line without injuring the subglottic area. At this moment, the laryngoscope is removed and the rigid optic is placed through the RB, and advanced within the trachea under direct vision.

Intubation with RB through a tracheotomy is also possible. For this method, the rigid tube is introduced obliquely through the tracheotomy, previously numbed with local anesthetics. This maneuver must be carefully performed to avoid lesion of the posterior tracheal wall.

Some Conclusions

Before the FB introduction, the use of RB was almost limited to surgeons. During a British study, it was observed that, even though only 2% of the 39,564 bronchoscopies completed between 1974 and 1986 used RB, more than 90% were performed by surgeons. This work also noted that 81% of the bronchoscopists used FB, 9% of them were using both techniques, and 8% used the FB through the RB [34].

In a review made by the American College of Chest Physicians, only 8% of the responding endoscopists were using RB [20]. The reasons are multiple, but some of the most important ones are that the FB is more available and easier to use than the RB, which requires special training not given routinely during training programs.

These data ratify a known fact: obtaining training on the RB technique is diffcult, for several reasons. The frst one is that its teaching is not part of the pulmonary specialist training as we discuss, while FB training is included. Besides, its use is generally associated with therapeutic procedures such as laser, stents placement, and that requires specifc technology not always available. Another inconvenience is that the technique is indeed diffcult, and requires full dedication to learn it. The number of procedures to become profcient varies from person to person. In addition, when profciency is obtained, a number of regular procedures are required in order to maintain the ability, and to get the interest of the involved team: nurses and anesthesiologists. In general, it is advisable that the person who is interested in learning interventionism fol-

lows a formal training with an expert, in a place where adequate numbers of procedures are performed per year. Many experts agree that expertise on RB takes years, and that courses and seminaries (although indispensable to a complete learning) are not enough to initiate the individual practice without supervision. The ACCP guidelines published in 2003 recommended that a trainee should perform at least 20 procedures in a supervised setting to establish basic competency in patients with normal airways, and then he/she should perform 10 procedures per year in order to maintain competency. They also recommended that program directors should decide whether or not the candidate is able to perform RB procedures without supervision [35].

The ideal bronchoscopist should be able to perform both FB and RB, on the pediatric and adult population. Given that lung cancer incidence continues rising and today the multimodality approach to treatment includes a pulmonary physician able to perform palliative procedures according to need, the RB will continue to be indicated. This instrument has unique features that make it irreplaceable and it is also complementary to many other tools, particularly when treating central airway diseases. Though still RB is performed by a minority of physicians, there is an increased interest to train and maintain profciency in rigid bronchoscopy and we are sure that it will be more so in the future.

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Introduction and De nition of Anesthesia for Interventional Bronchoscopy

Introducing the bronchoscope into the airway has proved to be a challenge since the invention of the rst bronchoscope. Airway refexes, such as the gag, cough, and laryngospasm, hemodynamic alteration, and anxiety induced by the passage of the bronchoscope into the airway forced the bronchoscopist to be skilled and hurried to perform the procedure [1]. As a result, interest in using anesthesia to ameliorate the airway refexes and patient’s anxiety associated with bronchoscopy has emerged. A wide range of anesthesia techniques were developed to accommodate a variety of interventional bronchoscopic procedures such as simple diagnostic bronchoscopy, advanced diagnostic bronchoscopy, therapeutic bronchoscopic interventions, and pleural procedures. The scope of depth of anesthesia needed for various interventional bronchoscopic procedures encompasses local anesthesia as the sole anesthetic modality, moderate sedation/

M. Sarkiss (*)

Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center,

Houston, TX, USA

e-mail: msarkiss@mdanderson.org

analgesia (“conscious sedation”) with or without local anesthesia, and general anesthesia [2]. Moderate sedation/analgesia (“conscious sedation”) is de ned by the American Society of Anesthesiologist (ASA) as “a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained [3].” Moderate sedation may progress to deep sedation/analgesia or even general anesthesia during the same procedure. Once under deep sedation, “the patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained [3].” At the other end of the spectrum during general anesthesia “patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired [3].”

Although the current guidelines do not identify what depth of anesthesia is needed for various procedures, it is generally accepted that simple diagnostic and interventional airway procedures of short duration are well tolerated by the patient when performed under local anesthesia and/or moderate sedation. Meanwhile, more complex interventional bronchoscopic procedures that require a still eld, have a longer duration, and entail more risk to the patient due to comorbidities or a compromised airway are best performed under general anesthesia. General anesthesia has the added advantage of the availability of special modes of ventilation and monitoring that can be provided and managed by anesthesia provider while the bronchoscopist focuses on the procedure. This chapter will provide a brief historical perspective, the indications and contraindications for different levels of anesthesia, the equipment required, and the application of the techniques. Finally, a summary and recommendations are presented.

History and Historical Perspective

When the rigid bronchoscope was invented in 1865 by Dr. Killian, anesthesia had not been discovered and the procedure was performed on conscious patients. The patients were advised to repeatedly touch their pharynx and vocal cords for several weeks before the procedure to desensitize their airway refexes. The physicians performing the procedures practiced on a corpse head or healthy volunteers. According to early reports, this practice allowed the bronchoscopists to become “extremely skilled and swift as operations had to be performed within seconds before the view disappeared [1].” Multiple attempts to anesthetize the airway with ammonia, iodine, belladonna, or potassium bromide had failed. In 1884, Jellinek introduced cocaine, the rst local anesthetic, for airway exam and reported its bene ts by stating that “by eliminating the refexes of the pharynx and the larynx it was possible to perform some of the operations in which even the most skillful artists in surgery had failed. The procedure completely changed.

Virtuosity gave way to careful methodology, skill to exactness and the former almost endless preparation that so often tried the patience of the physician as well as of the patient could be almost completely abandoned” [1]. Similarly, Killian emphasized the advantages of using cocaine during bronchoscopy by stating that “whether one stops inspection with the rigid tube at the bifurcation or passes on for some distance into a major bronchus does not matter for the patient. If he is suf ciently cocainized he does not even realize it” [1].

In 1968, the fexible bronchoscope was invented by Ikeda and gradually replaced the rigid bronchoscope. Compared to the rigid bronchoscope, the fexible bronchoscope is better tolerated by the patient, even without anesthesia due to its small diameter and plasticity. Flexible bronchoscopy was initially used for simple diagnostic bronchoscopic procedures of short duration making local anesthetics an ideal technique for anesthesia. However, a subset of anxious patients remained unable to tolerate the procedure. As a result, conscious sedation with anxiolytics and opioids, to ameliorate anxiety and cough, respectively, became common practice for airway procedures in addition to local anesthetics. As theeld of interventional bronchoscopy expanded, a growing number of lengthy and technically demanding procedures especially in patients with severe comorbidities and compromised central airway emerged. The use of the rigid bronchoscope was revived to aid in the management of large airway tumors, procedure-related complications, and to allow for ventilation during lengthy procedures. Accordingly, a renewed interest in monitored anesthesia care (MAC) or general anesthesia has emerged. Currently, some centers in the United States and Europe made it their standard practice to have an anesthesiologist provide either sedation or general anesthesia to selected patients undergoing interventional bronchoscopic procedures. This arrangement allows the interventionalist to direct his or her full attention to the procedure, with minimal or no discomfort to the patient, while the anesthesiologist vigilantly manages the patient’s airway, ventilation, medical condition, and the anesthesia.