in and is
visually secured the foreign body with forceps.
Only then, once the airway is physically controlled, can you
consider giving a muscle relaxant if needed.
OK, that's a critical point trap #2 can you do rigid bronchoscopy
under sedation? The answer is an emphatic no.
It requires general anesthesia and in most cases muscle
relaxation to allow the passage of that large metal tube past
the vocal cords without causing trauma.
The only nuances in some complex tracheal stenosis cases where
you might preserve spontaneous ventilation, but that is still a
form of GA, not just sedation. And the third trap, we've
mentioned it, but let's hit it one more time.
Jet ventilation. The mistake is forgetting the
egress, forgetting the outflow. If you describe jet ventilating
into a closed system, you are describing A fatal Barrow
trauma. It is an automatic fail.
OK session 21 diagrams and exam presentation.
If I have to draw the bronchoscopy airway setup for a
10 mark answer, what does that look like?
Keep it simple but clear. Draw the patient supine, Draw
the anesthesia machine on the left or right, but make a note
that you need a long circuit an extension tubing, because the
anesthesiologist is often displaced to the side to give
the surgeon room at the head of the bed.
Right, the surgeon is at the head.
The surgeon is at the head. Draw the oxygen source for your
jet ventilation as a separate high pressure line and show the
monitors, ECG, SAPS, probe, BP cuff and make sure they're
positioned to be visible to both you and the surgeon.
What about a cannot ventilate flu chart?
Very high yield box #1 call for help.
Box 2 ask surgery to withdraw the scope immediately.
Box three, attempt mask ventilation with 100 to O2.
If that fails Box 4 insert LMA. If that fails box 5 intubate.
Preferably with a video learning to scope and if that fails.
Cannot intubate. Cannot ventilate.
You go to your surgical airway algorithm.
Scalpel. Bougie tube.
A cricothyroidotomy. You have to show you have a plan
for failure. OK, finally, Section 22 summary
and exam conclusion. Can you give me the elevator
pitch for the exam? The final take home message?
OK, here are the absolute key points.
Bronchoscopy is a shared airway procedure requiring absolute
constant communication, hypoxia and.
Arrhythmias are your primary enemies.
You must anticipate them, right? Three.
Choose GA for rigid therapeutic or uncooperative cases.
Choose topical with sedation for cooperative diagnosis.
Agnostic, flexible cases. EBUS requires immobility, so you
should lean towards GA with an LMA or a large ETT.
Never forget the egress rule for jet ventilation.
And #7. Communication with the
pulmonologist or surgeon is the most important monitoring tool
you have. Communication with the
pulmonologist is the most important monitoring tool.
I love that. That's the perfect concluding
line. It saves lives, it really does.
If they are about to take a biopsy, they need to tell you so
you can ensure the patient is deep and doesn't move.
If you are losing the airway, you need to tell them clearly
and loudly to get out. This has been incredibly high
yield. I actually feel like I can
structure that 15 mark question now.
Just remember the structure we talked about, definition,
indications, Physiology, anesthetic management, and
complications. Stick to that framework and you
will pass. Thank you so much for this.
To our learner listening, visualize that shared airway
setup before you walk into the exam hall.
Keep your airway clear and your answers even clearer.
Good luck. See you next time on the Deep
Dive.