Transcript Medical Thoracoscopy

ANAESTHESIA FOR THORACOSCOPY,
VATS, BAL,MEDIASTINOSCOPY AND
ESOPHAGOSCOPY
BY- DR SUCHIT KHANDUJA
MODERATOR- DR AJAY SOOD
MEDICAL THORACOSCOPY
History
• Thoracoscopy was introduced together with laparoscopy
in 1910 by Hans-Christian Jacobaeus.
• Jacobaeus initiated the therapeutic application of
thoracoscopy for lysis of pleural adhesions
• With the advent of anti-tuberculosis drugs, thoracoscopy
was abandoned for several decades.
• Recent technologic advances such as improved optical
and video technology have revitalized the use of this
procedure as a diagnostic and therapeutic tool.
History
• Excellent results of laparoscopic surgery and
the tremendous advances in endoscopic
technology stimulated many thoracic surgeons
to develop minimally invasive techniques, which
were termed therapeutic or surgical
thoracoscopy, as well as video-controlled or
video-thoracoscopic surgery, or video-assisted
thoracic surgery (VATS).
• Pleuroscopy (medical thoracoscopy) is
considered as a part of the field of interventional
pulmonology.
INDICATIONS OF MEDICAL
THORACOSCOPY
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Pleuroscopy
Pleural effusions
Staging of lung cancer
Staging of diffuse malignant mesothelioma
Pleurodesis by talc poudrage
Contraindications
Absolute:
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Size of free pleural space <6-10 cm usually due to
extensive adhesions.
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Respiratory insufficiency requiring ventilatory support.
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Pulmonary arterial hypertension
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Uncorrectable bleeding disorders.
Relative:
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Intractable cough.
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Hypoxemia.
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Unstable cardiovascular status.
Techniques
• Pleuroscopy is an invasive technique that should
be used only when other, simpler methods do not
provide the diagnosis.
• The technique is actually very similar to chest
tube insertion by means of a trocar.
• There are two different techniques of diagnostic
and therapeutic pleuroscopy.
Techniques
1. The first method uses a single entry site, usually
with a 9-mm trocar, for a thoracoscope with a
working channel for accessory instruments and
optical biopsy forceps that is employed under local
anesthesia.
2. In the other technique, as used by Jacobaeus for
lysis of adhesions, two entry sites are used: one
with a 7-mm trocar for the examination telescope
and the other with a 5-mm trocar for accessory
instruments, including the biopsy forceps.
3. General anesthesia is preferred for above
Equipment
A, Trocar and cannula with valve.
B, Single-incision thoracoscope (9
mm diameter).
C, Biopsy forceps with straight optical
device.
D, Magnified view of optical device
and forceps in the thoracoscope
shaft ready for biopsy.
•The single-entry-site technique is usually done with a 9-mm diameter
trocar and a cannula with valve.
•The two-entry-site technique uses a 7-mm trocar for the first site of
entry, with appropriate telescopes and forceps, and similar accessory
instruments. For the second site of entry, a 5-mm trocar is used.
Equipment
Semirigid pleuroscope with
biopsy forceps
•It has the advantage that the skills involved in operating the instrument are
already familiar to the practicing bronchoscopist.
•Its disadvantages compared to rigid thoracoscopic instruments are the
smaller biopsy specimens. However, the flexible tip allows very
homogeneous distribution of talc on all pleural surfaces.
Equipment
• The procedure suite should be equipped with
monopolar and, if possible, bipolar
electrocoagulation as well as equipment for
resuscitation and assisted ventilation,
electrocardiography, blood pressure monitoring,
defibrillator and as well as oxygen and vacuum
generators.
PREOPERATIVE PREPARATION
• Radiologic evaluation include
– P-A and lateral chest radiograph.
– Ultrasound for localization of the pleural fluid and for
diagnosis of fibrinous membranes or adhesions in the
pleural space.
– CT scan is not mandatory, but can be helpful in
certain situations such as loculated empyema and
localized lesions of the chest wall or diaphragm.
• ABG
• ECG
• Clinical laboratory tests
Pleuroscopic Technique
• The site of introduction of
the pleuroscope depends
in part on the location of
abnormalities to access
and the location of
potentially hazardous
areas to avoid.
• The region of the
diaphragm is unsuitable.
• The trocar is generally
introduced in the lateral
thoracic region between
the mid- and anterior
axillary line in the fourth
to seventh intercostal
space.
• Area is prepared with cleansing agent
• Local anesthesia is administered and after
making a small skin incision, the trocar is
advanced with a fairly forceful corkscrew
motion until the detectable resistance of
the internal thoracic fascia has been
overcome.
• The cannula of the trocar should lie at
least 0.5 cm within the pleural space.
Pleuroscopic Technique
• Pleural effusions should be removed completely by
using a suction tube that does not fully occlude the
cannula
• After complete removal of the effusion, or in cases
without effusion, the optical device is introduced
through the cannula, and the pleural space is then
inspected.
• Biopsies of the pleura and, if needed, of the lungs,
can be carried out most easily and safely by means
of the lung biopsy forceps.
• Although a single site of entry is generally sufficient,
a second site may be useful for biopsies or to perform
coagulation
Anesthesia
• Pleuroscopy by the single-entry-site technique is
usually done under local anesthesia with
premedication, using an antianxiolytic, a narcotic, or
both (e.g., midazolam and hydrocodone).
• Additional pain medication should be given during
the procedure, as required.
• An excellent alternative is sedation by propofol with
or without premedication.
• General anesthesia with intubation and ventilation is
not necessary for pleuroscopy
Complications
Mortality - 0.01-0.25 %
Morbidity:
• Desaturation during procedure (↓ LA) – <2%
• Persistent post-operative air leak (>7d) – <2% (pts with
spontaneous pneumothorax).
• Subcutaneous emphysema ( 0.5%)
• Rare – benign cardiac arrythmias, transient hypotension
and seeding of pathology in patients with malignant
mesothelioma.
VATS
Video-assisted Thoracic Surgery(VATS)
• VATS uses small incisions to perform therapeutic
interventions in the chest without spreading the ribs.
• VATS requires an operating room, general anesthesia
with single-lung ventilation, more than two (usually three)
entry sites, and complex instruments.
• Overall, it is a more invasive and expensive technique
with a higher risk than pleuroscopy
• In experienced hands and in the proper setting, VATS is
less invasive, is less expensive, and has a lower risk
than open procedures.
Indications
Lung biopsy
• Lobectomy
• Decortication
• Lung volume reduction
surgery
Pleura procedures
• Pleurectomy
(pneumothorax)
• Drainage/decortication
(empyema stage III)
Mediastinal procedures
• Resection of mediastinal
mass
• Thoracic
lymphadenectomy
• Thoracic duct ligation
• Pericardial window
• Sympathectomy
Esophageal procedures
• Excision of cyst, benign
tumors
• Esophagectomy
• Anti-reflux procedures
General Procedure
• The trocar and the camera are
placed in the midaxillary line in
approximately the eighth
intercostal space.
• Most of the surgeons use a
reusable 5-mm trocar and a
30-degree, 5-mm
thoracoscope.
• A 2-cm incision is made in
about the sixth intercostal
space in the mid-clavicular
line.
• An additional incision is made
in the fourth intercostal space
in the midaxillary line.
• A variety of equipment is
available for VATS
procedures.
Basic instrumentation for VATS
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“Three-chip” endoscopic video camera and high-definition television
monitor
Operating thoracoscope (with 5-mm biopsy channel)
Three standard-length ringed forceps
Suction-irrigation system 10 mm diameter
Endoscopic hook cautery (5 mm) with trumpeted suction
Standard electrocautery unit with extended tip for application through
intercostal access site
Landreneau “Masher” set
Bulbed syringe (60 ml)
Standard Metzenbaum scissors (10–12 in.)
Standard University of Michigan Mixner clamp (10–12 in.)
Standard-sized and pediatric Yankour metal suckers
Standard 28-French chest tubes (straight and right angled) and closed
drainage system
ANAESTHETIC IMPLICATIONS
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Thoracoscopic surgery can be performed under local, regional, or general
anesthesia with two-lung ventilation or OLV.
For minor diagnostic procedures VATS can be done in the awake patient.
Intercostal nerve blocks performed at the level of the incision and two
interspaces above and below provide adequate analgesia.
Partial collapse of the lung on the side of surgery occurs when air enters the
pleural cavity.
When using local anesthesia with the patient awake, it is hazardous to
insufflate gases under pressure into the hemithorax in an attempt to
increase visualization of the pleural space.
Changes in PaO2, PaCO2, and cardiac rhythm are usually minimal during
the procedure when it is performed under local anesthesia and the patient is
breathing spontaneously.
It is recommended that a high FIO2 is delivered via a facemask to overcome
the shunt due to the loss in lung volume caused by the unavoidable
pneumothorax.
For most invasive procedures VATS is performed under
general anesthesia with a DLT or a bronchial blocker to
achieve OLV.
Lung collapse will take longer when a bronchial blocker is
used; if rapid lung collapse is needed, a DLT may be the
preferred choice.
If the procedure is short in duration and the lung needs to
be deflated for only a brief period, blood gases are not
routinely monitored during the procedure.
However, for patients undergoing prolonged VATS
procedures such as lobectomy or for patients with
marginal pulmonary status, an arterial line and
measurement of arterial blood gases is required.
Paravertebral and intercostal blocks have been used with a
single dose of local anesthetics and have been shown to
reduce pain after thoracoscopic surgery for 6 hours
Contraindications and complications same
as medical thoracoscopy
BRONCHALVEOLAR LAVAGE
BRONCHOALVEOLAR
LAVAGE
General indications:
• Non-resolving pneumonia
• Diffuse lung infiltrates (interstitial and/or alveolar)
• Suspected alveolar hemorrhage
• Quantitative cultures for ventilator associated
pneumonia
• Infiltrates in an immunocompromised host
• Exclusion of diagnosable conditions by BAL,
usually infection
• Research
BAL can be diagnostic in the appropriate clinical setting
for:
• Alveolar hemorrhage
• Malignancies
– Lymphangitic carcinomatosis
– Bronchoalveolar carcinoma
– Other malignancies
• Infections
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PCP
Mycobacterial
Bacterial
Fungal
Viral
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Equipment
Flexible bronchoscope/DLT
Sterile collection trap
Suction tubing
Sterile saline
Vacuum source
Syringe
Optional 3 way stop-cock
Lidocaine 1-2%
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Preparation and Anesthetic implications
Obtain informed consent.
If an outpatient procedure, the patient should
be accompanied by a person designated to
drive the patient.
BAL should be planned to be performed prior
to any other bronchoscopic procedure.
Review radiographs to determine ideal site of
alveolar lavage.
– In diffuse infiltrates, the right middle lobe (RML)
or the lingula in the supine patient is preferred.
• Prepare bronchoscope/DLT, collection trap, and
tubing.
• Prepare supplemental oxygen and monitoring
equipment.
– ECG, pulse-oximetry, NIBP
• Premedicate with bronchodilators and/or warm the
saline solution for those at risk for bronchospasm.
• Position patient, preferably in supine position
when approaching RML or lingula.
• Apply monitors and supplemental oxygen.
• Sedation with a benzodiazepine and a narcotic will
allow patient comfort and minimize cough reflex.
Radiologic imaging, CT, and ventilationperfusion scans help to determine the
most impaired lung, which will be lavaged
first.
General anesthesia is induced and
maintained with intravenous infusions as
for lung transplantation.
• Airway management is with a left-sided
DLT.
• Precise placement of the tube is confirmed
by fiberoptic bronchoscopy
• Air-tight isolation is determined by
monitoring inspired and expired tidal
volumes with side-stream spirometry.
• Tube dislodgment and flooding of the
nonlavaged lung is a major complication of
this procedure.
• Specifically during lavage of the left lung, the
pressure of saline in the lung will tend to push
the bronchial cuff of the DLT proximally.
• To prevent this it is recommended that the
anesthesiologist maintain his or her hand on
the DLT, securing it firmly at the patient's
mouth, throughout the entire procedure.
• The pulmonary compliance of the ventilated
lung needs to be continuously monitored to
diagnose any liquid spillage from the lavage
lung.
• The patient is kept in the supine position
during the procedure.
• To improve the effectiveness of the
lavage, ventilation with FIO2 100% for a
few minutes is initiated after induction to
de-nitrogenate both lungs.
• OLV is instituted with the nonlavage lung.
• A disposable irrigation and drainage
system is used to instill approximately 1 L
of warm normal saline (37°C) into the
lavage lung
• The irrigating liquid is suspended 30 cm
above the patient's mid-chest level to the
lavage lung.
• Thereafter, the saline is rapidly drained by
gravity into a container positioned 60 cm
below or with the assistance of a small
level of suction (<20 cm H2O).
• This process is repeated as needed until
the effluent fluid is clear.
• Chest physiotherapy—is applied during
the filling and the drainage phases.
• The use of flannel protects the patient's
chest wall from trauma due to
physiotherapy during the percussion.
• If the cumulative total of the instilled fluid
volume exceeds the drainage volume by
more than 1000 mL a hydrothorax should
be suspected
• Oxygenation increases during the filling
phase and decreases during the emptying
• Changes are usually transient and well
tolerated.
• Inflation of a pulmonary artery catheter
balloon in the pulmonary artery of the
lavage lung while adding nitric oxide to the
ventilated lung or the use of ECMO to
maintain oxygenation and prevent
hypoxaemia.
• Usually 10 to 15 L is instilled and more
than 90% is recovered, leaving a deficit of
less than 10%.
• At the end of the procedure the lavaged
lung is thoroughly suctioned
• A dose of furosemide (10 mg) is
administered to increase diuresis of
absorbed saline.
• If the plan is to proceed to a lavage of the
contralateral lung there is a period of at
least 1 hour of two-lung ventilation.
• After the procedure, after re-intubation
with a single-lumen tracheal tube,
inspection with fiberoptic bronchoscopy is
performed for suctioning.
• Conventional ventilation with PEEP is
continued, usually for less than 2 hours.
• Alveolar infiltrates seen on the chest
radiography immediately after lavage
normally clear within 24 hours.
• Observation in the intensive care unit for
24 hours is part of the routine procedure
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Complications/Adverse events
No complications in up to 95%
Cough
Transient fever (2.5%)
Transient chills and myalgias
Transient infiltrates in most (resolves in 24
hours)
Bronchospasm (<1%)
Transient fall of lung function
Transient decrease in baseline PaO2
Need for mechanical ventilation
postoperatively.
ESOPHAGOSCOPY
ESOPHAGOSCOPY
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DIAGNOSTIC INDICATIONS
History of functional disease of esophagus
Radiological evidence of disease of
esopagus
Suspected foreign body of esophagus
Asessment of caustic ingestion
THERAPEUTIC INDICATIONS
• Removal of foreign bodies
• Dilation of cardia and division of
divericulum
• Injection in varices
CONTRAINDICATION
• Uncorrected medical disorder
• For rigid esophagoscopy severe
kyphoscoliotic disorder or cervical
spondylitis
POSITIONING
• Positioning is same as that for
laryngoscopy and bronchoscopy
• Table must have a flexible head rest
• On occasion shoulder role may be heplful
but pts head need to be extended during
esophagoscopy
INSTRUMENTS
A no. of flexible scopes
are available which
allow superior
visualisation
Rigid esophagoscope
may be round or
oval(hollinger or
jesberg) with or
without telescope.
ANAESTHETIC IMPLICATIONS
• Preoperative sedation may be needed
• With a flexible scope local anaesthesia is
used with concomitant sedation
• For children GA is used
• For rigid esophagoscopy GA is preferred
• Foreign body removal is done under GA
• All such pts must be considered to be full
stomach
• Rapid sequence anaesthesia preferred in
all such pts.
• Once airway is secured higher degree of
inhalational anaesthetic with muscle
relaxation given to ensure minimal
movement during procedure
• Greater chances of extubation because of
neck extension
Technique
• Can be done under LA/GA
• If GA is used intubation is first performed
• Esophagoscopy canbe performed without
laryngoscopy
• The scope is passed along the post pharangeal
wall to the level of arytenoids
• Narrow horizontal slit seen posterior to larynx
,leading edge of esophagoscope passed into the
slit and cricoid lifted anteriorly.
• Scope then passed into lumen of esopagus
• Once lumen of esophagus entered further
head extension may be needed.
• The mucosa is identified for any
pathological changes
• Scope is advanced gently without
excessive thrusting
• Care must be given to keep the telescope
within esophagoscope
MEDIASTINOSCOPY
MEDIASTINOSCOPY
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Mediastinoscopy is really a surgical
procedure which allows physicians to
view regions of the mediastinum.
INDICATIONS
• Diagnostic method of choice for detecting lymphoma,
including Hodgkin's disease
• Diagnosis of sarcoidosis and the staging of lung
cancer can also be attained through mediastinoscopy
• Allows physician to observe and draw out a sample from
the nodes for more study.
• Most reliable techniques for establishing histologic
diagnosis in patients with superior vena cava obstruction
Contraindications
• Previous mediastinoscopy is a relatively strong
contraindication to a repeat procedure
• Superior vena cava (SVC) syndrome increases the risk
of bleeding from distended veins and is a relative
contraindication.
Other relative contraindications include
1. Severe tracheal deviation
2. Cerebrovascular disease
3. Severe cervical spine disease with limited neck
extension
4. Previous chest radiotherapy
5. Thoracic aortic aneurysm
TECHNIQUE
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The majority of mediastinoscopies
are performed via the cervical
approach, entering the
mediastinum through a 3-cm
incision in the suprasternal notch.
A dissection is made between the
left innominate vein and the
sternum creating a tunnel in the
fascial layers.
The mediastinoscope is then
inserted anterior to the aortic arch.
The less commonly performed
anterior approach is through the
second intercostal space, lateral
to the sternal border; this is used
to inspect the lower mediastinum.
INVESTIGATIONS
• Should include chest X-ray, and CT scan aimed at evaluating the
location of the tumour, its relation to adjoining structures, and the
degree of tracheal compression.
• Pulmonary function tests are useful in detecting the severity of preexisting lung disease and effects of mediastinal mass.
• Flow–volume curves should be obtained in the upright and supine
position to evaluate functional impairment and ascertain the
presence of obstruction.
• Both inspiratory and expiratory flows are usually reduced in the
presence of an intrathoracic mass.
• A disproportionate decrease in maximal expiratory flow should raise
suspicion of tracheomalacia.
Premedication with Anaesthetic
management
• A short-acting benzodiazepine may be prescribed to decrease
anxiety; however, sedative drugs should be avoided if tracheal
obstruction is suspected.
• Large bore intravenous cannulae should be inserted and crossmatched blood should be available
• If the patient is asymptomatic, preoxygenation followed by
intravenous induction of anaesthesia can be performed.
• In the presence of respiratory obstruction, an awake intubation
under local anaesthetic is the technique of choice.
• This allows the entire anaesthetic and surgical team to
view the exact level of obstruction and the endotracheal
tube is passed distal to obstruction.
• In a more distal obstruction (carinal level), a rigid
bronchoscope should be available for low-frequency jet
ventilation.
• An inhalation induction may be used, followed by
intubation of the trachea under deep anaesthesia.
• The patient is placed in a 20° head-up position to reduce
venous congestion.
• Surgical access is improved by resting the shoulders on
a sandbag and the head on a head ring.
• An intravenous anaesthetic agent, inhalational
anaesthetic agent, or both, together with a
neuromuscular blocking agent and a bolus or continuous
infusion of a short-acting opioid will allow an adequate
level of anaesthesia and rapid postoperative recovery.
• Ventilation of both lungs through a single-lumen
endotracheal tube is usually adequate
• A reinforced tube is preferred to minimize the risk of the
tube kinking during surgery.
• With a long-standing mass, fibreoptic endoscopy should
be performed prior to extubation to rule out
tracheomalacia.
• Patients should only be extubated after full recovery of
reflexes and neuromuscular function;
• A short period of postoperative ventilation may be
required
• Local anaesthetic infiltration of the wound, superficial
cervical plexus and intercostal nerve blocks aid
postoperative analgesia.
• Postoperatively, a chest X-ray should be taken in all
patients in the recovery room to exclude pneumothorax.
• Patients should be observed specifically for dyspnoea
and stridor.
Monitoring
• Invasive arterial blood pressure monitoring is preferred for the early
detection of reflex arrhythmias and compression of major vessels
with mediastinoscope.
• This should preferably be sited in the right arm for detection of
brachiocephalic compression
• Alternatively, the pulse oximeter probe should be placed on the right
hand.
• Neuromuscular monitoring is mandatory in patients with myasthenia
gravis and Eaton–Lambert syndrome.
• The ventilator pressure gauge should also be observed to note any
acute increase in airway pressure, which indicates tracheal or
bronchial compression by the mediastinoscope.
Risks
• Hemorrhage
• Pneumothorax
• Recurrent laryngeal nerve injury, causing hoarseness
• Infection
• Tumor implantation within the wound
• Phrenic nerve injury
• Esophageal injury
• Chylothorax
• Air embolism
• Transient hemiparesis
THANX!!