Bronch suite culture?

[agranulocytosis]

Just trying to get a feel for what your experiences are like in the bronch suite...

For instance: at my training program, we get 3 slots for bronchs per day in our only bronch room, 1 anesthesia slot 2 days a week. GI does about 20-30 cases a day, about 1/2 with general anesthesia. Of course, our anesthesia slot is after all the GI anesthesia cases are done on those days, so it's delayed to the point of cancellation about 1/3 of the time.

Our only bronch nurse leaves at a certain time every day and will not stay late for our important cases, leaving her duties to a rotating nurse who will either mismanage our specimens, or fail to get the proper equipment we need for the case, or both.

For the non-anesthesia slots, we the fellows do the laryngeal prep - that means the lidocaine gargle, lidocaine neb, jackson forceps, etc. We process our own specimens: dividing them in appropriate containers for path/micro/cytology/flow/etc. Some fellows walk the specimens down to the lab to avoid the not-too-infrequent "Sorry Doc, we lost the specimen".

We get good numbers overall, but it's through sheer hustle and staying late on those bronch days.

What has your experience been?

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[tartesos]

Just trying to get a feel for what your experiences are like in the bronch suite...

For instance: at my training program, we get 3 slots for bronchs per day in our only bronch room, 1 anesthesia slot 2 days a week. GI does about 20-30 cases a day, about 1/2 with general anesthesia. Of course, our anesthesia slot is after all the GI anesthesia cases are done on those days, so it's delayed to the point of cancellation about 1/3 of the time.

Our only bronch nurse leaves at a certain time every day and will not stay late for our important cases, leaving her duties to a rotating nurse who will either mismanage our specimens, or fail to get the proper equipment we need for the case, or both.

For the non-anesthesia slots, we the fellows do the laryngeal prep - that means the lidocaine gargle, lidocaine neb, jackson forceps, etc. We process our own specimens: dividing them in appropriate containers for path/micro/cytology/flow/etc. Some fellows walk the specimens down to the lab to avoid the not-too-infrequent "Sorry Doc, we lost the specimen".

We get good numbers overall, but it's through sheer hustle and staying late on those bronch days.

What has your experience been?

We were red headed step children when it came to gi, they always took priority but we were able to do a bronch anytime any day, if the gi lab staff left they were called back. Rt and rn was responsible of collecting and labeling specimens, path took them down with them if they were there for rose.
And yet we all complained about the process (and they still do).


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[tartesos]

Don't worry once you get out to practice is a whole different ball game.


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[deleted547339]

Why are you using anesthesia???? If you’re an intensivist, why don’t you just sedate your own patients? That’s what we did where I trained.

 

[Vigileo]

Why are you using anesthesia???? If you’re an intensivist, why don’t you just sedate your own patients? That’s what we did where I trained.

General anesthesia should be the standard of care for more advanced bronchoscopy, including complete EBUS surveys of the mediastinum and navigational bronchoscopy. Much better for patient and physician. If you're just doing a BAL and transbronchs or one shot wonders on EBUS, then I'm all for us giving conscious sedation.

 

[Hamhock]

I think Roman is asking why a CCM doc doesn't just stick in the ETT, sedate, and proceed.
Who needs anesthesiology for this?
They have 'real' cases to do.
HH

 

[ProtonPump]

I think Roman is asking why a CCM doc doesn't just stick in the ETT, sedate, and proceed.
Who needs anesthesiology for this?
They have 'real' cases to do.
HH

I think they would be better off getting anesthesia. They will need RT for intubation and for the vent (to bring it and to change vent settings) then they will need someone to monitor the patient and order changes in vent settings as needed and that would probably be a different person than the one administering sedation. Plus they will be doing a TIVA in non-critically Ill patient (read need more drug to be under GA) while also trying to do their procedure. What's the upside for them ?

 

[deleted547339]

All I’m saying is that where I trained, anesthesia wasn’t involved with bronchs. It ran smoothly and I liked it quite a bit. Cases were never cancelled or delayed. Usually used LMAs. The only exception to this was the rare case that was booked for the OR which usually included a bronch, but was obviously there for another reason.

 

[ProtonPump]

All I’m saying is that where I trained, anesthesia wasn’t involved with bronchs. It ran smoothly and I liked it quite a bit. Usually used LMAs. The only exception to this was the rare case that was booked for the OR which usually included a bronch, but was obviously there for another reason.

Were these bronchs where the patients needed intubation ?

 

[deleted547339]

Were these broncos where the patients needed intubation ?

Rarely, if ever, intubated. Almost always LMA.

 

[Vigileo]

I think Roman is asking why a CCM doc doesn't just stick in the ETT, sedate, and proceed.
Who needs anesthesiology for this?
They have 'real' cases to do.
HH

Almost all of our advanced cases are LMA cases as well. Actually having people intubated can be a pain if you're doing EBUS due to scope size and going after high paratracheal LN. But if I'm trying to do computer-assisted navigational bronchoscopy and EBUS survey, I probably shouldn't be dicking around with sedation at the same time. That's what the anesthesiologist or CRNAs do all day and it's easy for them. I can put plastic between the cords and run sedation just fine but the pulmonologist's skill set is best used to focus on biopsing that nodule or getting that LN. Those cases, with complete mediastinal staging, can be long and are done best with dedicated anesthesia. If I'm just doing transbronchial biopsies,/BAL/endobronchial forceps bx or using EBUS to hit one or two LN, then I'll just do it under conscious sedation myself.

 

[Hamhock]

Almost all of our advanced cases are LMA cases as well. Actually having people intubated can be a pain if you're doing EBUS due to scope size and going after high paratracheal LN. But if I'm trying to do computer-assisted navigational bronchoscopy and EBUS survey, I probably shouldn't be dicking around with sedation at the same time. That's what the anesthesiologist or CRNAs do all day and it's easy for them. I can put plastic between the cords and run sedation just fine but the pulmonologist's skill set is best used to focus on biopsing that nodule or getting that LN. Those cases, with complete mediastinal staging, can be long and are done best with dedicated anesthesia. If I'm just doing transbronchial biopsies,/BAL/endobronchial forceps bx or using EBUS to hit one or two LN, then I'll just do it under conscious sedation myself.

That seems reasonable. Thank you for the explanation.

I hope this doesn't come across as annoying, but it still seems a pulmonologist with critical care training should be able to do all these cases with an LMA and deep sedation/general anesthesia (I hadn't previously considered the big advantage of an LMA over ETT)...but I may again be showing my lack of knowledge regarding the procedural focus needed for these "advanced" diagnostic or even interventional bronchoscopic techniques.

HH

 

[Vigileo]

That seems reasonable. Thank you for the explanation.

I hope this doesn't come across as annoying, but it still seems a pulmonologist with critical care training should be able to do all these cases with an LMA and deep sedation/general anesthesia (I hadn't previously considered the big advantage of an LMA over ETT)...but I may again be showing my lack of knowledge regarding the procedural focus needed for these "advanced" diagnostic or even interventional bronchoscopic techniques.

HH

No worries. We're lucky here that we have anesthesia coverage for advanced procedures. I could do the airway management and sedation, but the patient is better served if I'm focused on my task and someone else is running sedation. There's also the consideration of hospital policy and politics - i.e. I can put an LMA/intubate and run propofol, but some hospitals don't want non-anesthesia clinicians doing this outside of the ICU or in a code. I'm not sure what our hospital(s) policies are.

If you get the chance, you should see a navigational bronchoscopy, which we often dowith a complete EBUS survey of the mediastinum if we get malignancy on R.O.S.E or the suspicion is high. Navigating out to a 1 cm nodule virtually on a mapped computer screen and utilizing fluoroscopy for biopsy can be challenging and at times requires some fine motor skill and luck. The benefit of dedicated anesthesia coverage in those cases is significant, though not all places do it that way.

 

[agranulocytosis]

The vast majority of our bronchs are via moderate sedation alone. We will do most of our complete mediastinal surveys, trans bronchs, endo bronchs, TBNAs with moderate sedation alone. That's why we only have 2 general anesthesia slots per week. Those cases are generally reserved for the fragile CHF patient that may not get be safely sedated with moderate sedation alone, the patient with a large anterior mediastinal mass that might obstruct the airway during sedation, or the debulking of tracheal/bronchial stenosis with APC and cryo +/- electrocautery where we need time and concentration for hemostasis.

My frustrations are that given limited anesthesia spots, these cases are often cancelled and patients end up either waiting too long or just go elsewhere for their care. Nobody (read: CEOs, CMOs, bull**** administrators) wants that to happen.

My experience has been that with the intubated patients under GA, our cases are smoother and our yields better. We aren't concentrating on both the sedation and the case together, which often means repeat cases or referrals to IR or CTS for biopsy. I hate referring to CTS or IR.

 

[Vigileo]

The vast majority of our bronchs are via moderate sedation alone. We will do most of our complete mediastinal surveys, trans bronchs, endo bronchs, TBNAs with moderate sedation alone. That's why we only have 2 general anesthesia slots per week. Those cases are generally reserved for the fragile CHF patient that may not get be safely sedated with moderate sedation alone, the patient with a large anterior mediastinal mass that might obstruct the airway during sedation, or the debulking of tracheal/bronchial stenosis with APC and cryo +/- electrocautery where we need time and concentration for hemostasis.

My frustrations are that given limited anesthesia spots, these cases are often cancelled and patients end up either waiting too long or just go elsewhere for their care. Nobody (read: CEOs, CMOs, bull**** administrators) wants that to happen.

My experience has been that with the intubated patients under GA, our cases are smoother and our yields better. We aren't concentrating on both the sedation and the case together, which often means repeat cases or referrals to IR or CTS for biopsy. I hate referring to CTS or IR.

I'm guessing that's why our institution has decided to support us with anesthesia support for our cases, which is nice. Perhaps I'll be spoiled when I leave, but I think it's better for patients.