|Year : 2016 | Volume
| Issue : 4 | Page : 612-616
Endobronchial tumor laser resection: handling anesthetic challenges through a modified technique
Malik Sunny, Puri Arun, Bhandari Hricha, Malik Shraddha
Max Super Speciality Hospital, New Delhi, India
|Date of Submission||14-Oct-2015|
|Date of Acceptance||27-Mar-2016|
|Date of Web Publication||12-Jan-2017|
Department of Anaesthesiology, Max Super Specialty Hospital, PatparganjSunny Malik, MBBS, DA, DNB, Department of Anaesthesiology, Max Super Specialty Hospital, Patparganj, New Delhi
Source of Support: None, Conflict of Interest: None
Reported is a case of left mainstem bronchus carcinoid that was managed by means of a modified technique using a microlaryngeal tube for right lung ventilation and laser resection using an AMBU Ascope. The upper lobe of the left lung showed dramatic improvement on postoperative chest radiograph and computed tomography scan. Precautions for laser surgery and sharing of the airway by the surgeon and the anesthetist were taken care of during ventilation of the right lung. Soiling and tumor migration of the opposite lung were prevented intraoperatively and postoperatively.
Keywords: AMBU Ascope, endobronchial tumor, laser
|How to cite this article:|
Sunny M, Arun P, Hricha B, Shraddha M. Endobronchial tumor laser resection: handling anesthetic challenges through a modified technique. Ain-Shams J Anaesthesiol 2016;9:612-6
|How to cite this URL:|
Sunny M, Arun P, Hricha B, Shraddha M. Endobronchial tumor laser resection: handling anesthetic challenges through a modified technique. Ain-Shams J Anaesthesiol [serial online] 2016 [cited 2017 Jun 28];9:612-6. Available from: http://www.asja.eg.net/text.asp?2016/9/4/612/198251
| Introduction|| |
In the era of minimally invasive procedures, treatment of endobronchial carcinomas is made possible through the introduction of laser technique into clinical practice. Since its introduction in 1972, it has been used for palliative treatment in inoperable cases as well as for tumor volume reduction before surgery ,,.
Apart from the risks associated with laser, sharing of the airway by the surgeon and the anesthesiologist remains a major concern. Various anesthetic techniques have been described in the past for maintaining oxygenation and ventilation of the patient during the intraoperative period, such as local anesthesia, general anesthesia using a rigid bronchoscope, and high-frequency jet ventilation (HFJV), but these are not without complications . Multiple adverse effects that can occur during laser resection of endobronchial carcinomas comprise fire hazard, hemorrhage, pulmonary venous gas embolism, laser smoke bronchial irritation, and barotrauma ,,.
Endobronchial laser resections are performed using flexible fiberscopes and rigid bronchoscopes. Lasers such as KTP, argon dyes, YAP, Nd-YAG, and diode lasers are compatible for use in fiberoptic bronchoscopes, but Nd-YAG is the most commonly used because of its predictability for photocoagulation and vaporization on living tissue .
In all of the above techniques cited for airway management, the possibility of tumor migration and soiling of the opposite lung due to blood and secretions cannot be overlooked. Therefore, we describe a modified airway management technique for endobronchial tumor resection by means of laser, keeping in mind the proper ventilation of the unaffected lung as well as preventing complications associated with lasers and lung soiling.
| Case|| |
A 32-year-old male patient was admitted to our hospital with complaints of frequent coughing and difficulty in breathing, which had increased gradually over the past 1 month. He was diagnosed as a case of left main stem bronchus tumor and scheduled for laser resection of endobronchial carcinoma. His preoperative investigations including complete blood count, kidney function test, liver function test, and coagulation profile were within normal limits. Chest radiograph revealed left main stem bronchus intraluminal radio-opacity with complete collapse of the left lung ([Figure 1]). Contrast-enhanced computed tomography scan showed a moderately enhancing soft-tissue density mass within the left bronchus below the carina. Images of the left lung showed evidence of volume loss with ipsilateral mediastinal shift and raised hemidiaphragm ([Figure 2]). Videolaryngobronchoscopy was performed showing growth in the left bronchus intraluminally, and the right bronchus was found patent. Biopsy from the tumor mass demonstrated that it was a neuroendocrine tumor. Preoperative pulmonary function test illustrated early small airway obstruction with FEV1 of 1.24 l and FEV1/FVC 62% of predicted. The patient was accepted under ASA III. Written informed consent was obtained from the patient. Preoperatively, steam inhalation and nebulization with levosalbutamol and budesonide was continued. Hydrocort 100 mg intravenously was given at bedtime and early morning on the day of the surgery. An arterial blood gas analysis was performed that revealed PO2 73.7 mmHg, PCO2 36 mmHg, and pH 7.446. The patient was preoxygenated with 100% oxygen for 3 min, received induction with fentanyl 100 μg intravenously and propofol 80 mg intravenously, relaxed with atracurium 40 mg intravenously, and a microlaryngeal tube (MLS) 5.0 secured using a C-MAC laryngoscope. The tube was pushed down into the right mainstem bronchus under real-time guidance with the AMBU Ascope and cuff inflated with saline. It had an insertion cord of 3.8 mm diameter, channel width of 1.2 mm, and a bending angle of 130°. A mouth gag was introduced by the side of the MLS tube for introduction of the AMBU Ascope and laser resection of the left bronchus tumor through its side channel ([Figure 3] and [Figure 4]). One-lung ventilation was successfully maintained during laser resection intraoperatively (low tidal volume 300 ml, high respiratory rate 18, and a low FiO2 35%), thus preventing any soiling of the normal lung. Intermittent apneic oxygenation was used as a part of the fire prevention protocol. At the end of the surgery, the MLS tube was exchanged with a 7-mm cuffed endotracheal tube rail-roaded on the fiberoptic bronchoscope that was put by the side of the MLS tube. The MLS tube was taken back after suctioning under real-time fiberoptic guidance and cuffed endotracheal tube 7.0 was introduced. The patient was mechanically ventilated on one lung overnight and shifted to two-lung ventilation the next day after checking for any bleeding. The patient was successfully extubated and shifted to the ward. Serial chest radiograph and computed tomography showed opening of the left upper lobe, which was confirmed on minimum-intensity projection ([Figure 5] and [Figure 6]).
|Figure 1: Preoperative chest radiograph showing white out left hemithorax, suggesting collapse.|
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|Figure 2: Preoperative computed tomography of the chest with multiplanar reformation revealing moderately enhancing intraluminal soft-tissue density mass within the left mainstem bronchus.|
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|Figure 3: Microlaryngeal tube (MLS) tube with parallel mouth gag along with AMBU Ascope in situ.|
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|Figure 5: Postoperative chest radiograph revealing expansion of the left upper lobe.|
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|Figure 6: Postoperative computed tomography (CT) scan on minimum-intensity projection.|
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| Discussion|| |
Over the past few decades there has been an increase in the incidence of bronchial carcinomas. This has resulted in the day-to-day addition of various types of modalities being used for increasing survival in patients with endobronchial carcinomas. Such techniques include endobronchial prosthesis, laser resection, silastic stent placement, metallic stents, photodynamic therapy, electrocautery, cryotherapy, and balloon dilatation .
Carcinoid is a type of neuroendocrine tumor that can occur endobronchially. They account for less than 1% of all primary lung neoplasms . Although surgery is considered the gold standard treatment for bronchial carcinoids, the introduction of lasers in 1972 ,, has led to a shift in the growing acceptance for endobronchial laser ablations as a part of the initial treatment. Our patient suffered from left main stem bronchus tumor, which was found to be neuroendocrine in origin on histopathology. Laser resection was chosen as the primary modality of treatment as previous reviews had shown a high survival rate in such patients because of their tendency for central localization and polypoidal growth pattern along with a low rate of locoregional and distant metastases ,.
Anesthesia for airway surgeries is in itself a quite complicated task. Sharing of the airway by the surgeon and the anesthesiologist makes things relatively more complex to manage. Laser resections are different because of their use in a highly inflammatory gas zone, thus becoming a fire hazard. Various anesthetic techniques such as manual jet ventilation, HFJV, distal tracheal intubation, tracheostomy, spontaneous ventilation, and cardiopulmonary bypass should be kept in mind by the anesthesiologist and the choice should vary depending on the location of the tumor in the airway .
Resections have been performed under local anesthesia with spontaneous ventilation in the past, but the possibility of frequent coughing, patient movement, tumor migration, and instrumental injury to the airway cannot be ruled out. Thus, we chose general anesthesia as the first anesthetic option in our case. The most common and easy option is the use of the rigid bronchoscope under general anesthesia employing an HFJV technique or a modified procedure that incorporates an aluminum-wrapped insufflating catheter placed subcarinally into the contralateral bronchus . The rigid bronchoscope has easy control over ventilation and bleeding because of a spacious channel that can slot in the suction catheter, the laser, and the forceps simultaneously. However, both of the above techniques are not without shortcomings. The rigid bronchoscope leads to severe instrumentation, is inapproachable for the upper lobe and segmental bronchi, and HFJV leads to air trapping, causing lung hyperinflation . Moreover, the subcarinally placed insufflating catheter augments barotrauma to the ventilated lung as a result of decreased dead space and increasing alveolar volume while maintaining the same ventilator pattern .
Apart from these, tumor migration and soiling of the healthy lung can be a possibility as illustrated by Embley and Fairbairn  where a piece of tumor from the left main bronchus was aspirated into the more patent right bronchus, thus causing respiratory discomfort. Therefore, to avoid such a disaster we chose a modified technique of one-lung ventilation through a MLS that was put into the patent right mainstem bronchus and the surgeon was allowed to operate with a laser by the side channel of the disposable AMBU Ascope placed through a mouth gag secured just parallel to the MLS tube ([Figure 3] and [Figure 4]). The patient was well ventilated with low tidal volume, high respiratory rate, and a low FiO2. Intermittent apneic oxygenation was used during laser resection as a part of fire hazard prevention. By using the above technique, we were able to maintain a patent airway and prevent any seepage of blood and secretions into the contralateral healthy lung. A case reported by Olivier et al. also utilized fiberoptic bronchoscopy, YAG laser for intratracheal/bronchial tumor mass, and stent placement . Moreover, similar to the insufflation catheter it was thought that any jet of gases if coming upstream by the side of the small MLS tube will definitely prevent entrainment of laser plumes and any aspiration of debris. At the end of the surgery, the MLS tube was withdrawn and a rail-roaded cuffed endotracheal tube 7.0 on the fiberoptic bronchoscope was introduced into the right bronchus for further mechanical ventilation. The patient was shifted to two-lung ventilation after confirming negligible blood ooze and extubated uneventfully the next day under real-time fiberoptic guidance.In our experience, this method was safe enough in terms of effective ventilation and compartmentalization of the two lungs. However, sharing of the airway in laser resections needs a close communication and understanding between the surgeon and the anesthesiologist. We conclude that the anesthesiologist should be well versed with all the techniques of providing general anesthesia with adequate ventilation in airway tumor cases and the choice depends upon the site of the tumor and the nature of surgery. Apart from providing ventilation, all emergency resuscitation equipment and the rigid bronchoscope should be readily available in case any tumor migration occurs to the healthy lung.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]