Navigational Bronchoscopy and Endobronchial Ultrasound Bronchoscopy (EBUS)

Anesthesia Implications

Position: Supine
Time: 1-2 hours (average)
Blood Loss: Very Low (5-10 ml)
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: Yes

From the pros: “One of the biggest objectives for anesthesia in a navigational bronchoscope is to avoid atelectasis so they can go as deep as they can”

Preoperative considerations – Successful navigational bronchoscopy requires minimizing atelectasis and patient movement. Pre-operative incentive spirometry can help avoid atelectasis and guide the setting of the procedure’s tidal volume, typically exceeding 10%-15% above the spirometry’s maximum value, or 10-12 cc/kg of ideal body weight.

Intubation – Use of the largest feasible endotracheal tube (eg. 9.0 or 8.5 is recommended). Limit pre-oxygenation to around 80% to prevent absorptive atelectasis. Rapid intubation is essential to prevent atelectasis. Use strategies such as deep breaths, high positive end-expiratory pressure (PEEP), and adequate flow rate in case of difficulties.

Post-intubation – aim to reduce the fraction of inspired oxygen (FiO2) to 30% after intubation. Paralyzation is needed to prevent motion artifacts during CBCT scan/FluoroNav spins but not required for Endobronchial Ultrasound Bronchoscopy (EBUS).

Intraoperative Atelectasis Prevention – Apply 10-12 of PEEP as tolerated clinically, and consider 12-15 for obese patients. Other strategies include a breath hold at peak inspiration for advanced imaging, 20-40 cm H2O on the APL valve during breath holds, breath holds during biopsies (especially in lower lobe and basilar segments), and recruitment maneuvers as necessary.

Electromagnetic navigation bronchoscopy is a guided bronchoscopy technique that incorporates a conventional bronchoscope, an electromagnetic generator with sensors, and a computer software loaded with the patient’s thoracic CT images. A small, flexible channel extending from the bronchoscope navigates through the bronchial tree to reach lesions, even in the lung’s periphery and pleura. The flexible channel features a removable sensor at its tip, the locatable guide, which localizes the probe. When direct airway visualization becomes unfeasible, the software and electromagnetic sensors enable navigation in a virtual reality mode, referencing the sensor’s position and the surrounding CT scan data.