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Welcome back to the Deep Dive. 
Today we're shifting gears a 

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little. 
We are moving away from General 

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Medical curiosities and stepping
directly into the line of fire. 

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If you're listening to this, 
chances are you aren't just 

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looking for some cocktail party 
trivia about lungs. 

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No, not today. 
You're likely an anesthesia 

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resident, maybe staring down the
barrel of the Goudreaux 

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University in the anesthesiology
exams or the DNB final theory, 

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and you need to know this topic 
cold. 

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That is absolutely right. 
Today isn't about casual 

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learning, it's about survival. 
There's Fival. 

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I like that. 
It is. 

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It's about walking into that 
exam hall, facing a senior MD 

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faculty member who's been 
managing airwaves for 30 years, 

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and knowing exactly what to say 
when they hand you a 

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bronchoscope and ask, how do you
keep this patient alive? 

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The stakes are definitely high. 
Yeah. 

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So here's a premise for today's 
deep dive. 

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We're treating this strictly as 
a simulated Viva and theory prep

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session. 
Exactly. 

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I'm going to play the role of 
the inquisitive, you know, 

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slightly stressed resident. 
Let's just call me the learner. 

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I've read the books, I've 
skimmed through Miller and 

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Morgan. 
I've looked at Kaushik 

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Jothanat's notes, but I really 
need to synthesize it all into 

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something coherent. 
And I'll play the role of the 

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examiner or maybe your senior 
mentor. 

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My job is to strip away all the 
fluff. 

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We're going to take that whole 
stack of sources, your standard 

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texts, the review notes, 
question bank patterns and 

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convert them into high yield 
pass grade answers. 

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OK. 
So our mission statement for 

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today is simple. 
Convert these complex airway 

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procedures, specifically 
bronchoscopy and endobronchial 

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ultrasound or EBUS, into 
structured answers that are 

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going to score marks. 
That's the goal. 

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And we're focusing heavily on 
this shared airway concept 

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because that really seems to be 
the pivot point for everything 

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in this topic. 
It is the absolute core. 

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Look, if you understand the 
shared airway, you pass. 

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If you don't respect it, you 
fail. 

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And that's true in the exam and 
more importantly, in the 

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operating room. 
Right, let's do it. 

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Let's. 
Get started part A introduction 

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and exam framing. 
OK, Section 1, I'm sitting in 

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the exam. 
I get a short note or a Viva 

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question. 
I have to start with 

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definitions. 
I can't just say looking into 

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the lungs, Yeah. 
Don't do that. 

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How do we define bronchoscopy in
a way that sounds professional? 

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Precision is key. 
So bronchoscopy is defined as 

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the visualization of the 
tracheobronchial tree. 

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Simple as that. 
OK, but to show you really know 

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your stuff you have to 
immediately follow up. 

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You say it allows for three 
distinct activities, inspection,

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diagnostic sampling and 
therapeutic intervention. 

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Inspection, diagnosis, therapy. 
Got it. 

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Simple structure. 
Now what about EBUS? 

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That's endobronchial ultrasound.
That seems to be the buzzword in

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all the recent papers and exams 
it. 

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Is and for good reason. 
EBUS is a technique that 

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combines bronchoscopy with 
ultrasound imaging. 

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Now, why does an examiner care 
about this? 

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Because standard bronchoscopy 
only sees the inside surface of 

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the airway. 
You know the mucosal. 

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Layer the lining. 
Exactly. 

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EBUS let's you visualize 
structures adjacent to the 

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bronchial wall. 
We're not just looking at the 

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tunnel anymore, We are literally
looking through the wall at 

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parabronchial lesions. 
And this is the most important 

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part mediastinal lymph nodes. 
So if I were to put it simply, 

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regular bronchoscopy sees the 
tunnel, but Ebus sees what's 

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buried in the dirt outside the 
tunnel. 

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That is a very fair analogy. 
Yeah. 

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And for exam relevance, you have
to nail the Y. 

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Bronchoscopy identifies 
endobronchial abnormalities, 

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tumors, foreign bodies, bleeding
sites, right? 

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EBUS is now the gold standard 
for staging lung cancer. 

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It allows for transbronchial 
needle aspiration, TBNA of those

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mediastinal nodes without having
to cut the patient open for a 

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media stenoscopy. 
It's a huge deal. 

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OK, that makes perfect sense. 
And that brings us to the 

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concept, what you called the 
crucial concept, the shared 

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airway. 
Why is this the biggest hurdle? 

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Because it represents A 
fundamental physiological 

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conflict. 
It's a turf war. 

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A turf war, Okay. 
As the anesthesiologist, your 

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job is to use the airway to keep
the patient alive by delivering 

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oxygen and removing CO2. 
Right, my one job. 

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Your one job. 
Meanwhile, the pulmonologist or 

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the surgeon needs that exact 
same airway to do their job. 

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To pass a scope, take a biopsy, 
or remove a foreign body. 

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You are competing for the same 
anatomical real estate. 

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Competition for the airway. 
Use that exact phrase in an 

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exam. 
If you say this procedure 

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necessitates absolute 
coordination due to the inherent

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competition for the airway, you 
have already scored points. 

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The bronchoscope itself is an 
obstruction. 

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It increases resistance to 
airflow. 

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It's a physiological stress test
you're imposing on the patient. 

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OK. 
So before we really get into the

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weeds of how we manage that, 
what are the common question 

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patterns we need to be ready for
what's going to be on the test? 

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In the Gujarat University or DNB
pattern, you'll see short notes 

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things like anesthetic 
management of rigid bronchoscopy

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or jet ventilation. 
The classic 5 markers. 

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Exactly your bread and butter 
questions. 

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Then for the long 10 to 15 mark 
answers, you have to expect a 

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clinical scenario. 
The absolute classic is describe

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the anesthetic challenges and 
management of a child with a 

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foreign body in the bronchus. 
Oh yeah. 

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We definitely need to role play 
that one. 

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Later we will. 
And then in the Viva, it's hands

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on. 
They'll hand you a scope, ask 

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you to identify it. 
Is this rigid or flexible? 

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Or they'll hit you with a 
crisis. 

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The sats are dropping, the 
patient is spasming. 

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What do you do? 
Right now? 

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You need to have that algorithm 
ready to go. 

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OK. 
Let's move to Part B, then. 

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Bronchoscopy. 
You've marked this as absolutely

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essential. 
It is. 

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We have two main players here, 
flexible and rigid. 

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Yeah, I admit I sometimes get 
confused about when exactly we 

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use which. 
Aside from the obvious fact that

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one is stiff, how do I 
differentiate them for the 

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examiner? 
You differentiate them based on 

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three things, structure, 
utility, and the anesthetic 

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requirement. 
OK, so flexible fiber optic 

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bronchoscopy. 
It's pliable, it's maneuverable.

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It has a much smaller diameter. 
The key exam differentiator is 

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that it can often be done under 
topical anesthesia or just light

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sedation. 
Right, the patient can be awake 

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Ish. 
Exactly. 

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And you use it for diagnosis and
for reaching the distal Airways,

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the really small bronchi where a
big metal tube just can't go. 

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And the rigid bronchoscope. 
Think of it as a weapon. 

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Seriously. 
It's a hollow, straight metal 

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tube. 
It's non yielding. 

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Morgan's textbook is crystal 
clear on this. 

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Rigid bronchoscopy is 
traditionally the technique of 

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choice for three main things. 
Yeah, what are they? 

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Tracheal obstruction, massive 
hemoptysis, and foreign body 

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removal. 
Foreign bodies, bleeding, 

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obstruction, rigid. 
Correct. 

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And the exam differentiator for 
the rigid scope is that it 

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almost always requires general 
anesthesia, GA, and usually with

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muscle relaxation. 
You cannot shove a wide metal 

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pipe down a conscious person's 
throat. 

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It's just not going to happen. 
OK, so to summarize it for an 

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examiner, I'd say flexible is 
for diagnosis, distal reach, and

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patient comfort. 
Rigid is for intervention, 

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proximal control, foreign 
bodies, and massive bleeding. 

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That is a perfect summary. 
Nail that and you're golden on 

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that question. 
Let's talk indications in 

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Section 3. 
We've listed a few, but let's be

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thorough. 
If I have to list out diagnostic

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indications, what am I saying? 
So you're drawing from your 

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sources. 
Like Koushik Jothanath's notes 

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for the Oxford Handbook, your 
diagnostic list is about 

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investigating symptoms. 
Things like an unexplained 

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cough, hemoptysis, a new wheeze 
or stridor. 

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OK, the common stuff. 
The common stuff. 

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Then there's suspected 
neoplasms. 

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You're hunting for cancer. 
Collection of microbiological 

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specimens? 
That's your Bal. 

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The broncho Viola lavage for 
infections. 

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And don't forget assessment of 
the vocal cords for palsies. 

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You see this a lot before a big 
thyroid surgery or after a 

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prolonged intubation. 
OK. 

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And therapeutic. 
This feels like where the real 

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high stakes anesthesia work 
happens. 

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It is. 
This is where it gets serious. 

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Foreign body removal is the big 
one, especially in Pediatrics. 

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The peanut and the Blancos. 
The peanut, the Lego, you name 

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it. 
Then removal of tenacious 

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secretions or mucus plugs, often
in ICU patients who just can't 

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clear their own chest. 
Laser resection of tumors to 

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open up the airway, which is 
incredibly high risk for an 

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airway fire. 
Oh wow. 

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Tracheal dilation for stenosis 
and stent placement to keep a 

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collapsed airway open. 
So from my perspective as the 

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anesthetist, how do I group 
these in my head? 

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You group them by risk. 
It's risk stratification. 

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Diagnostic usually implies a 
shorter, less stimulating 

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procedure where sedation might 
be enough. 

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Therapeutic, like digging out a 
foreign body or lasering A tumor

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implies a high risk of 
obstruction of losing the 

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airway. 
And it almost always mandates 

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general anaesthesia to ensure 
the patient is perfectly still 

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while there are sharp 
instruments or lasers in their 

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lungs. 
Right, that makes total sense. 

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OK, let's get into the 
Physiology in Section 4. 

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You called this exam gold. 
So what has actually happened to

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the patient's body when we stick
a scope down their airway? 

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It's a cascade of bad things for
gas exchange. 

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It really is. 
First, the shared airway problem

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we talked about effectively 
means obstruction. 

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The scope itself reduces the 
cross-sectional area of the 

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airway, right? 
And you have to remember Quizo's

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law resistance is inversely 
proportional to the radius to 

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the 4th power. 
A small decrease in radius leads

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to a huge increase in 
resistance. 

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It's like trying to breathe 
through a coffee stirrer while 

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you're running. 
Exactly. 

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And that leads directly to the 
second major challenge, hypoxia.

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OK, you get hypoventilation 
because of that insane 

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resistance. 
You get VQ mismatch because of 

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atelectasis, parts of the lung 
just collapse. 

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And don't forget suctioning. 
This is a key point for exams. 

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What about suctioning? 
When the surgeon or the 

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pulmonologist suctions blood or 
mucus, they are also suctioning 

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away your oxygen and your lung 
volume. 

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They are actively de recruiting 
the lungs. 

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That's a great point. 
They're literally vacuuming the 

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air out of the patient's lungs. 
They are and 3rd hypercapnia. 

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The CO2 builds up because of 
that hypoventilation or because 

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of periods of apnea, especially 
during rigid bronchoscopy where 

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you might have to stop 
ventilating completely for a 

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minute to let them work. 
And what about the body's own 

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reaction? 
The reflexes? 

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Oh. 
The airway irritation is 

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profound. 
The airway is one of the most 

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sensitive parts of the body. 
Any instrumentation causes an 

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intense sympathetic stimulation,
tachycardia, hypertension. 

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Right, the fight or flight 
response. 

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A massive 1 and it triggers 
protective reflexes, coughing, 

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laryngosasm, bronchospasm. 
If you are doing this procedure 

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and your anesthesia is too 
light, the vocal cords will slam

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shut and then you're in real 
trouble. 

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O The anesthetic goal is this 
this balancing act. 

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We have to blunt those reflexes 
so they don't cough or spasm, 

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but we have to keep them 
breathing or ventilated enough 

234
00:10:42,880 --> 00:10:45,240
to stop them from turning blue. 
You have just perfectly 

235
00:10:45,240 --> 00:10:47,760
described the art of 
bronchoscopy anesthesia. 

236
00:10:48,040 --> 00:10:50,880
You are walking a tightrope 
between too light, where they 

237
00:10:50,880 --> 00:10:53,520
spasm and fight you, and too 
deep, where they stop breathing 

238
00:10:53,520 --> 00:10:55,560
entirely and their blood 
pressure crashes. 

239
00:10:55,800 --> 00:10:58,440
That's the challenge. 
That segues perfectly into Part 

240
00:10:58,440 --> 00:11:00,800
C, anesthetic management. 
This is the real meat of the 

241
00:11:00,800 --> 00:11:01,840
answer, right? 
Absolutely. 

242
00:11:01,920 --> 00:11:04,240
So before we even induce, we 
need to assess the patient. 

243
00:11:04,840 --> 00:11:07,240
Section 5 preoperative 
assessment. 

244
00:11:08,000 --> 00:11:10,520
What are we looking for that's 
specific to this procedure? 

245
00:11:10,600 --> 00:11:12,880
So your standard airway 
evaluation is a given. 

246
00:11:12,880 --> 00:11:15,920
Melamotty, neck movement, thyro,
mental distance, all of that. 

247
00:11:16,560 --> 00:11:19,840
But Miller's textbook really 
emphasizes that you must look 

248
00:11:19,840 --> 00:11:22,400
for specific pathology related 
to the procedure. 

249
00:11:22,560 --> 00:11:25,520
Is there stridor? 
If a patient has strider at 

250
00:11:25,520 --> 00:11:28,000
rest, their airway is already 
critical. 

251
00:11:28,000 --> 00:11:29,360
You have to be incredibly 
careful. 

252
00:11:29,360 --> 00:11:31,960
Is the trachea deviated on the 
chest X-ray? 

253
00:11:31,960 --> 00:11:33,160
And you have to look at the 
scans. 

254
00:11:33,160 --> 00:11:37,520
You must look at the CT scan. 
Is there a big mediastinal mass 

255
00:11:37,520 --> 00:11:41,040
compressing the airway? 
Is it an extrinsic compression? 

256
00:11:41,240 --> 00:11:44,120
Because if there is extrinsic 
compression and we paralyze 

257
00:11:44,120 --> 00:11:46,120
them. 
The airway might collapse 

258
00:11:46,120 --> 00:11:47,760
completely. 
It's called dynamic airway 

259
00:11:47,760 --> 00:11:49,840
collapse. 
The muscles holding the airway 

260
00:11:49,840 --> 00:11:53,280
open relax, the positive 
pressure in the chest is lost 

261
00:11:53,600 --> 00:11:56,360
and the mass just crushes the 
trachea flat. 

262
00:11:56,360 --> 00:11:59,440
That's a cannot intubate, cannot
ventilate nightmare. 

263
00:11:59,440 --> 00:12:01,240
The ultimate nightmare. 
So you have to know the nature 

264
00:12:01,240 --> 00:12:02,720
of the obstruction before you 
start. 

265
00:12:02,720 --> 00:12:06,280
Is it fixed or is it dynamic? 
OK, so beyond the anatomy of the

266
00:12:06,280 --> 00:12:09,520
airway, what about the lungs 
themselves of a parent chemo? 

267
00:12:09,880 --> 00:12:11,960
Respiratory reserve is 
absolutely key. 

268
00:12:12,160 --> 00:12:15,040
Many of these patients have 
underlying COPD or asthma, 

269
00:12:15,360 --> 00:12:16,840
right? 
The sources, like the 

270
00:12:16,840 --> 00:12:20,480
perioperative asthma guidelines,
emphasize optimization. 

271
00:12:20,680 --> 00:12:22,360
You want them on their 
bronchodilators. 

272
00:12:22,560 --> 00:12:25,360
You want them to have had their 
steroids, metal medisolone or 

273
00:12:25,360 --> 00:12:27,560
hydrocortisone on board if 
they're reactive. 

274
00:12:27,760 --> 00:12:31,360
What about smoking? 
And smoking cessation, though, 

275
00:12:31,480 --> 00:12:34,080
you know, practically for an 
urgent scope, you're almost 

276
00:12:34,080 --> 00:12:37,400
never going to get the 4 to 8 
weeks lead time that's required 

277
00:12:37,400 --> 00:12:40,680
for real meaningful benefit. 
But you should mention it. 

278
00:12:40,680 --> 00:12:44,160
And other comorbidities. 
Cardiac status is huge. 

279
00:12:44,360 --> 00:12:46,800
Remember that massive 
sympathetic surge I mentioned? 

280
00:12:46,800 --> 00:12:48,600
Yeah, the tachycardia and 
hypertension. 

281
00:12:48,680 --> 00:12:52,600
If your patient has ischemic 
heart disease, that tachycardia 

282
00:12:52,600 --> 00:12:56,000
and hypertension during the 
scoping can cause a myocardial 

283
00:12:56,000 --> 00:12:57,680
infarction right there on the 
table. 

284
00:12:58,000 --> 00:13:01,080
You need to identify patients 
who cannot tolerate that stress 

285
00:13:01,120 --> 00:13:04,480
or who can't tolerate the 
inevitable periods of apnea or 

286
00:13:04,480 --> 00:13:05,720
hypoventilation. 
OK. 

287
00:13:06,120 --> 00:13:08,920
Now for the big decision, the 
one that seems to trip people 

288
00:13:08,920 --> 00:13:12,080
up, Section six, choice of 
anesthesia. 

289
00:13:12,400 --> 00:13:15,840
Is it topical with sedation or 
is it general anesthesia? 

290
00:13:16,240 --> 00:13:18,040
How do I make this decision for 
the examiner? 

291
00:13:18,160 --> 00:13:21,280
You frame it as a risk benefit 
analysis based on the patient, 

292
00:13:21,280 --> 00:13:24,960
the procedure, and the operator.
Topical anesthesia with sedation

293
00:13:24,960 --> 00:13:28,560
is primarily for diagnostic 
flexible bronchoscopy. 

294
00:13:28,560 --> 00:13:31,880
In a cooperative patient. 
You use a spray as you go 

295
00:13:31,880 --> 00:13:35,080
technique with lidocaine, or you
nebulize it beforehand. 

296
00:13:35,760 --> 00:13:38,200
The beauty of this is that it 
preserves spontaneous 

297
00:13:38,200 --> 00:13:41,920
respiration, which is inherently
safer if the airway is already 

298
00:13:41,920 --> 00:13:45,000
precarious. 
And GA when is that the answer? 

299
00:13:45,200 --> 00:13:48,720
GA is mandatory for rigid 
bronchoscopy, full stop. 

300
00:13:48,760 --> 00:13:50,200
No exceptions. 
No exceptions. 

301
00:13:50,200 --> 00:13:52,440
It's also the standard of care 
for pediatric patients. 

302
00:13:52,440 --> 00:13:56,400
They will not cooperate 
uncooperative adults any complex

303
00:13:56,400 --> 00:14:00,280
therapeutic procedure like 
stenting or laser, and usually 

304
00:14:00,280 --> 00:14:04,800
for lengthy EB West procedures. 
I see Kaushik Jothanaths notes 

305
00:14:04,800 --> 00:14:06,560
list advantages and 
disadvantages. 

306
00:14:06,920 --> 00:14:09,200
What's the headline there? 
For GA, the advantage is you 

307
00:14:09,200 --> 00:14:11,960
have a totally controlled 
airway, you have immobility, you

308
00:14:11,960 --> 00:14:14,760
have complete control over 
oxygenation and ventilation. 

309
00:14:14,760 --> 00:14:16,520
And the downside? 
The disadvantages are the 

310
00:14:16,520 --> 00:14:19,440
hemodynamic fluctuations from 
the drugs and a longer recovery 

311
00:14:19,440 --> 00:14:21,440
time. 
Sedation, on the other hand, 

312
00:14:21,680 --> 00:14:24,280
keeps them breathing on their 
own, but if they cough or move 

313
00:14:24,280 --> 00:14:27,480
at the wrong time, the surgeon 
can't work or worse, perforates 

314
00:14:27,480 --> 00:14:29,640
the airway. 
So if the examiner puts me on 

315
00:14:29,640 --> 00:14:32,160
the spot and asks when do I say 
GA is mandatory? 

316
00:14:32,160 --> 00:14:35,840
You give them a firm clear list.
Foreign body removal, all 

317
00:14:35,840 --> 00:14:40,360
pediatric patients, massive 
hemoptysis, and all rigid 

318
00:14:40,360 --> 00:14:42,760
bronchoscopy do not waver on 
those 4. 

319
00:14:42,800 --> 00:14:44,680
OK, got it. 
Let's talk about the plumbing 

320
00:14:44,840 --> 00:14:47,720
Section 7 airway management 
techniques. 

321
00:14:47,840 --> 00:14:50,840
We've got a few options here. 
We do for flexible bronchoscopy.

322
00:14:50,840 --> 00:14:54,760
You can go nasal or oral. 
The nasal route is quite common 

323
00:14:54,760 --> 00:14:56,840
for awake fiber optic 
procedures. 

324
00:14:57,000 --> 00:14:58,640
Right? 
But you must tell the examiner 

325
00:14:58,640 --> 00:15:00,440
you'll use vasoconstrictors 
first. 

326
00:15:00,720 --> 00:15:04,080
Something like phenilephrine or 
xylometasoline spray in the 

327
00:15:04,080 --> 00:15:06,280
nose. 
You have to prevent epistaxis. 

328
00:15:06,760 --> 00:15:09,280
A Nosebleed ruins the view 
before you even start the 

329
00:15:09,280 --> 00:15:11,040
procedure. 
That's a great practical point. 

330
00:15:11,040 --> 00:15:13,080
What about the LMA? 
I've seen that used a lot. 

331
00:15:13,280 --> 00:15:16,040
The LMA is a fantastic tool for 
this. 

332
00:15:16,120 --> 00:15:17,920
Miller's describes it as a 
conduit. 

333
00:15:17,920 --> 00:15:19,640
It's a brilliant description. 
Why conduit? 

334
00:15:19,640 --> 00:15:22,520
You place the LMA, the patient 
is breathing through it, and you

335
00:15:22,520 --> 00:15:25,440
simply pass the flexible scope 
through the Lma's channel. 

336
00:15:25,720 --> 00:15:28,760
It's much wider than an 
endotracheal tube of a similar 

337
00:15:28,760 --> 00:15:31,640
size, so there's less resistance
to breathing around the stove. 

338
00:15:31,640 --> 00:15:33,040
And you can see the chords 
better. 

339
00:15:33,240 --> 00:15:37,240
Exactly, it sits above the vocal
cords so you can visually all 

340
00:15:37,240 --> 00:15:40,320
the subglottic structures 
perfectly, and it's excellent 

341
00:15:40,320 --> 00:15:42,640
for maintaining spontaneous 
respiration while keeping the 

342
00:15:42,640 --> 00:15:44,200
upper airway patent. 
OK. 

343
00:15:44,680 --> 00:15:47,520
And for rigid bronchoscopy, 
what's the airway there? 

344
00:15:47,520 --> 00:15:50,880
For rigid bronchoscopy, the 
scope is the airway. 

345
00:15:50,880 --> 00:15:54,440
No, that metal tube becomes your
endotracheal tube. 

346
00:15:54,880 --> 00:15:57,960
You attach your ventilation 
circuit to a special side port 

347
00:15:57,960 --> 00:16:01,680
on the scope. 
But, and this is a huge but, 

348
00:16:02,080 --> 00:16:05,960
when the surgeon opens the back 
of the scope to insert forceps 

349
00:16:05,960 --> 00:16:08,520
or a suction catheter. 
The circuit is open to the room.

350
00:16:08,520 --> 00:16:11,400
The whole circuit is open. 
You lose all your pressure, all 

351
00:16:11,400 --> 00:16:13,360
your tidal volume, it just vents
out. 

352
00:16:13,480 --> 00:16:15,440
So you're only really 
ventilating when they close that

353
00:16:15,440 --> 00:16:16,720
little back window. 
Correct. 

354
00:16:16,720 --> 00:16:18,480
It's an intermittent ventilation
technique. 

355
00:16:18,480 --> 00:16:20,480
You're constantly communicating,
ventilating, ventilating. 

356
00:16:20,480 --> 00:16:22,400
OK, they're opening, suctioning.
OK. 

357
00:16:22,400 --> 00:16:26,880
They're closed ventilating again
or use jet ventilation, but 

358
00:16:26,880 --> 00:16:29,080
we'll get to that. 
OK, let's talk drugs. 

359
00:16:29,520 --> 00:16:32,440
Section 8, sedation and drug 
considerations. 

360
00:16:32,960 --> 00:16:35,480
What's our ideal cocktail? 
The goals are simple. 

361
00:16:35,480 --> 00:16:39,840
You want anxiolysis, amnesia and
profound cough suppression, and 

362
00:16:39,840 --> 00:16:42,000
you need to maintain hemodynamic
stability. 

363
00:16:42,480 --> 00:16:45,760
So benzodiazepines like 
mirazolem are standard for 

364
00:16:45,760 --> 00:16:48,800
anxiolysis. 
You know, maybe .05 to .15 

365
00:16:48,800 --> 00:16:53,120
mileageocruises for opioids. 
Fentanyl is very common, but 

366
00:16:53,120 --> 00:16:56,520
remifentanyl is the real 
superstar here, especially for 

367
00:16:56,520 --> 00:16:58,720
the exam. 
OK, why remifentanyl? 

368
00:16:58,720 --> 00:17:01,640
I know it's expensive, but why 
is it the preferred exam answer?

369
00:17:02,200 --> 00:17:05,040
Because of its unique 
pharmacokinetics, it has a very,

370
00:17:05,040 --> 00:17:07,839
very short context sensitive 
half life. 

371
00:17:08,119 --> 00:17:10,560
It's not metabolized by the 
liver or kidneys. 

372
00:17:10,800 --> 00:17:13,839
It's broken down by plasma 
estrasis all over the body. 

373
00:17:13,839 --> 00:17:16,680
So it's gone almost instantly. 
Almost instantly you can run a 

374
00:17:16,680 --> 00:17:20,119
high dose infusion to completely
knockout the cough reflex during

375
00:17:20,119 --> 00:17:22,760
the most stimulating parts of 
the procedure, and then you turn

376
00:17:22,760 --> 00:17:25,720
it off and the patient is waking
up and breathing spontaneously 

377
00:17:25,720 --> 00:17:28,600
within minutes. 
For a stimulating procedure like

378
00:17:28,600 --> 00:17:31,560
rigid bronchoscopy where you 
need a rapid wake up to check 

379
00:17:31,560 --> 00:17:33,920
airway reflexes, it is 
absolutely ideal. 

380
00:17:33,920 --> 00:17:36,560
What about Propofol? 
Propofol is your workhorse. 

381
00:17:36,640 --> 00:17:39,840
It's standard for induction and 
maintenance, usually as a taiva,

382
00:17:39,840 --> 00:17:41,920
a total intravenous anesthesia 
infusion. 

383
00:17:42,120 --> 00:17:44,600
Whytiva over an inhalational 
gas? 

384
00:17:44,920 --> 00:17:47,600
Because the circuit is open to 
the room so often, right? 

385
00:17:48,000 --> 00:17:51,120
If you were using SEVA fluorine,
most of it would just leak out, 

386
00:17:51,280 --> 00:17:53,720
polluting the OR and not keeping
the patient asleep. 

387
00:17:54,680 --> 00:17:58,240
TFLY gives you consistent depth 
regardless of circuit leaks. 

388
00:17:58,240 --> 00:18:01,400
And I see dexmitotomidine 
mentioned in the Yow and Artuzio

389
00:18:01,400 --> 00:18:03,520
source, Yeah, Where does that 
fit in? 

390
00:18:03,640 --> 00:18:06,160
Dexmitotomidine is a great 
choice for what's called 

391
00:18:06,160 --> 00:18:10,000
cooperative sedation. 
It provides sedation and some 

392
00:18:10,000 --> 00:18:12,960
analgesia without causing 
significant respiratory 

393
00:18:12,960 --> 00:18:14,720
depression. 
It's great if you want the 

394
00:18:14,720 --> 00:18:17,640
patient awake enough to follow 
commands, but comfortable and 

395
00:18:17,640 --> 00:18:20,120
not caulking. 
And one last thing, don't forget

396
00:18:20,120 --> 00:18:22,120
the anti cialagogue. 
You must not forget it. 

397
00:18:22,120 --> 00:18:24,600
Glycopyrrolite is your friend. 
You have to dry up the 

398
00:18:24,680 --> 00:18:26,640
ecretions. 
If the lens of the scope is 

399
00:18:26,640 --> 00:18:29,480
constantly being covered by 
mucus, the rocedure fails. 

400
00:18:29,840 --> 00:18:32,840
A dry airway is a hay airway for
the bronchoscopist. 

401
00:18:32,840 --> 00:18:36,120
Right. 
Moving to Section 9, oxygenation

402
00:18:36,120 --> 00:18:38,800
and ventilation strategies, 
We've touched on the side port 

403
00:18:38,800 --> 00:18:41,400
ventilation for the rigid scope,
but what is this concept of 

404
00:18:41,400 --> 00:18:43,800
apneic oxygenation? 
Morgan explains this very well. 

405
00:18:43,800 --> 00:18:46,080
It's a fascinating physiological
principle. 

406
00:18:46,360 --> 00:18:50,160
It relies on the mass movement 
of oxygen from the alveoli into 

407
00:18:50,160 --> 00:18:53,720
the blood. 
So you insufflate oxygen, 

408
00:18:53,720 --> 00:18:56,560
usually veer a small catheter 
deep into the airway. 

409
00:18:57,200 --> 00:19:00,480
Even if the patient isn't taking
a breath, if they're apneic, the

410
00:19:00,480 --> 00:19:03,840
oxygen in their lungs is still 
being rapidly absorbed into the 

411
00:19:03,840 --> 00:19:06,200
bloodstream. 
This creates a pressure 

412
00:19:06,200 --> 00:19:10,560
gradient, a sort of vacuum, a 
sub atmospheric pressure in the 

413
00:19:10,560 --> 00:19:14,240
alveoli that literally pulls 
more oxygen down the trachea 

414
00:19:14,240 --> 00:19:16,640
from your source. 
So you're getting oxygenation, 

415
00:19:16,640 --> 00:19:19,160
but the CO2 doesn't leave. 
That's the catch exactly. 

416
00:19:19,160 --> 00:19:21,240
You get oxygenation without 
ventilation. 

417
00:19:21,640 --> 00:19:24,360
The CO2 has no way out, so it 
accumulates, leading to a 

418
00:19:24,360 --> 00:19:26,360
progressive respiratory 
acidosis. 

419
00:19:26,840 --> 00:19:29,480
You're limited by time, usually 
only 10 to 20 minutes before the

420
00:19:29,480 --> 00:19:31,600
patient's pH drops dangerously 
low. 

421
00:19:31,720 --> 00:19:33,480
Got it. 
And now for the big buzzword, 

422
00:19:34,120 --> 00:19:37,680
jet ventilation. 
Ah yes, jet ventilation uses 

423
00:19:37,680 --> 00:19:39,600
something called a Sanders 
injector. 

424
00:19:39,840 --> 00:19:42,800
It's a device that shoots a high
pressure jet of pure oxygen down

425
00:19:42,800 --> 00:19:44,520
the scope. 
So you're just blasting oxygen 

426
00:19:44,520 --> 00:19:46,800
in? 
You are, and as that high 

427
00:19:46,800 --> 00:19:50,680
pressure jet shoots forward, it 
entrains room air from the side 

428
00:19:50,680 --> 00:19:53,000
port. 
That's the Venturi effect, which

429
00:19:53,000 --> 00:19:55,320
increases the total volume 
delivered to the patient. 

430
00:19:55,320 --> 00:19:57,200
What's the danger? 
It sounds risky. 

431
00:19:57,360 --> 00:20:00,680
The danger is Barrow trauma, 
massive Barrow trauma. 

432
00:20:00,680 --> 00:20:02,880
You are blasting high pressure 
into the lungs. 

433
00:20:03,280 --> 00:20:05,960
If that air has no way to get 
out, let's say because of a ball

434
00:20:05,960 --> 00:20:08,640
valve obstruction from a tumor 
or the scope is wedged too 

435
00:20:08,640 --> 00:20:12,520
tightly in the trachea, you will
blow a pneumothorax or a 

436
00:20:12,520 --> 00:20:14,840
pneumomedia Steinem. 
It's a catastrophic 

437
00:20:14,840 --> 00:20:17,000
complication. 
So what is the absolute number 

438
00:20:17,000 --> 00:20:19,240
one rule? 
Rule #1 of jet ventilation 

439
00:20:19,440 --> 00:20:21,520
always ensure an egress path for
the gas. 

440
00:20:21,680 --> 00:20:23,920
If air goes in, air must be able
to come out. 

441
00:20:24,000 --> 00:20:27,520
Always ensure an egress path. 
Yeah, I'm tattooing that on my 

442
00:20:27,520 --> 00:20:29,960
brain. 
Let's shift gears now to Part D,

443
00:20:29,960 --> 00:20:32,720
endobronchial ultrasound, or 
EBUS. 

444
00:20:33,120 --> 00:20:35,120
This seems to be more and more 
common in exams. 

445
00:20:35,120 --> 00:20:38,040
It's essential now it's largely 
replacing surgical media 

446
00:20:38,040 --> 00:20:39,320
stenoscopy, so you have to know 
it. 

447
00:20:39,320 --> 00:20:42,880
OK, Section 10, Principles and 
types, what is it fundamentally?

448
00:20:42,960 --> 00:20:46,640
Fundamentally, EBUS involves an 
ultrasound probe that's been 

449
00:20:46,640 --> 00:20:49,440
incorporated into the tip of a 
flexible bronchoscope. 

450
00:20:50,040 --> 00:20:53,600
It allows us to, as we said, see
through the bronchial wall. 

451
00:20:54,040 --> 00:20:56,520
And there are two types, radial 
and convex. 

452
00:20:56,600 --> 00:21:00,960
That's right, the radial probe 
gives you a 360° view, which is 

453
00:21:00,960 --> 00:21:03,800
good for looking at peripheral 
lesions or small pulmonary 

454
00:21:03,800 --> 00:21:06,120
nodules. 
But the convex probe is the one 

455
00:21:06,120 --> 00:21:09,640
we use most for staging. 
It gives a linear view which is 

456
00:21:09,640 --> 00:21:12,880
what allows for the needle 
aspiration, the TB and a. 

457
00:21:12,960 --> 00:21:15,560
You can see the needle in real 
time on the ultrasound as it 

458
00:21:15,560 --> 00:21:18,880
enters the lymph node. 
So why do we as anesthetists 

459
00:21:18,880 --> 00:21:20,800
care so much? 
Isn't it just another 

460
00:21:20,800 --> 00:21:23,360
bronchoscopy from our end? 
No, it's very different. 

461
00:21:23,360 --> 00:21:26,280
It's a hybrid procedure with a 
unique set of challenges. 

462
00:21:26,640 --> 00:21:30,560
It has the invasiveness and risk
of a deep biopsy combined with 

463
00:21:30,560 --> 00:21:32,720
the significant airway 
obstruction of a large. 

464
00:21:32,720 --> 00:21:34,920
Scope. 
So Section 11 indications, you 

465
00:21:34,920 --> 00:21:36,480
said it's mainly for cancer 
staging. 

466
00:21:36,560 --> 00:21:40,080
Primarily the number one 
indication is staging of non 

467
00:21:40,080 --> 00:21:43,200
small cell lung cancer. 
They're looking for spread of 

468
00:21:43,200 --> 00:21:45,440
cancer to the mediastinal lymph 
nodes. 

469
00:21:46,040 --> 00:21:49,080
If those nodes are positive, the
patient might not be a candidate

470
00:21:49,080 --> 00:21:52,400
for surgical resection. 
The result of this one test can 

471
00:21:52,400 --> 00:21:54,520
determine the patient's entire 
treatment plan. 

472
00:21:54,640 --> 00:21:57,720
It's a high stakes procedure. 
OK, This is why Section 12 calls

473
00:21:57,720 --> 00:22:01,440
it Exam Gold. 
What are the specific anesthetic

474
00:22:01,440 --> 00:22:04,760
challenges in Ebos that are 
different from a regular scope? 

475
00:22:04,920 --> 00:22:08,000
OK, first duration. 
An EBS procedure is generally 

476
00:22:08,000 --> 00:22:10,720
much longer than a quick look. 
See bronchoscopy. 

477
00:22:10,920 --> 00:22:13,680
They have to systematically map 
out all the lymph node stations 

478
00:22:13,680 --> 00:22:15,480
and then carefully sample each 
one. 

479
00:22:15,480 --> 00:22:17,440
So more time under anesthesia, 
more risk. 

480
00:22:17,440 --> 00:22:19,520
Exactly. 
Second, the scope size. 

481
00:22:19,720 --> 00:22:23,040
EBOS scopes are bulkier. 
They're almost 7mm in diameter. 

482
00:22:23,400 --> 00:22:26,840
If you put that scope through a 
standard size 7.5 or 8 point O 

483
00:22:26,840 --> 00:22:29,600
endotracheal tube, you are 
blocking a huge percentage of 

484
00:22:29,600 --> 00:22:32,240
the lumen airway resistance goes
right through. 

485
00:22:32,240 --> 00:22:33,600
The roof and someone mentioned a
balloon. 

486
00:22:33,680 --> 00:22:37,120
Right, this is critical. 
To get a good ultrasound image, 

487
00:22:37,160 --> 00:22:40,440
the operator has to inflate a 
small saline filled balloon at 

488
00:22:40,440 --> 00:22:43,320
the tip of the scope, pressing 
it against the airway wall. 

489
00:22:43,480 --> 00:22:46,400
So that creates a complete 
obstruction of that bronchus 

490
00:22:46,400 --> 00:22:49,520
while they're scanning A. 
Complete 100% obstruction. 

491
00:22:49,520 --> 00:22:53,200
So if they are in the right main
brontus and they inflate that 

492
00:22:53,200 --> 00:22:56,480
balloon, you are now effectively
doing one lung ventilation. 

493
00:22:56,480 --> 00:22:58,640
Wow. 
But without a double lumen tube 

494
00:22:58,640 --> 00:23:01,960
or a bronchial blocker. 
Precisely so if the patient has 

495
00:23:01,960 --> 00:23:05,400
poor respiratory reserve to 
begin with, they will desaturate

496
00:23:05,400 --> 00:23:08,080
instantly. 
And the kicker, I'm guessing, is

497
00:23:08,080 --> 00:23:10,000
immobility. 
That's the absolute kicker. 

498
00:23:10,000 --> 00:23:12,600
The pulmonologist is passing a 
sharp needle through the 

499
00:23:12,600 --> 00:23:16,360
bronchial wall into a lymph node
that is often sitting right next

500
00:23:16,360 --> 00:23:20,160
to the pulmonary artery or the 
aorta if the patient coughs or 

501
00:23:20,160 --> 00:23:22,760
moves at that exact moment. 
That's a disaster. 

502
00:23:22,760 --> 00:23:25,880
You puncture a major vessel. 
It's a catastrophe, a massive 

503
00:23:25,880 --> 00:23:28,720
bleed in the mediastinum. 
So while you can technically do 

504
00:23:28,720 --> 00:23:31,840
these procedures under deep 
sedation for exams and often in 

505
00:23:31,840 --> 00:23:35,360
real world practice, for safety,
general anesthesia is strongly 

506
00:23:35,360 --> 00:23:37,640
preferred. 
You need that absolute guarantee

507
00:23:37,640 --> 00:23:40,720
of immobility. 
OK, so that leads to Section 13 

508
00:23:41,080 --> 00:23:45,240
techniques for EBUS. 
If GA is the way to go, what's 

509
00:23:45,240 --> 00:23:46,680
the airway? 
Divisive choice? 

510
00:23:46,920 --> 00:23:49,000
This is a great discussion point
for an exam. 

511
00:23:49,360 --> 00:23:52,640
Miller's actually suggests that 
an LMA can be a better choice 

512
00:23:52,640 --> 00:23:53,720
here. 
An LMA. 

513
00:23:53,720 --> 00:23:57,840
Why not a definitive ET. 
Because the LMA, A superglottic 

514
00:23:57,840 --> 00:24:00,880
airway, sits above the glottis. 
This allows you to pass the 

515
00:24:00,880 --> 00:24:04,600
large ebus scope through the 
vocal cords, and you still have 

516
00:24:04,600 --> 00:24:07,320
the entire tracheal lumen to 
ventilate around the scope. 

517
00:24:07,680 --> 00:24:10,320
It can offer lower resistance 
than trying to cram that big 

518
00:24:10,320 --> 00:24:12,840
scope down a relatively narrow 
endotracheal tube. 

519
00:24:12,880 --> 00:24:15,440
I see, but I imagine some people
still prefer an ECT. 

520
00:24:15,440 --> 00:24:18,320
Oh absolutely. 
Many anesthetist prefer a large 

521
00:24:18,320 --> 00:24:22,280
bore endotracheal tube tube like
a size 8.5 or even a nine point 

522
00:24:22,280 --> 00:24:26,560
O to ensure a definitive secured
airway, especially if there's a 

523
00:24:26,560 --> 00:24:29,760
high risk of bleeding. 
Both are valid options and you 

524
00:24:29,760 --> 00:24:31,920
should be able to discuss the 
pros and cons of each. 

525
00:24:31,920 --> 00:24:34,000
OK, that's a key point. 
Let's move to Part E 

526
00:24:34,000 --> 00:24:36,840
complications and safety. 
This is another really high 

527
00:24:36,840 --> 00:24:39,800
yield area, Section 14. 
What can go wrong? 

528
00:24:40,280 --> 00:24:43,160
The most common thing to go 
wrong by far is hypoxia 

529
00:24:43,480 --> 00:24:45,840
desaturation due to all the 
reasons we've already discussed,

530
00:24:45,880 --> 00:24:48,560
obstruction, suctioning, VQ 
mismatch. 

531
00:24:48,600 --> 00:24:51,280
After that. 
Bronchospasm and laryngospasm, 

532
00:24:51,480 --> 00:24:54,720
especially if the anesthesia is 
too light for the degree of 

533
00:24:54,720 --> 00:24:56,720
stimulation. 
What about bleeding? 

534
00:24:56,760 --> 00:25:00,240
Bleeding is a major concern, 
especially after a biopsy or a 

535
00:25:00,240 --> 00:25:02,840
TBNA. 
Miller's notes that it's usually

536
00:25:02,840 --> 00:25:06,680
self limiting, just a bit of 
oozing, but it can be massive 

537
00:25:06,680 --> 00:25:09,040
and life threatening. 
And pneumothorax. 

538
00:25:09,440 --> 00:25:12,200
That's a real risk with any 
transbronchial biopsy. 

539
00:25:12,520 --> 00:25:15,320
If the needle goes too far, it 
punctures the pleura and the 

540
00:25:15,320 --> 00:25:18,360
lung collapses. 
Or, of course, barotrauma from 

541
00:25:18,360 --> 00:25:20,360
jet ventilation. 
And arrhythmias. 

542
00:25:20,360 --> 00:25:24,960
Very common, usually due to that
huge sympathetic surge or from 

543
00:25:24,960 --> 00:25:27,400
hypoxia. 
You can also get profound 

544
00:25:27,400 --> 00:25:30,680
bradycardia if there's strong 
vagal stimulation deep in the 

545
00:25:30,680 --> 00:25:33,320
airway. 
OK, Section 15, Management of 

546
00:25:33,320 --> 00:25:35,760
complications. 
Let's do this rapid fire Viva 

547
00:25:35,760 --> 00:25:37,680
style. 
I'm in the middle of the case. 

548
00:25:37,840 --> 00:25:39,480
The pulse oximeter alarm is 
going off. 

549
00:25:39,480 --> 00:25:42,440
Sats are dropping to 85. 
What is the first thing I do? 

550
00:25:42,600 --> 00:25:45,400
You stop everything, you tell 
the operator stop the procedure,

551
00:25:45,400 --> 00:25:48,280
then you ask them to withdraw 
the scope to the mid trachea, or

552
00:25:48,280 --> 00:25:50,120
if necessary, remove it 
entirely. 

553
00:25:50,120 --> 00:25:52,640
Get the obstruction out. 
Get the obstruction out, then 

554
00:25:52,640 --> 00:25:56,760
you administer 100% oxygen and 
you gently assist ventilation 

555
00:25:56,760 --> 00:25:59,720
with the bag. 
You cannot ventilate effectively

556
00:25:59,720 --> 00:26:01,920
with that huge scope still 
blocking the airway. 

557
00:26:02,160 --> 00:26:05,880
OK, new scenario. 
They just took a biopsy and now 

558
00:26:05,880 --> 00:26:09,480
there's bright red blood filling
the airway, bleeding. 

559
00:26:09,600 --> 00:26:13,880
First suction, then you can 
instill cold saline through the 

560
00:26:13,880 --> 00:26:17,200
scope to cause vasoconstriction.
You can also give topical 

561
00:26:17,200 --> 00:26:21,160
epinephrine solution A1 in 
10,000 or ONE in 20,000 solution

562
00:26:21,160 --> 00:26:23,080
down the scope. 
And if it's massive? 

563
00:26:23,080 --> 00:26:25,720
If it's massive, the operator 
can wedge the tip of the 

564
00:26:25,720 --> 00:26:28,440
bronchoscope into the bleeding 
bronchus to tamponate it. 

565
00:26:28,840 --> 00:26:31,400
This also protects the healthy 
lung from being flooded with 

566
00:26:31,400 --> 00:26:34,600
blood and you should immediately
turn the patient so the bleeding

567
00:26:34,600 --> 00:26:35,520
side is down. 
Right, good. 

568
00:26:35,520 --> 00:26:36,200
Lung up. 
Yeah. 

569
00:26:36,560 --> 00:26:39,360
OK, last one. 
I hear a wheeze and I can't 

570
00:26:39,360 --> 00:26:43,320
ventilate bronchospasm. 
First, deep in the anesthesia, 

571
00:26:43,600 --> 00:26:45,840
increase your propofol or your 
volatile agent. 

572
00:26:46,000 --> 00:26:48,320
Civil fluorine is a potent 
bronchodilator. 

573
00:26:48,640 --> 00:26:51,960
At the same time give 
bronchodilator cellbutamol puffs

574
00:26:51,960 --> 00:26:54,320
right into the circuit. 
So if the examiner asked me, 

575
00:26:54,320 --> 00:26:56,760
what is your primary safety rule
during any of these 

576
00:26:56,760 --> 00:26:59,920
complications? 
Your answer is safety first. 

577
00:26:59,960 --> 00:27:03,200
I would immediately stop the 
procedure, withdraw the scope 

578
00:27:03,320 --> 00:27:05,480
and secure the airway and 
ventilation. 

579
00:27:05,840 --> 00:27:08,680
You never try to fix the problem
through the disaster while the 

580
00:27:08,680 --> 00:27:10,480
scope is still obstructing 
everything. 

581
00:27:10,880 --> 00:27:18,160
OK Part F Post procedure care 
Section 16 Monitoring the 

582
00:27:18,160 --> 00:27:20,640
procedures done. 
The patient is waking up. 

583
00:27:20,920 --> 00:27:22,400
What are we watching for? 
Like a hawk. 

584
00:27:22,560 --> 00:27:25,320
You're watching for the return 
of their airway reflexes. 

585
00:27:25,400 --> 00:27:28,760
They absolutely must have them 
back before discharge to prevent

586
00:27:28,760 --> 00:27:31,800
aspiration, especially if you 
used a lot of topical anesthesia

587
00:27:31,800 --> 00:27:34,120
on their vocal cords. 
They need to be able to protect 

588
00:27:34,120 --> 00:27:36,240
their own airway. 
What about hemodynamics? 

589
00:27:36,680 --> 00:27:39,280
You're watching for any delayed 
bleeding, which can manifest as 

590
00:27:39,280 --> 00:27:42,040
tachycardia or hypertension. 
And oxygenation you. 

591
00:27:42,040 --> 00:27:43,840
Have to watch for a delayed 
pneumothorax. 

592
00:27:43,840 --> 00:27:45,400
It doesn't always show up 
immediately. 

593
00:27:45,680 --> 00:27:49,280
If they did a biopsy, a post 
procedure chest X-ray is often 

594
00:27:49,280 --> 00:27:51,520
very prudent. 
At the very least, you need 

595
00:27:51,520 --> 00:27:54,240
close observation for any signs 
of respiratory distress, 

596
00:27:54,240 --> 00:27:56,520
desaturation, or subcutaneous 
emphysema. 

597
00:27:57,160 --> 00:27:59,440
Section 17. 
What are the discharge criteria?

598
00:27:59,440 --> 00:28:00,960
When is it safe for them to go 
home? 

599
00:28:01,120 --> 00:28:04,360
You use the standard pads, the 
post anesthetic discharge 

600
00:28:04,360 --> 00:28:07,440
scoring system. 
They have to be awake elite with

601
00:28:07,440 --> 00:28:10,360
stable vitals. 
But specifically for an airway 

602
00:28:10,360 --> 00:28:13,000
procedure exam answer, you add 
three more things. 

603
00:28:13,000 --> 00:28:19,120
OK, ensure no stride or ensure 
no active hemoptysis and ensure 

604
00:28:19,120 --> 00:28:22,200
they have the ability to swallow
water without coughing or 

605
00:28:22,200 --> 00:28:23,360
choking. 
Perfect. 

606
00:28:23,600 --> 00:28:25,840
All right, Part G, This is where
we bring it all together for the

607
00:28:25,840 --> 00:28:29,160
exam. 
Section 18, flexible versus 

608
00:28:29,200 --> 00:28:31,880
rigid bronchoscopy. 
This is a classic comparison. 

609
00:28:32,000 --> 00:28:34,240
Let's build that mental table 
for the examiner. 

610
00:28:34,240 --> 00:28:35,800
Let's do it. 
It's all about direct 

611
00:28:35,800 --> 00:28:38,280
comparison. 
Indication flexible is for 

612
00:28:38,280 --> 00:28:40,400
diagnosis and looking at 
peripheral lesions. 

613
00:28:40,840 --> 00:28:43,840
Rigid is for foreign bodies, 
massive bleeds and central 

614
00:28:43,840 --> 00:28:44,840
obstructions. 
Got it. 

615
00:28:45,000 --> 00:28:46,560
Row 2. 
Anesthetic. 

616
00:28:46,800 --> 00:28:49,920
Flexible usually uses sedation, 
Rigid always uses GA. 

617
00:28:50,040 --> 00:28:52,560
Row 3 ventilation. 
Flexible you're looking at 

618
00:28:52,560 --> 00:28:54,960
spontaneous breathing or 
ventilation via an LMA. 

619
00:28:55,400 --> 00:28:58,640
For rigid, it's either the 
sidearm port or jet ventilation.

620
00:28:58,880 --> 00:29:02,400
And finally, complications. 
Flexible has a much lower risk 

621
00:29:02,400 --> 00:29:04,880
of airway trauma. 
Rigid has a higher risk of 

622
00:29:04,880 --> 00:29:07,840
dental damage, lip injury, and 
laryngeal trauma from insertion.

623
00:29:08,000 --> 00:29:08,760
OK. 
That's clear. 

624
00:29:09,080 --> 00:29:13,680
Now Section 19, bronchoscopy 
versus EBS, how do we compare 

625
00:29:13,680 --> 00:29:16,280
those? 
EBS is a specific high tech 

626
00:29:16,280 --> 00:29:21,600
subset of flexible bronchoscopy.
The purpose is different staging

627
00:29:21,600 --> 00:29:24,920
for EBS versus general diagnosis
or therapy for standard 

628
00:29:24,920 --> 00:29:27,000
bronchoscopy. 
And the airway management 

629
00:29:27,000 --> 00:29:28,440
reflects. 
That it does. 

630
00:29:28,560 --> 00:29:32,480
EBS leans very heavily towards 
general anesthesia with an LMA 

631
00:29:32,480 --> 00:29:34,520
or a large ETT. 
Why? 

632
00:29:34,880 --> 00:29:37,400
Because you need that absolute 
immobility and you have to 

633
00:29:37,400 --> 00:29:40,200
manage the airway obstruction 
from the larger scope. 

634
00:29:40,640 --> 00:29:43,040
A standard flexible 
bronchoscopy, on the other hand,

635
00:29:43,240 --> 00:29:44,800
leans much more towards 
sedation. 

636
00:29:44,920 --> 00:29:48,680
Perfect section 20 common exam 
questions and Viva traps. 

637
00:29:49,080 --> 00:29:50,400
We mentioned the foreign body 
child. 

638
00:29:50,400 --> 00:29:52,600
Let's really role play this. 
The examiner asked me. 

639
00:29:52,800 --> 00:29:54,520
I have a three-year old who has 
inhaled a peanut. 

640
00:29:54,680 --> 00:29:57,560
It's in the right vein bronchus.
How do you induce anesthesia? 

641
00:29:57,680 --> 00:30:00,320
Is the ultimate trap. 
Do not say rapid sequence 

642
00:30:00,320 --> 00:30:02,440
induction. 
Do not say I would paralyze the 

643
00:30:02,440 --> 00:30:03,800
child. 
You will fail on the spot. 

644
00:30:03,800 --> 00:30:06,400
So what's the right answer? 
The correct safe answer is 

645
00:30:06,840 --> 00:30:10,040
inhalational induction with 
civil slurane maintaining 

646
00:30:10,040 --> 00:30:13,600
spontaneous ventilation. 
Why is paralysis so incredibly 

647
00:30:13,600 --> 00:30:16,080
dangerous here? 
Because the negative pressure 

648
00:30:16,080 --> 00:30:18,840
generated by spontaneous 
breathing actually helps to keep

649
00:30:18,840 --> 00:30:20,920
the airway open around the 
foreign body. 

650
00:30:21,360 --> 00:30:24,640
If you paralyze them, all the 
airway muscles relax, the 

651
00:30:24,640 --> 00:30:28,240
mediastinum can shift, and that 
peanut might dislodge and move, 

652
00:30:28,560 --> 00:30:31,600
turning a partial obstruction 
into a complete can't ventilate 

653
00:30:31,600 --> 00:30:34,080
obstruction. 
You maintain spontaneous 

654
00:30:34,080 --> 00:30:37,120
ventilation until the surgeon 
has the rigid scope in and is 

655
00:30:37,120 --> 00:30:39,360
visually secured the foreign 
body with forceps. 

656
00:30:39,840 --> 00:30:42,800
Only then, once the airway is 
physically controlled, can you 

657
00:30:42,800 --> 00:30:44,640
consider giving a muscle 
relaxant if needed. 

658
00:30:44,640 --> 00:30:49,600
OK, that's a critical point trap
#2 can you do rigid bronchoscopy

659
00:30:49,600 --> 00:30:53,000
under sedation? 
The answer is an emphatic no. 

660
00:30:54,000 --> 00:30:56,400
It requires general anesthesia 
and in most cases muscle 

661
00:30:56,400 --> 00:31:00,560
relaxation to allow the passage 
of that large metal tube past 

662
00:31:00,560 --> 00:31:02,560
the vocal cords without causing 
trauma. 

663
00:31:03,480 --> 00:31:06,880
The only nuances in some complex
tracheal stenosis cases where 

664
00:31:06,880 --> 00:31:09,680
you might preserve spontaneous 
ventilation, but that is still a

665
00:31:09,680 --> 00:31:12,960
form of GA, not just sedation. 
And the third trap, we've 

666
00:31:12,960 --> 00:31:14,520
mentioned it, but let's hit it 
one more time. 

667
00:31:14,560 --> 00:31:17,040
Jet ventilation. 
The mistake is forgetting the 

668
00:31:17,040 --> 00:31:21,320
egress, forgetting the outflow. 
If you describe jet ventilating 

669
00:31:21,320 --> 00:31:24,480
into a closed system, you are 
describing A fatal Barrow 

670
00:31:24,480 --> 00:31:26,560
trauma. 
It is an automatic fail. 

671
00:31:26,720 --> 00:31:30,240
OK session 21 diagrams and exam 
presentation. 

672
00:31:30,480 --> 00:31:34,960
If I have to draw the 
bronchoscopy airway setup for a 

673
00:31:34,960 --> 00:31:36,600
10 mark answer, what does that 
look like? 

674
00:31:36,600 --> 00:31:39,760
Keep it simple but clear. 
Draw the patient supine, Draw 

675
00:31:39,760 --> 00:31:42,400
the anesthesia machine on the 
left or right, but make a note 

676
00:31:42,400 --> 00:31:45,560
that you need a long circuit an 
extension tubing, because the 

677
00:31:45,560 --> 00:31:48,000
anesthesiologist is often 
displaced to the side to give 

678
00:31:48,000 --> 00:31:49,480
the surgeon room at the head of 
the bed. 

679
00:31:49,720 --> 00:31:50,960
Right, the surgeon is at the 
head. 

680
00:31:50,960 --> 00:31:53,680
The surgeon is at the head. 
Draw the oxygen source for your 

681
00:31:53,680 --> 00:31:56,760
jet ventilation as a separate 
high pressure line and show the 

682
00:31:56,760 --> 00:32:00,560
monitors, ECG, SAPS, probe, BP 
cuff and make sure they're 

683
00:32:00,560 --> 00:32:03,120
positioned to be visible to both
you and the surgeon. 

684
00:32:03,160 --> 00:32:05,120
What about a cannot ventilate 
flu chart? 

685
00:32:05,280 --> 00:32:07,880
Very high yield box #1 call for 
help. 

686
00:32:07,880 --> 00:32:10,720
Box 2 ask surgery to withdraw 
the scope immediately. 

687
00:32:10,720 --> 00:32:13,840
Box three, attempt mask 
ventilation with 100 to O2. 

688
00:32:14,120 --> 00:32:19,280
If that fails Box 4 insert LMA. 
If that fails box 5 intubate. 

689
00:32:19,480 --> 00:32:22,400
Preferably with a video learning
to scope and if that fails. 

690
00:32:22,640 --> 00:32:24,520
Cannot intubate. 
Cannot ventilate. 

691
00:32:24,600 --> 00:32:26,520
You go to your surgical airway 
algorithm. 

692
00:32:26,920 --> 00:32:28,160
Scalpel. 
Bougie tube. 

693
00:32:28,560 --> 00:32:31,280
A cricothyroidotomy. 
You have to show you have a plan

694
00:32:31,280 --> 00:32:35,480
for failure. 
OK, finally, Section 22 summary 

695
00:32:35,480 --> 00:32:38,280
and exam conclusion. 
Can you give me the elevator 

696
00:32:38,280 --> 00:32:40,800
pitch for the exam? 
The final take home message? 

697
00:32:40,800 --> 00:32:42,680
OK, here are the absolute key 
points. 

698
00:32:42,680 --> 00:32:46,680
Bronchoscopy is a shared airway 
procedure requiring absolute 

699
00:32:46,680 --> 00:32:48,960
constant communication, hypoxia 
and. 

700
00:32:48,960 --> 00:32:50,680
Arrhythmias are your primary 
enemies. 

701
00:32:50,720 --> 00:32:52,840
You must anticipate them, right?
Three. 

702
00:32:53,280 --> 00:32:57,320
Choose GA for rigid therapeutic 
or uncooperative cases. 

703
00:32:57,440 --> 00:33:00,200
Choose topical with sedation for
cooperative diagnosis. 

704
00:33:00,280 --> 00:33:04,280
Agnostic, flexible cases. 
EBUS requires immobility, so you

705
00:33:04,280 --> 00:33:07,720
should lean towards GA with an 
LMA or a large ETT. 

706
00:33:07,760 --> 00:33:10,480
Never forget the egress rule for
jet ventilation. 

707
00:33:10,520 --> 00:33:12,400
And #7. 
Communication with the 

708
00:33:12,400 --> 00:33:15,720
pulmonologist or surgeon is the 
most important monitoring tool 

709
00:33:15,720 --> 00:33:16,960
you have. 
Communication with the 

710
00:33:16,960 --> 00:33:19,400
pulmonologist is the most 
important monitoring tool. 

711
00:33:19,600 --> 00:33:21,280
I love that. 
That's the perfect concluding 

712
00:33:21,280 --> 00:33:23,720
line. 
It saves lives, it really does. 

713
00:33:23,720 --> 00:33:26,600
If they are about to take a 
biopsy, they need to tell you so

714
00:33:26,600 --> 00:33:28,880
you can ensure the patient is 
deep and doesn't move. 

715
00:33:29,240 --> 00:33:32,680
If you are losing the airway, 
you need to tell them clearly 

716
00:33:32,680 --> 00:33:35,920
and loudly to get out. 
This has been incredibly high 

717
00:33:35,920 --> 00:33:37,240
yield. 
I actually feel like I can 

718
00:33:37,240 --> 00:33:39,280
structure that 15 mark question 
now. 

719
00:33:39,400 --> 00:33:41,880
Just remember the structure we 
talked about, definition, 

720
00:33:41,880 --> 00:33:44,840
indications, Physiology, 
anesthetic management, and 

721
00:33:44,840 --> 00:33:47,520
complications. 
Stick to that framework and you 

722
00:33:47,520 --> 00:33:49,600
will pass. 
Thank you so much for this. 

723
00:33:49,680 --> 00:33:52,640
To our learner listening, 
visualize that shared airway 

724
00:33:52,640 --> 00:33:54,440
setup before you walk into the 
exam hall. 

725
00:33:54,720 --> 00:33:57,720
Keep your airway clear and your 
answers even clearer. 

726
00:33:57,800 --> 00:33:59,560
Good luck. 
See you next time on the Deep 

727
00:33:59,560 --> 00:33:59,920
Dive.