Bronchoscopy

[not-on-fire]

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Any pearls from the group for sedation/airway management for EBUS cases? I'm a pulmonologist and so far I've only done them with a bite block and sedation with either fentanyl/midazolam or propofol (although I find that the larger doses of propofol almost always cause a great deal of upper airway obstruction). Except for one non-EBUS bronch with a LMA, which was a dream. Here, anesthesia does all sedation for bronchoscopies. My colleagues wanted a protected airway but they didn't have a large enough tube/LMA available for the case. What are you seeing/doing?

 

[caligas]

Try the Igel brand lma, we do thousands per year with these. Scope passes ez.

 

[lord_jeebus]

Cookgas Air-Q

 

[Stank811]

LMA is not going to protect the airway but will help with the upper airway obstruction

 

[Arch Guillotti]

Cookgas Air-Q

Second the Air-Q. Easy to go through.

 

[cchoukal]

LMA is not going to protect the airway but will help with the upper airway obstruction

+1. Still, I've done and handful of bronchs via LMA (I have the residents scope an aintree thru an LMA as a conduit for intubation over the aintree to simulate a can't-intubate-cant-ventilate resuce), and i've had no problems passing the scope. We use LMA-brand "LMA-unique" and they work well.

 

[somedumbDO]

Nasal airway under Mac w propofol. It ablates airway reflexes better stick some o2 down and call it a day

 

[Planktonmd]

I strongly suggest that you have an anesthesiologist help you do your procedures so you can focus on doing what you need to do and he/she can make sure your patient stays alive.

 

[not-on-fire]

I am happy to have anesthesiologists administer sedation/keep patient alive. However, I am asking what I can suggest to make things go more smoothly. What tools are people using? The EBUS scope can only fit through a size 8.5 ETT tube or higher, and the ETT makes it harder to access paratracheal nodes. It proved controversial to proceed with moderate sedation and a bite block in absence of sufficiently large ETT/LMA. I am distressed that some seem to hate doing bronchoscopy cases; I want to make it better. Thanks for the replies, I will see what we can get.

 

[periopdoc]

What is wrong with placing an 8.5 ETT? It is about the diameter of a double lumen tube.

I know, you aren't making that call.

- pod

 

[proman]

What is wrong with placing an 8.5 ETT? It is about the diameter of a double lumen tube.

I know, you aren't making that call.

- pod

Funny I do these with a 9.0 ETT, the EBUS bronch is bigger than a regular bronch and I don't have to use IV agents. Sometimes I use a sux or remi drip if they need help calming down. I think a 35Fr DLT is about a 10.0 ETT. A lot use some sort of supraglottic airway, I'll only use an LMA for upper trachea lesions. My pulmonologists are happy with this way and I am too.

 

[urge]

Any pearls from the group for sedation/airway management for EBUS cases? I'm a pulmonologist and so far I've only done them with a bite block and sedation with either fentanyl/midazolam or propofol (although I find that the larger doses of propofol almost always cause a great deal of upper airway obstruction). Except for one non-EBUS bronch with a LMA, which was a dream. Here, anesthesia does all sedation for bronchoscopies. My colleagues wanted a protected airway but they didn't have a large enough tube/LMA available for the case. What are you seeing/doing?

I do them with LMA's. A size 4 is more than enough. Those things have a huge opening, just have to cut the slits at the end.

I don't understand how it doesn't fit. Are your bronching midgets, or do you use a horse ebus scope?

 

[not-on-fire]

Only average people with regular EBUS scope so far. Maybe I should have inspected the LMAs available myself. They said that it had not worked the week prior with same scope. I know for sure they didn't have larger than a 8 ETT.

 

[urge]

Only average people with regular EBUS scope so far. Maybe I should have inspected the LMAs available myself. They said that it had not worked the week prior with same scope. I know for sure they didn't have larger than a 8 ETT.

Internal diameter of a LMA Unique size 4 is 10mm. No reason why it wouldn't fit.
http://www.scribd.com/doc/72148878/LMA-Airways-Manual

Just cut the slits and send for the next patient.