A Blueprint for Success: A Multidisciplinary Approach to Clinical Operations Within a Bronchoscopy Suite.

Building an efficient facility for advanced bronchoscopic procedures involves many considerations. This review places particular emphasis on anesthesiology services, based on experience at a tertiary/quaternary care referral academic medical center. Topics include equipment requirements, applicable clinical standards, and multidisciplinary collaboration. Patient flow arrangements for both outpatients and inpatients, from preoperative care to discharge/disposition, are highlighted. The importance of effective business planning, personnel training, leadership, communication, team building, quality of care, and patient safety are also discussed.

Updates and controversies in anesthesia for advanced interventional pulmonology procedures.

PURPOSE OF REVIEW: Advanced bronchoscopic procedures continues to grow, and are now commonly used to diagnose and/or treat a variety of pulmonary conditions that required formal thoracic surgery in past decades. Pharmacologic developments have provided new therapeutic options, as have technical advances in both anesthesia and interventional pulmonology. This review discusses technical and clinical issues and advances in providing anesthesia for advanced bronchoscopic procedures. It also discusses some controversial issues that have yet to be fully resolved. RECENT FINDINGS: We discuss anesthetic considerations for new procedures such as the new technology used in electromagnetic navigation bronchoscopy, and bronchoscopic cryotherapy. We also review new ventilation strategies as well as pharmacologic advances and recent trends in the utilization of anesthetic adjuvants, and the use of short-acting opioids like remifentanil, and alpha agonist sedatives such as dexmedetomidine. SUMMARY: The anesthetic framework and the discussions presented here should help forge effective communication between the interventional pulmonologist and the anesthesiologist In the Bronchoscopy Suite nonoperating room anesthesia with the goal of enhancing patient safety.

Recent trends in airway management.

Clinical airway management continues to advance at a fast pace. To help update busy anesthesiologists, this abbreviated review summarizes notable airway management advances over the past few years. We briefly discuss advances in video laryngoscopy, in flexible intubation scopes, in jet ventilation, and in extracorporeal membrane oxygenation (ECMO). We also discuss noninvasive ventilation in the forms of high-flow nasal cannula apneic oxygenation and ventilation and nasal continuous positive airway pressure (CPAP) masks. Emerging concepts related to airway management, including the physiologically difficult airway and lower airway management, new clinical subspecialties and related professional organizations such as Anesthesia for Bronchoscopy, the Society for Head and Neck Anesthesia, and fellowship training programs related to advanced airway management are also reviewed. Finally, we discuss the use of checklists and guidelines to enhance patient safety and the value of large databases in airway management research.

Combined Use of a Fiberscope and Fuji Uniblocker for Removal of Retained Bronchial Tissue Glue After Repair of a Disrupted Left Main Bronchus.

We describe the novel combined use of a fiberoptic bronchoscope and a Fuji Uniblocker placed outside the endotracheal tube (ETT) for removal of a retained BioGlue polymerized tissue fragment (2.8 × 0.8 cm) from the right main bronchus (RMB). The patient was a trauma victim who presented with a diffuse axonal injury, cervical spine and maxillofacial injuries, and a flail chest, and the procedure we describe took place following the surgical repair of a disrupted left main bronchus. Endoscopic retrieval using different sizes of grasping forceps and a Dormia basket failed to remove the foreign body (FB). Under combined GlideScope videolaryngoscopic and bronchoscopic guidance, a 9.0 F Uniblocker was introduced outside the ETT, placed into the RMB beyond the FB, initially inflated, and then gradually increased in volume during withdrawal from the RMB into the trachea so as to trap the FB between the tip of the ETT and the blocker balloon. The ETT, bronchoscope, blocker catheter, and the FB were then removed from the glottis as a single unit. The FB was then removed using Magill forceps with the aid of a GlideScope. We conclude that the combined use of a GlideScope, bronchoscope, and an Uniblocker placed outside the ETT can be an effective method for removal of a retained FB.

Color spectrographic respiratory monitoring from the external ear canal.

The need for simple and reliable means of respiratory monitoring has existed since the beginnings of medicine. In the present study, we describe the use of color spectrographic analysis of breathing sounds recorded from the external ear canal as a candidate technology to meet this need. A miniature electret microphone was modified with the addition of an adapter to allow it to be placed comfortably in the external ear canal. The amplified signal was then connected to a real-time color spectrogram program running on a laptop personal computer utilizing the Windows operating system. Based on the results obtained, we hypothesize that the real-time display of color spectrogram breathing patterns locally or at a central monitoring station may turn out to be a useful means of respiratory monitoring in patients at increased risk of respiratory depression or other respiratory problems. Finally, we conducted a statistical analysis that suggests that significant spectrogram differences may exist among some groups investigated in the study.

The association between preinduction arterial blood pressure and postoperative cardiovascular, renal, and neurologic morbidity, and in-hospital mortality in elective noncardiac surgery: an observational study.

BACKGROUND: The association between preinduction blood pressure (BP) and postoperative outcomes after noncardiac surgery is poorly understood. Whether this association depends on the presence of risk factors for poor cardiovascular outcomes remains unclear. Accordingly, we evaluated the association between preinduction BP and its different components; isolated systolic hypertension (ISH) and wide pulse pressure (WPP), and postoperative complications in patients with and without revised cardiac risk index (RCRI) components. METHODS: We analysed consecutive patients undergoing elective noncardiac surgery at Cleveland Clinic. Separate analyses were undertaken for patients with and without any RCRI components. Preinduction BP was assessed both continuously and according to hypertension stages. Logistic regression was used to assess the association between the BP values and composite of in-hospital mortality as well as cardiovascular, renal, and neurologic morbidity. We considered the following potential confounding factors in our analysis; year of surgery, age, sex, race, BMI, and American College of Cardiology/American Heart Association surgical procedure risk classification. RESULTS: Of 58 276 patients, 10 512 had one or more RCRI components. For those with no RCRI, no significant relationship was found between preinduction BP and outcome after adjustment for confounders. For patients with RCRI, the adjusted incidence was the greatest among those with normal preinduction SBP and DBP of less than 70 mmHg. Among patients with preinduction DBP greater than 75 mmHg, risk rose slightly with increasing SBP. However, we found no association between preinduction hypertension stages, ISH, or WPP and the composite outcome in patients with and without RCRI. CONCLUSION: Preinduction low DBP less than 70 mmHg or SBP greater than 160 mmHg and not ISH, nor WPP were associated with an increased risk of postoperative complications in noncardiac surgery patients with one or more RCRI components.

Analysis of central venous pressure (CVP) signals using mathematical methods.

Central venous pressure (CVP) is an important clinical parameter for physicians but only the absolute CVP value is typically monitored in the intensive care unit (ICU). In this study, we propose a novel mathematical method to present and analyze CVP signals. A total of 44 suitable samples were chosen from a total of 65 collected in an ICU. Pre-processing of the samples included rate reduction and digital filtering. The statistical features of time and frequency domain, wavelet, and empirical mode decomposition of these signals were extracted. We found no significant difference among the CVP signals regarding sex, smoking, coronary disease, and respiration mode of the samples.

Dexmedetomidine suppresses intractable hiccup during anesthesia for cochlear implantation.

We report on the successful use of dexmedetomidine to treat persistent intractable hiccup in a child who underwent cochlear implantation under sevoflurane-fentanyl anesthesia.

A multi-channel acoustics monitor for perioperative respiratory monitoring: preliminary data.

This study pertains to a six-channel acoustic monitoring system for use in patient monitoring during or after surgery. The base hardware consists of a USB data acquisition system, a custom-built six-channel amplification system, and a series of microphones of various designs. The software is based on the MATLAB platform with data acquisition drivers installed. The displayed information includes: time domain signals, frequency domain signals, and tools to aid in the detection of endobronchial intubation. We hypothesize that the above mentioned arrangement may be helpful to the anesthesiologist in recognizing clinical conditions like wheezing, bronchospasm, endobronchial intubation, and apnea. The study also evaluated various types of microphone designs used to transduce breath sounds. The system also features selectable band-pass filtering using MATLAB algorithms as well as a collection of recordings obtained with the system to establish what respiratory acoustic signals look like under various conditions.

Tips and Troubleshooting for Use of the GlideScope Video Laryngoscope for Emergency Endotracheal Intubation.

Video laryngoscopy (VL) is still a relatively novel advancement in airway management that offers many potential benefits over direct laryngoscopy. These advantages include decreased time to intubation in difficulty airways, unique opportunities in teaching as the video screen allows for real time teaching points, increased first pass success, particularly with novice operators, and decreased cervical spine motion during intubation. Despite the advantages, the intubation procedure itself has some subtle but significant differences from direct laryngoscopy that change the expected motion as well as troubleshooting techniques, which might discourage the use of the GlideScope by practitioners less familiar with the product. With the hope of generating confidence in the video laryngoscopy procedure, we have compiled some basic tips that we have found helpful when intubating with the GlideScope. These tips include inserting the blade to the left of midline to improve space allowed for the endotracheal tube itself, backing the scope up a small amount to improve the view, holding the tube close to the connector to improve maneuverability, and withdrawing the tube with your thumb to improve advancement through the cords. We hope that, with these tips, in conjunction with ample practice, clinicians can gain comfort and experience with all the tools at our disposal in an effort to provide the best possible care for our patients.

Airway anesthesia: theory and practice.

Topical anesthesia of the airway is a necessary for awake intubation and is usually achieved using lidocaine delivered by various means. Although some experts favor the use of airway blocks, a more common approach is to use pure topical methods in combination with "spray as you go" techniques. Once the topicalization is complete, the patient should be able to easily tolerate the use of an oral airway used to facilitate awake oral intubation. Nasal intubation requires additional topicalization of the nasal passages in conjunction with a vasoconstrictor. Finally, judicious sedation is frequently used when awake intubation is carried out.

An update of the role of renin angiotensin in cardiovascular homeostasis.

The renin angiotensin system (RAS) is thought to be the body's main vasoconstrictor system, with physiological effects mediated via the interaction of angiotensin II with angiotensin I receptors (the "classic" RAS model). However, since the discovery of the heptapeptide angiotensin 1-7 and the development of the concept of the "alternate" RAS system, with its ability to reduce arterial blood pressure, our understanding of this physiologic system has changed dramatically. In this review, we focus on the newly discovered functions of the RAS, particularly the potential clinical significance of these developments, especially in the realm of new pharmacologic interventions for treating cardiovascular disease.