Case: Navigational Bronchoscopy

[ethilo]

60yoF BMI 51 COPD with bronchodilator and tiotropium, chronic 5L home O2 and BiPAP at night for sleep, asthma, recent TTE HFpEF Grade 1 diastolic heart failure, mild concentric LVH, HTN, HLD, NIDDM2. Has had a chronic dry cough and 1 episode of scant hemoptysis, now RLL lung mass lights up. Undergoing navigational bronchoscopy posted for 5 hours procedural time.

...GO!

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[facted]

What is there to discuss? GA with ETT, possible Aline for sats/paco2 measurements, esp around extubation. Doesn't seem like a super complicated case.

 

[Arch Guillotti]

Why is it going to take so long?

 

[Ezekiel2517]

Cancel the case. Tell the patient to find a new surgeon. 5 hours for this is ridiculous. Are you sure they aren't doing a lung transplant as well?

 

[dhb]

You forgot pulmHTN in your description.
I'd like to see his pulm functional tests: why do this procedure if he's not going to tolerate the treatment (lobectomy or pneumonectomy).
On the bright side if he has lung cancer he might loose some weight.

 

[Planktonmd]

It's going to be a nightmare!

 

[deleted171991]

It's going to be a nightmare!

Yep. That's why it's a good case for oral boards simulation. There are some difficult scenarios one should think about. So, residents, why don't you try your best at developing a plan for this, including all the things that may go wrong?

 

[facted]

What exactly is so complicated about this case? 5L NC O2? Guess what, the dude lives at low SP02 and you're gonna give him high Fio2 on the vent. The time factor is extreme, no doubt, but most of these I've done are maybe 2 hours tops. I'm just not sure what everyone here is worried about. Give pre-op bronchodilators, put an 8.0 ETT in, discuss oxygenation issues with the pulm person if there are intra-op issues, and run TIVA if you want so you don't sevo the room. Otherwise, it's just a GA case. We do one lung ventilation on patients like this all the time, and they usually do just fine...here you're actually gonna ventilate both lungs

 

[ethilo]

Here are some of the key points I discussed with my attending:

Do you commit deep or try to keep them as light as possible? It's somewhere in the middle that will cause the most trouble.
Pros for deep: Minimize risk of movement during procedure
Pros for light: Shorten PACU time, less risk of post-op pulmonary complications, minimize atelectasis

Do you TIVA vs GA?
Pros for TIVA: less gas exposure to operator, likely less bucking / airway irritation / bronchospasm on emergence
Pros for GA: Keeps them deep enough, cheap, easy

...and as someone pointed out, we thought the length of the booking request was long.

And PFTs had FEV/FVC 42%, FEV1 0.64 L, no sig BD response, 6-minute walk = <900 for symptoms of dyspnea.


Fortunately (unfortunately?) I got diverted to doing a liver transplant instead and didn't have to do the case. Woohoo

 

[nimbus]

I still don't understand what anyone could possibly be doing through a bronchoscope for 5 hours.

 

[dhb]

FEV1 0.64L... send him home with his 5L of O2

 

[deleted59964]

Here are some of the key points I discussed with my attending:

Do you TIVA vs GA?
Pros for TIVA: less gas exposure to operator, likely less bucking / airway irritation / bronchospasm on emergence
Pros for GA: Keeps them deep enough, cheap, easy

huh?
TIVA=GA

 

[ethilo]

my apologies... TIVA vs inhalational

huh?
TIVA=GA

 

[ethilo]

it ended up being 2 hours

 

[Iso4ane]

There is another advantage to TIVA, pulmonologist cant suck your medication out and/or affect your delivery.

 

[chessknt]

You forgot pulmHTN in your description.
I'd like to see his pulm functional tests: why do this procedure if he's not going to tolerate the treatment (lobectomy or pneumonectomy).
On the bright side if he has lung cancer he might loose some weight.

Depending on location and pet this may be the only viable way to diagnose the cancer and guide onc treatment since he is a poor candidate for surgical biopsy. Not done for surgical resection only.

And 5 hours for this is nuts

 

[dhb]

Depending on location and pet this may be the only viable way to diagnose the cancer and guide onc treatment since he is a poor candidate for surgical biopsy. Not done for surgical resection only.

And 5 hours for this is nuts

He'll die regardless but if you really what a biopsy it can be done in 10min with minimal sedation

 

[dannyboy1]

Seriously, people are overthinking this case. GA with a tube. If you are worried about movement give muscle relaxant. Bronchodilators if needed. Are people here really going to tell the pulmonary doc to move faster??!!. Some surgeons are fast, some are slow. This is part of anesthesia life. If it will take 5 hours make sure to pee beforehand and bring a granola bar...

 

[chessknt]

He'll die regardless but if you really what a biopsy it can be done in 10min with minimal sedation

A vats biopsy in 10 mins with minimal sedation? You must have a demigod for a surgeon.

And with advances in targeted lung cancer treatments it is possible to get significant benefit in some types of cancers so diagnosis is important.

 

[dhb]

Biopsy via flexible bronch.

 

[dhb]

And with advances in targeted lung cancer treatments it is possible to get significant benefit in some types of cancers so diagnosis is important.

"60yoF BMI 51 COPD with bronchodilator and tiotropium, chronic 5L home O2 and BiPAP at night for sleep, asthma, FEV1 0.6L, recent TTE HFpEF Grade 1 diastolic heart failure, mild concentric LVH, HTN, HLD, NIDDM2"

If this guy isn't dying of cancer then nobody is, which would mean we can all live happily into eternity
:rainbow unicorn emoji:

 

[dhb]

Seriously, people are overthinking this case. GA with a tube. If you are worried about movement give muscle relaxant. Bronchodilators if needed. Are people here really going to tell the pulmonary doc to move faster??!!. Some surgeons are fast, some are slow. This is part of anesthesia life. If it will take 5 hours make sure to pee beforehand and bring a granola bar...

I'm not a guy to overthink a case but i doubt a BMI 51 living on half a lung on 5L hime O2 with recent hemoptysis is going to do well after a 5h GA with someone dicking around in his lungs.

 

[dannyboy1]

I'm not a guy to overthink a case but i doubt a BMI 51 living on half a lung on 5L hime O2 with recent hemoptysis is going to do well after a 5h GA with someone dicking around in his lungs.

You are right. But what are you going to do. Delay for pulm clearance-his pulmonologist is bringing him to the OR! For better or worse the decision was made that this procedure is needed for optimal treatment of his cancer. I don't think that any of us is an expert enough in oncology to argue this point. I also don't think that telling the patient that this procedure is necessary but your doc sucks will go over well Best you can do is warn about post-op mechanical ventilation and proceed with GA

 

[chessknt]

"60yoF BMI 51 COPD with bronchodilator and tiotropium, chronic 5L home O2 and BiPAP at night for sleep, asthma, FEV1 0.6L, recent TTE HFpEF Grade 1 diastolic heart failure, mild concentric LVH, HTN, HLD, NIDDM2"

If this guy isn't dying of cancer then nobody is, which would mean we can all live happily into eternity
:rainbow unicorn emoji:

He isn't though--it obviously has not induced cachexia nor would a solitary lung mass explain his o2 requirement. He could live for years with proper treatment until he dies of chf or something else that isn't cancer.

 

[pgg]

Best you can do is warn about post-op mechanical ventilation and proceed with GA

There it is. Not much else to do, except do it and be done with it.

 

[nimbus]

Update? How did he do?

 

[Ronin786]

Doesn't seem like a difficult case. That said, bronchoscopies are about the only case I use remifentanil on. No need to worry about deep vs light and residual effects post-operatively.

 

[dhb]

We can put anybody to sleep but should we?
Sometimes other docs (who aren't better than us) need a reality check, especially oncologists.

 

[facted]

We can put anybody to sleep but should we?
Sometimes other docs (who aren't better than us) need a reality check, especially oncologists.

This is 100% true, especially for end of life procedures (demented bed bound patients with broken hips come to mind...), but I'm not sure that this patient meets that criteria. He's sick, no doubt. But what about his case really worries you? His BMI? 5L NC? If the nav bronch finds his lesion and they can biopsy appropriately perhaps his treatment is chemo and radiation and not surgery? Doing one lung on this guy for a wedge or lobe would not be fun, but it's also not 100% impossible either.

 

[ethilo]

I didn't do the case, but I looked at the record - Ended up doing gas, ett, straight forward, Extubated without difficulty. I talked to the resident afterward, he was as surprised as I was she didn't have any bronchospasm with extubating or trouble in pacu. The case took 2 hours, done by a pulmonologist.