Table 1 Anesthesia for advanced guided bronchoscopy

1

Preprocedure

Recruit lung volume, assess tolerance to higher PEEP, and prevent atelectasis

Perform incentive spirometry

2

Preoxygenation

Avoid absorption atelectasis

Modest FiO₂ (0.6 to 0.8) as tolerated

3

Anesthesia type

Need for a completely motionless patient

TIVA with propofol and muscle paralysis

4

Intubation

Enable gas passage past the bronchoscope with the least increase in circuit pressure

Use a larger endotracheal tube (usually ≥ 8.5, but as guided by patient anatomy)

Minimize atelectasis by avoiding traditional rapid-sequence intubation (i.e., avoid FiO₂ of 1.0 and Suxamethonium)

Perform an expeditious intubation using non-depolarizing muscle relaxants

5

Post-intubation

Reverse any induction-related atelectasis and assess hemodynamic stability during higher PEEP

Conduct up to 4 recruitment maneuvers as tolerated

Maintain FiO₂ at the lowest tolerable level

Maintain optimal lung inflation

PEEP of up to 10–12 cm H₂O for upper lobe biopsies, consider higher PEEP for lower lobe lesions or obese patients

An increase in tidal volumes may be considered

6

Breath-hold: timing

Reduce motion artifact

Breath-hold at peak inspiration (end of a normal tidal breath)

Breath-hold: pressure

Maintain a constant circuit pressure and PEEP and reduce diaphragmatic movement

Manually adjust APL valve to maintain circuit pressure at desired PEEP level

Breath-hold: duration

To minimize lung movement during imaging, allow time for pressure to equilibrate

Maintain breath-hold for 5–10 s before beginning imaging sweep

7

Biopsy

Ensure consistent settings between imaging and biopsy

Maintain settings at the same levels as Step 6

8

Post-procedure

Exclude pneumothorax and assess any residual atelectasis

Routine reversal and post-procedure methods. Perform chest X-ray