CHAPTER 2

Anaesthesia for interventional bronchoscopy

A. Lorx, L. Valko , I. Pe nzes Dept of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary. Correspondence: A. Lorx, Dept of Anaesthesiology and Intensive Therapy, Semmelweis University, Ku tvo lgyi u t 4, H-1125 Budapest, Hungary. E-mail: lorxa@kut.sote.hu

Anaesthesia for bronchoscopic interventions demands close and continuous collaboration between the anaesthetist and the bronchologist, who share the confined and sometimes collapsing space of the patients airways. The anaesthetist must be experienced in the handling of difficult airway situations and in the provision of complex peri-operative management, as the patients are often medically incapacitated, and provide complex airway management dilemmas. Critical airway situations can develop within a few seconds, and various rescue techniques should therefore be readily to hand with which to maintain open airways and ventilation. Before the intervention the anaesthetist and bronchologist should discuss in detail the patients diagnostic status and the plans; this will ensure that both teams know the underlying pathophysiology, the likely complications that may arise, and the contingency rescue plan should total airway collapse occur. Depending on the procedures involved, anaesthesia may range from slight topical sedation to deep narcosis and muscle relaxation with controlled ventilation.

Anatomy and physiological consequences

The functional anatomy of the airways is divided into that of the upper airways (including the nose, pharynx and larynx) and that of the lower airways (comprising the trachea and the bronchial tree as far as the alveoli). The larynx has a flexible and dynamic attachment, which protects the airway while allowing smooth movements for speech. The trachea measures 1013 cm in length, 1.8 cm in antero-posterior diameter and 2 cm in lateral diameter. The C-shaped cartilaginous rings in the trachea provide anterior and lateral patency for the lumen, while leaving a membranous posterior section. The trachea is elastic and can lengthen by 5 cm during deep inspiration [1]; the lumen can also be totally collapsed by the application of an external pressure of 3040 cmH2O to the neck. Signs of upper airway obstruction are usually late in onset, and manifest only when the lumen diameter is reduced by y75%. Dynamic obstruction due to widening of the membranous part of the trachea is very common; in tracheomalacia, the expiratory effort and cough can worsen the obstruction and lead to total airway collapse. Innervation comes from the vagus nerve through the superior nerve and basically through the recurrent laryngeal nerve. Blood is supplied from the lateral aspect in a
Eur Respir Mon, 2010, 48, 1832. Printed in UK - all rights reserved. Copyright ERS 2010; European Respiratory Monograph. Print ISSN: 1025-448x; online ISSN: 2075-6674. DOI: 10.1183/1025448x.00990209

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segmental fashion, from branches of the subclavian, innominate, inferior thyroid, internal thoracic, first intercostal and bronchial arteries.

Pre-operative assessment
Patients awaiting endotracheal surgery can be expected to have concurrent medical conditions and habits that contribute to a poor pulmonary status. The pre-operative assessment should, therefore, cover the cardiovascular status, the ventilatory status and function, the localisation and degree of airway obstruction, the coagulation status, and the arterial blood gas (ABG) besides the physical examination, the anamnestic data and routine pre-operative tests and questions. Any factors affecting the respiratory status should be evaluated. A chest radiograph, tomography and pulmonary function testing can be helpful, providing a reliable picture of the nature of the obstruction, thereby guiding the decision-making relating to the intervention and anaesthesia, [2, 3], but routine preoperative pulmonary function testing is still questionable and has only a limited role as a predictor of post-operative pulmonary complications (PPCs) [4]. Three-dimensional reconstruction and surface modelling of the tracheal lumen after spiral computed tomography correlate well with the findings of video-recorded intra-operative endoscopy and hence there is a potential for representation of the pathological anatomy [5]. Pre-operative treatment, such as changes in medications or physiotherapy, might have a role in selected cases to reduce the subsequent PPCs, but many of the patients are in poor condition, or the underlying disease or comorbidity imposes real limitations on the use of these techniques. Most of the patients benefit from a sitting position and the inhalation of humidified supplementary oxygen. Diagnostic and pre-operative treatment options are also limited in the event of urgency. Patients should be clearly informed concerning the procedures and the risks involved, and their consent should be obtained, as both the anaesthesia and the surgery are associated with high risks. A patient can be of appreciable aid with calm behaviour when the intervention is carried out under slight sedation. It is sufficient for patients to have no food by mouth for 4 h but to allow clear fluids by mouth until 2 h before bronchoscopy [6].

Pre-medication
Patients at risk of airway obstruction and ventilatory failure should not receive any sedatives, as these can easily result in severe hypoxaemia and respiratory insufficiency, even in small doses [7]. Otherwise, anxiolytics (usually lorazepam or midazolam) may be administered the day before the intervention. Depending on their current medical condition, patients may benefit from inhaled bronchodilators, antacids and other premedication [8]. Similarly, a careful re-evaluation of chronic drug intake is advised before any intervention requiring any level of anaesthesia. The omission of regular drugs may result in cardiorespiratory instability, thereby giving rise to difficulties during the procedure. The discontinuation of anticoagulants and thrombocyte aggregation inhibitors prior to the procedure should be considered when invasive sampling is planned. In a recent study, a short-acting b-agonist did not prove superior to placebo in patients with chronic obstructive pulmonary disease undergoing bronchoscopy [9]. Steroids (usually mentioned empirically) may be of potential benefit; in our practice, we administer them only in cases of complicated and risky manoeuvres. Pre-operative anticholinergic drugs have been routinely used to dry the airways, and to prevent
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vagotonic bradycardia and bronchoconstriction [10, 11]. Several studies have questioned the use of pre-operative atropine [11], which did not display any clinical benefit relative to placebo [12]. Atropine pre-medication has several side-effects including tachycardia. Since myocardial ischaemia has been reported during the procedure, tachycardia should be avoided, and the regular use of pre-operative atropine should be revised [13, 14]. As tachycardia and hypertension are induced by bronchoscopy or laryngoscopy alone, leading to ischaemic episodes, clonidine might be an alternative drug in the preoperative therapy [15]. Codeine phosphate displays an antitussive effect in patients undergoing bronchoscopy under light local anaesthesia and midazolam sedation [16]. Codeine (20120 mg) can be given orally or intramuscularly as pre-medication. In patients who received codeine orally (0.4 mg?kg-1) 60 min before bronchoscopy, the required dose of supplementary local anaesthetic requirements and the degree of desaturation were significantly lower as compared with those in the placebo group. The patient volume status should be evaluated and when necessary resuscitated. Accordingly, for the peri-operative period of the intervention, insertion of a wide-bore peripheral venous line is paramount.

Monitoring
Patients should be monitored routinely with ECG, an automated noninvasive blood pressure device and a pulse oxymeter. Additionally, resuscitation equipment for airway management (nasal and oral airways, anaesthesia masks, laryngoscope and blades, endotracheal tubes, intubating stylets, self-inflating bag-valve-mask and suction) and for cardiac emergencies (defibrillator) must be readily available in the bronchoscopy suite, together with appropriate drugs (epinephrine, lidocaine, amiodarone, procaineamide, sodium bicarbonate, calcium chloride, atropine, propofol, sodium thiopental, succinylcholine and reversal agents). During deep sedation or general anaesthesia, a relaxometer for neuromuscular blockade and a capnograph are also required, as hypercapnia with hypoventilation can occur. The monitoring of carbon dioxide tension may also be performed with transcutaneous probes [17]. For a patient with poorly controlled blood pressure, or when regular ABG sampling is needed, an invasive arterial line is suitable. Bispectral index monitoring may facilitate maintenance of an adequate depth of anaesthesia and ensure amnesia, especially with a total intravenous anaesthesia approach [18], and the Ramsay score is helpful in cases of sedation. Patients should be re-evaluated at least every 2 min throughout the intervention. Besides the use of modern monitors, the stethoscope and visual assessment of the patient are frequently required. Sedation and anaesthesia for bronchoscopy should be performed by an anaesthetist in a well-equipped operating theatre, where all potentially necessary instruments, drugs and diagnostic tools are readily available (fig. 1).

Topical anaesthesia and sedation

For most (diagnostic) interventions with a flexible bronchoscope, general anaesthesia is not necessary. Adequate sedation and topical anaesthesia are applied in many centres [19]. Lidocaine (210%), benzocaine (20%), tetracaine (1%) and cocaine (4%) are usually mentioned. Benzocaine is relatively short-acting, tetracaine has potentially toxic sideeffects, and cocaine may have an additive effect. Lidocaine is most commonly used, in view of its relatively wide margins of safety and its low rate of tissue toxicity. When
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Fig. 1. Operating theatre for interventional bronchoscopy.

applied onto the mucosal surface, 2550% of the peak blood concentrations following intravenous administration are achieved. When applied deep in the bronchi, significantly higher serum levels may be attained. Lidocaine spray can be applied onto the tongue, oropharynx or pharynx, or alternatively 4% lidocaine solution can be applied by gargling or instilled by adaptor directly to the pharynx. The trachea can be anaesthetised by the transtracheal injection of 2% lidocaine at the level of the ligamentum conicum. WEBB et al. [20] found this procedure to be superior to the spray as you go technique. To help decrease the gag reflex and blunt the haemodynamic response to laryngoscopy, a lingual nerve block can be performed bilaterally at the anterior tonsillar pillar, by injecting 2 mL of 2% lidocaine via a 25-gauge spinal needle or by holding 5% lidocaine paste on a gauze pad in contact with the tonsillar pillar for 3045 s. Blocking the superior laryngeal nerve anaesthetises the lower pharynx and laryngeal epiglottis. This is most easily accomplished by injecting local anaesthetic into the thyrohyoid membrane just lateral to the superior cornu of the thyroid cartilage [8]. Independently of the mode of application, the toxic dose should not be exceeded. MILMAN et al. [21] concluded that a dosage of lidocaine ,7 mg?kg-1 is safe.

Sedation
Bronchoscopy is an intervention that is highly likely to arouse anxiety, pain, shortness of breath and fear in the patient as the manipulation in the airways triggers numerous reflexes, and the ambiance in the operating room with its array of instruments is a foreign circumstance that people can seldom tolerate. Sedation is therefore strongly recommended in order to reduce the stress reaction, enhance patient collaboration, diminish the levels of anxiety and fear, provide amnesia and facilitate the intervention, even if only topical anaesthesia is used [22]. Nonetheless, some clinical studies have demonstrated that good patient tolerance and satisfaction may be achieved through the use of local anaesthetics without sedation [23, 24]. Various drugs and combinations are utilised for sedation; the most common ones are discussed below.
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Benzodiazepines
Midazolam, diazepam and lorazepam are the three benzodiazepines most frequently used as sedatives for bronchoscopy. When used alone, their effect on the cardiorespiratory function is limited relative to that of their combination with opiates (common practice), when each drug potentiates the other in giving rise to respiratory depression [7]. Regardless of which drug is used, a dose reduction is necessary in elderly patients so as to avoid complications. Lorazepam is four times as potent as diazepam, and has a slower onset and a longer duration of action. The dosage is around 2 mg orally, but it can also be given intravenously; it has no active metabolite and it may have an anterograde amnesic effect. Diazepam can also be given either orally or intravenously. The oral route needs a minimum of 1 h to produce a measurable sedative effect. The intravenous route demands caution, as the solution contains propylene glycol (and usually lidocaine), which causes pain and a high incidence of thrombophlebitis. Diazepam has an active metabolite, which results in longer duration of actions and elimination. The dosage is y1020 mg intravenously, though a significant dose reduction may be needed in the elderly. Midazolam is water-soluble and short-acting, without a significantly active metabolite. It produces retrograde and procedural amnesia and sedation; as it can be administered via various routes (intravenous, oral or intramuscular), this is the benzodiazepine most extensively used for sedation. The dosage may vary according to the requirements; it is usually in the range 0.070.15 mg?kg-1. When higher doses are given, the longer recovery periods may complicate the procedures. The effects of benzodiazepines can be antagonised with flumazenil, a competitive antagonist, with a high affinity for the benzodiazepine receptors. The duration of its action is short, and therefore continuous infusion or repetitive boluses may be needed to antagonise the benzodiazepines. Following its application, a somewhat longer observation period is needed, as the patient can become obtunded after the elimination of the flumazenil.

Propofol
Propofol is a sedative-hypnotic alkyl-phenol agent that produces sedation at lower doses and general anaesthesia at higher ones. It should be given intravenously by titrating a continuous infusion to the appropriate level of action, which can vary from patient to patient. The onset of action is short, and when its action has concluded, the recovery period is also rapid, without a need for antagonists. Fospropofol disodium is a water-soluble prodrug of propofol with unique pharmacokinetic/pharmacodynamic properties. In a recent phase 3 study, fospropofol provided safe and effective sedation for patients undergoing flexible bronchoscopy [25].

Opiates
Opiates are usually administered in conjunction with propofol or benzodiazepines, as the latter have only a sedative, and not an analgesic effect. Apart from the analgesic effects of opiates, they reduce coughing reflexes and potentiate sedation. Unfortunately, there are many side-effects, including respiratory depression, nausea, vomiting, histamine release, urinary retention, chest wall rigidity, dysphoria and pruritus. For most interventions, shorter-acting opioids such as fentanyl, alfentanyl or remifentanyl should be considered, as the duration of the bronchoscopy is usually ,30 min.
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Morphine and meperidine are long-acting drugs suitable only for long-lasting procedures. A number of studies have compared various combinations with propofol or benzodiazepines [2629], and it has been concluded that most of the combinations are appropriate; selection should be based on the local requirements. Naloxone, an opiate antagonist, may be used to antagonise respiratory depression caused by an opioid overdose. Naloxone reverses not only the respiratory side-effects, but also the analgesia, although it too has many side-effects, such as nausea, hypertension, arrhythmia and pulmonary oedema. The duration of action is short, with a risk of renarcotisation. Hence, it is not recommended for general use. The application of fentanyl, alfentanyl or (much better) remifentanyl eliminates the need for naloxone.

General anaesthesia
For more complicated bronchoscopic procedures, such as prolonged laser therapy, stent implantation (usually with rigid instruments) or when the patient is uncooperative (children), restless or agitated, general anaesthesia is necessary. In such cases, management of the airways and ventilation are crucial. The patient should be anaesthetised and relaxed only if the airways and ventilation can be secured with certainty. Step-by-step sedation without relaxation and exploratory laryngoscopy might be advised in the event of expected difficulty, during the maintenance of spontaneous ventilation. Both inhalational and intravenous anaesthesia are applicable for intervention; selection between them should be based on the technique being used.

Inhalational anaesthesia
Inhalative agents can be used when the ventilatory circuit is closed, or mostly closed, mainly for flexible bronchoscopy with a mask or a laryngeal mask airway (LMA). Adequate agent concentrations can not be ensured with open circuit ventilation procedures, such as jet and rigid bronchoscopies; in these cases, therefore, volatile anaesthetics are not recommended. Moreover when volatile agents are used, mask leakage can result in significant environmental pollution. For induction and maintenance therapy, sevoflurane appears to be the best choice, as it is nonirritative, and even relatively high concentrations are comparatively well tolerated; therefore, rapid induction is possible without coughing, laryngospasm and apnoea or haemodynamic instability. Inhalative agents have a bronchodilator effect mediated by nitric oxide or arachidonic acid derivatives. Tracheal intubation can be performed at i1.3 minimum alveolar concentration. As sevoflurane has a reasonably low impact on the respiratory drive, spontaneous ventilation can be maintained when required. In a study of patients that were not pre-medicated, a vital capacity rapid inhalation induction technique with 4.5% inspired sevoflurane induced anaesthesia faster and was believed to be safer than spontaneous ventilation because it was associated with less excitatory movements, which may lead to more pronounced complications [30]. In another study of 102 patients, a comparison of propofol and 8% sevoflurane followed by maintenance with 2% sevoflurane revealed that induction was faster with propofol, but sevoflurane was associated with a lower occurrence of apnoea and a shorter time for the re-establishment of spontaneous ventilation. Sevoflurane also offered the advantages of a smoother transition to the maintenance phase, a smaller decrease in mean arterial blood pressure and lower costs than propofol. However, a post-operative questionnaire revealed that more patients found induction more unpleasant with sevoflurane than with propofol [31].
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Intravenous anaesthesia
Etomidate is a carboxylated imidazole derivative with a rapid onset of action and minimal haemodynamic risk. The use of etomidate infusions results in a suppression of steroid synthesis (both glucocorticoids and mineralocorticoids) in the adrenal cortex. This effect, which has been demonstrated after a single dose, lasts for about 24 h. There is no evidence that a single induction dose of etomidate has any effect on morbidity or mortality. Seizure-like activity is seen occasionally; myoclonic movement originating at the spinal cord level is often a probable mechanism, increasing the likelihood of complications. In our own practice, therefore, we use etomidate very rarely. Thiopental is an ultrashort-acting barbiturate that is most commonly applied in the induction phase of general anaesthesia. It is not used to maintain anaesthesia in surgical procedures as its infusion displays zero-order elimination kinetics, leading to a long period before consciousness is regained. Propofol may be a better choice for induction and also for maintenance, as it tends to blunt the airway reflexes, resulting in a decrease in airway muscle tone. Propofol is usually very well tolerated and is easily controllable, but it has been associated with more pronounced apnoea and hypotension than is the case with thiopental. Regardless of this, it is one of the most commonly used hypnotic agents. Ketamine may be useful for the promotion of spontaneous ventilation, but the sideeffects of increased secretions, hypertension and adverse psychological effects should be borne in mind. Instead, S-ketamine might be considered. Opioids should be used to provide effective analgesia in conjunction with hypnoid drugs. The maintenance phase of anaesthesia should be tailored to the surgical needs and to the demands of the procedures. The widespread availability of target-controlled infusion devices makes this an easy approach when propofol and remifentanyl are used, but current local procedures, based on simple infusion devices, the fractional dosing of selected agents, empiricism and experience, have proved fully than adequate to cope with any serious case. A combination of inhaled and intravenous agents is also effective.

Muscle relaxation
Muscle relaxation can be provided with a succinylcholine drip (with precurarisation) for short procedures, or preferably with intermittent boluses of nondepolarising agents titrated to effect for longer procedures. Mivacurium is a short-acting, nondepolarising agent with a rapid onset of action and a rapid recovery. It is suitable for intubation and maintenance therapy when repeated doses are given, and it has ended the need for succinylcholine. Nerve stimulator monitoring at the orbiclaris occuli is generally thought to reflect the response of the laryngeal muscles to neuromuscular blockade more accurately; however, this may be agent-dependent and is usually unnecessary in our practice.

Airway management and ventilation

Recent advances in anaesthesia, airway management and bronchoscopy make almost any of the standard airway management techniques applicable, depending on the type
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and duration of the procedure. The decision should be made in conjunction with the surgeon, with regard to the medical status of the patient, so as to provide an adequate route for ventilation and leaving sufficient space for the surgical intervention. The site and type of operation and the instruments used for bronchoscopy also govern the suitability of the technique for anaesthesia. Briefly, most diagnostic procedures can readily be performed with local anaesthetics and light anaesthesia without securing the airways. When necessary, spontaneous ventilation can be augmented with bag and mask ventilation with a bronchoscope swivel attachment or with jet ventilation through a jet catheter inserted into the trachea. Jet ventilation below the vocal cords also acts against aspiration as the relatively high net outflow exerts a protective effect. The LMA offers a novel means of access to the laryngeal region, providing a safe route for anaesthesia and the insertion of flexible bronchoscopes (fig. 2). Ventilation can be performed via an attached balloon, positive-pressure ventilator, by jet ventilation or by spontaneous ventilation. Depending on the size of the LMA and the internal diameter of its tubing, the airway resistance can increase significantly when the instruments and catheters are passed through it. Obstruction in the airways can cause dynamic hyperinflation when jet ventilation is used below the high-resistance part of the airways, and can lead to hypoventilation during spontaneous breathing. Tracheal intubation or rigid bronchoscopes are regularly used for complicated cases, as this technique does not limit the duration of surgery and is applicable for procedures in the lower part of the bronchial tree. It allows the use of deep anaesthesia and even muscle relaxation with controlled mechanical ventilation, but also the possibility of spontaneous breathing. Mechanical ventilation too can be employed as conventional or

a)

b)

c)

Fig. 2. Flexible bronchoscopy through a) a highlow jet tube, b) an endotracheal tube with a swivel adaptor and c) the laryngeal mask airway.

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jet ventilation. In view of the limited internal diameter of these instruments, increased airway resistance has to be considered. Most bronchoscopic procedures as a rule of thumb cause intermittent periods of hypoxia. Transient hypoxia may be tolerated, but a safety arterial oxygen saturation (Sa,O2) threshold of 90% (with the patient at rest breathing room air) has been proposed, which is normally equivalent to an arterial oxygen tensoion of 8 kPa [32]. It has been reported that, in high-risk hypoxaemic patients, noninvasive positive-pressure ventilation during the procedure can be effective in preventing hypoxic episodes [33].

Jet ventilation
Jet ventilation is a technique that is applicable in cases involving opened airways; tracheal surgery is one of the fields where it is commonly employed. Numerous methods and devices for low and high frequency and driving pressures have been developed since the 1960s based on the Venturi principle. Jet ventilation can be applied to open airways at the level of the glottis, infraglottically inside the trachea or supraglotticaly when the jet stream is directed into the trachea. When connected to the rigid bronchoscope, the jet stream can enter the lumen of the device along the lower half of the instrument or at the level of the connector. Obstruction-free outflow is required for appropriate operation in order to avoid over inflation of the respiratory system. Oxygenation during jet ventilation depends basically on the oxygen content of the inspired gas, the mean alveolar pressure and the ventilation/perfusion balance, while carbon dioxide elimination depends on the minute ventilation and the deadspace ratio. The minute ventilation can be increased by elevating the driving pressure, by using a wider catheter, or (as lower frequency is associated with a deeper penetration) by decreasing the frequency from the high-frequency range. Sophisticated jet ventilators are capable of monitoring the end-expiratory and peak-inspiratory pressure at the level of measurement. The saturation can be monitored without difficulty, as a carbon dioxide level ABG or transcutaneous monitoring device is required. As an alternative, if the high-frequency jet is stopped and conventional rates are applied (by triggering the ventilator manually), end-tidal carbon dioxide levels can be estimated. Visual observation of the movement of the chest wall and abdomen can be a good clinical substitute for the monitoring of ventilation. An obstruction distal to the jet catheter reduces the effectiveness of ventilation, while a proximal obstruction can lead to hyperinflation and baro/volutrauma. Adequate ventilation can usually be achieved with a frequency of 150250 cycles?min-1 and a driving pressure of 1.52.5 bar in adults. The advantages of jet ventilation include the free space left for procedures, which works even with open airways, that it supports gas exchange for long procedures, and the situations where there is less movement of the respiratory system as compared with conventional ventilation. When the jet catheter is driven distal to the site of intervention, the risk of aspiration (debris and blood) is lower as there is a high rate of gas flow towards the airway opening [34]. The oxygen fraction should be controlled and kept at low levels when a laser is applied, so as to avoid airway fires. Various multilumen catheters, tubes and attachments are available on the market, which make the application and monitoring of jet ventilation more flexible (fig. 3). Jet flow can be administered through a jet catheter driven directly into the trachea (fig. 4) or at any level proximal to the pharynx, or it can be attached to the connector of the instruments used by the surgeon (laryngoscope and bronchoscope (fig. 5)). Depending on the dynamic
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e)

d)

c)

b)

a)

Fig. 3. The most commonly used ways to adapt jet ventilation. a) Highlow jet tube, b) double-lumen jet catheter, c) transtracheal jet catheter, d) jet adaptor (applicable to any type of tubes), and e) jet nozzle. Arrow: connector to the jet nozzle; arrowhead: additional channel to monitor pressure, gas concentrations, etc.

a)

b)

c)

d)

e)

Fig. 4. a) Supraglottical, b) subglottical and c) tracheal views of the airway and double-lumen jet catheter in situ. d) The jet stream connected to the main channel (blue connector) of the catheter and a second channel serves for airway (tracheal) pressure monitoring (red connector). e) The tracheal jet ventilation with a double-lumen jet catheter for flexible bronchoscopy.

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Fig. 5. Connecting the jet nozzle to the rigid bronchoscope. The jet nozzle attached to the predefined jet connector (white arrow) of the rigid bronchoscope. Ambient air is entrained with the jet stream (white arrowhead), even when manipulators are inserted (black arrow).

behaviour of these applications, different settings of the ventilatory parameters may be required. As a general rule, the parameters should be selected according to the recent set-up and resulting effect; differences in equipment, in the site of jet entrance and in the mechanical properties of the patients respiratory system all have a significant impact on the effectiveness of jet ventilation. Numerous methods have been developed for high- and low-frequency jet ventilation, including the combination of jet ventilators with conventional ventilators. In a study of .1,500 patients, high-frequency jet ventilation (1.615 Hz) combined with lowfrequency streams (0.20.3 Hz) was applied successfully supraglottically through a special jet laryngoscope. It was found that oxygenation and ventilation could be maintained even in cases of severe stenosis [35]. SCHAPERA et al. [36] utilised an injection and suction system with success in animals during simulated total airway obstruction. The technique of jet ventilation is highly variable: in skilful hands, it is safe and effective, and can be adapted to any situation involving bronchoscopy. During the recovery phase, the driving pressure can be gradually decreased to lowering minute ventilation and allowing the re-establishment of spontaneous ventilation. As the patient ventilation recovers, the jet catheter can be withdrawn without problem.

Anaesthesia reversal and post-operative care

At the end of the surgical procedures, the neuromuscular blockade must be reversed. In our practice, we administer an antagonist only when partial reversal has already occurred, which minimises the risk of recurarisation as the antidotes have relatively short half-times. The neuromuscular agent should be selected with regard to the duration of the planned intervention; when needed, a fractional dosage of blocker is usually enough to lengthen the paralysis as required without delaying the reversal excessively. The airways should be secured until the patient can keep them open and
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ventilate spontaneously. Rigid bronchoscopes and the LMA can be left in situ as long as the patient tolerates them. Patients should not be discharged to post-operative care until spontaneous ventilation, airway patency, reflexes, stable circulation and consciousness have all been re-established in the operating room. All patients should be observed for at least 3060 min after bronchoscopy or for 2 h after rigid bronchoscopy or intervention. Observation can take place at the operating room or in a recovery room. The monitoring of ventilation features, such as Sa,O2, the respiratory rate, the respiratory pattern (visible signs of obstruction, the work of breathing and paradoxia) and ABG (when required), and circulation features, such as blood pressure, heart rate and ECG, is of paramount importance. The post-operative care should focus on the most common complications, such as acute airway obstruction, bleeding, mucus retention, pneumothorax, respiratory failure and cardiac dysfunctions. Hypoxic events subsequent to bronchoscopic procedures can occur in as many as 80% of the patients; oxygen supplementation after the procedure successfully reduces such hypoxic episodes, particularly in subjects with an impaired lung function [37]. Discharge from the recovery room can be performed when the patient is conscious, when all aspects of the ventilatory and airway reflexes have been restored, and when the patient has the ability to take deep breaths and to cough effectively without signs of severe obstruction. The recovery room should be close to the operating room, as any acute obstruction (stent dislocation) may be life-threatening and require immediate intervention.

Conclusion
Anaesthesia may range from slight topical sedation to deep narcosis and muscle relaxation with controlled ventilation for bronchoscopic interventions. The anaesthetist must be experienced in the handling of difficult airway situations and in the provision of complex peri-operative management. Critical airway situations can develop within a few seconds, and various rescue techniques should therefore be readyily at hand with which to maintain open airways and ventilation. For most (diagnostic) interventions with a flexible bronchoscope, general anaesthesia is not necessary, but adequate sedation and topical anaesthesia are required. General anaesthesia is necessary for the complicated bronchoscopic procedures, such as prolonged laser therapy, stent implantation or when the patient is uncooperative, restless or agitated. Both inhalational and intravenous anaesthesia are applicable for the intervention. Any of the standard airway management techniques are suitable for bronchoscopic interventions; the decision should be made in conjunction with the surgeon, with regard to the medical status of the patient, so as to provide an adequate route for ventilation and leaving sufficient space for the surgical intervention. The LMA offers a novel means of access to the laryngeal region, providing a safe route for anaesthesia and the insertion of flexible bronchoscopes. Ventilation can be performed via an attached balloon, positive-pressure ventilator, by jet ventilation or by spontaneous ventilation. The jet is a unique, highly variable and frequently applied technique for ventilation; in skilful hands, it is safe and effective, and can be adapted to any situation involving bronchoscopy even with open airways. All patients should be observed for at least 30 60 min after bronchoscopy or for 2 h after rigid bronchoscopy or intervention, focusing on the most common complications, such as hypoxia, acute airway obstruction, bleeding, mucus retention, pneumothorax, respiratory failure and cardiac dysfunctions.
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Summary
The provision of anaesthesia for bronchoscopic procedures poses a number of challenges and requires that the anaesthetist be fully familiar with different airway management, ventilation and anaesthesia techniques. The pre-operative management includes a complete assessment of the patient and detailed planning of the possible course of the diagnostic or therapeutic procedure in close cooperation with the bronchologist. As with any anaesthesia, continuous monitoring of the vital signs is crucial, and the management of both cardiac and respiratory complications should be prepared for. The range of possible forms of anaesthesia is wide, depending on the difficulty and length of the procedure, and spans from topical anaesthesia and mild sedation to general anaesthesia with muscle relaxation. Sedation can be achieved with intravenous drugs and combinations, such as benzodiazepines, propofol and opiates, whereas general anaesthesia can be produced with intravenous or volatile anaesthetics or a combination of both. Adequate ventilation and an appropriate level of oxygenation must be ensured during bronchoscopic procedures, though it is often difficult; the course of the procedure determines the level of ventilatory assistance needed. Most bronchoscopies can be performed with spontaneous ventilation or bag and mask ventilation, but other situations may call for more invasive airway management procedures, such as the laryngeal mask airway or endotracheal intubation (with either an endotracheal tube or a rigid bronchoscope) and positive-pressure or jet ventilation. The latter can be executed with the use of different connectors, catheters and swivel attachments. The special characteristics of jet ventilation make it an ideal method for guaranteeing adequate oxygenation during bronchoscopy, whether the patient is breathing spontaneously or is under general anaesthesia, and its role in bronchoscopic anaesthesia is therefore pivotal. Post-operative monitoring until full recovery from the anaesthesia is an absolute necessity in order to avoid respiratory complications and rapidly emerging lifethreatening complications, such as stent displacement. Keywords: Airway surgery, anaesthesia, bronchoscopy, jet, laryngeal mask airway, ventilation.

Statement of interest None declared.

References
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