Anesthesia for Bronchoscopy and VATS

• Common thoracic procedures require careful anesthetic management, with attention to ventilation, positioning, and potential complications.

Bronchoscopy & Endobronchial Ultrasound (EBUS)

• Can be performed under awake or general anesthesia with various airway options like LMA or ETT.
• Ventilation can be spontaneous, apneic oxygenation, positive pressure, or jet ventilation.
• Either an oral or nasal approach can be utilized.
• TIVA or VA can be used, along with anticholinergics.
• Standard monitoring is required, but ETCO₂ monitoring can be challenging.
• Protect the patient's teeth and eyes during the procedure.
• If a laser is used, keep FiO₂ below 30% to reduce fire risk.

Video-Assisted Thoracoscopic Surgery (VATS)

• VATS is a minimally invasive technique.
• Useful for diagnosing and managing pleural disease, pulmonary nodules, and interstitial lung disease, as well as performing lobectomies and spine surgery.
• Patients are positioned in lateral decubitus.
• Can be performed under local, regional, or general anesthesia.
• Ventilation options include one-lung ventilation (OLV) or two-lung ventilation (TLV).
• High FiO₂ may be needed to overcome shunt from pneumothorax.
• Chest tube placement is common post-operatively.

Lung Lobectomy

• Involves the surgical removal of a lung lobe via open thoracotomy or VATS.
• General anesthesia with OLV is typically used.
• Patient positioning is lateral decubitus.
• A posterolateral thoracotomy incision is made.
• Post-operative analgesia is provided via thoracic epidural or paravertebral block.
• Standard monitoring plus arterial line is required.
• Pancoast tumors, carcinomas of the superior sulcus, can compress nearby structures, and sleeve lobectomy, usually for bronchogenic carcinoma, may require resection of major vessels and heparinization.

Pneumonectomy

• The surgical removal of an entire lung.
• Used as curative treatment for lesions involving the mainstem bronchus or extending to the hilum.
• General anesthesia with OLV is required.
• Patient positioning is lateral decubitus.
• A posterolateral thoracotomy incision is made.
• Right pneumonectomy has a higher 30-day mortality due to greater loss of lung tissue.
• Extrapleural pneumonectomy may include removal of lymph nodes, pericardium, diaphragm, parietal pleura, and chest wall.
• Sleeve pneumonectomy is used for tumors involving the proximal mainstem bronchus or carina, usually on the right side.
• Post-pneumonectomy pulmonary edema is a common complication.

Mediastinoscopy

• Indicated for mediastinal masses in the anterior/superior mediastinum.
• Airway obstruction is the most feared complication.
• Tracheobronchial compression typically occurs distal to the ETT.
• If pre-op supine dyspnea or cough is present, there's a high risk for obstruction on induction.
• Avoid muscle relaxants until the ability to ventilate is confirmed.

Thymectomy for Myasthenia Gravis

• Myasthenia Gravis (MG) is a disease of the neuromuscular junction (NMJ) with decreased acetylcholine receptors.
• Patients with MG are resistant to succinylcholine and sensitive to non-depolarizing neuromuscular blockers (NDNMBs).
• Surgical approaches include full or partial sternotomy and video-assisted thoracoscopic surgery (VATS).
• Risk factors for needing post-operative ventilatory support include disease duration > 6 years, chronic respiratory illness, daily pyridostigmine dose > 750 mg/day, and vital capacity (VC) < 2.9 L.

Esophageal Surgery

• Common indications include tumors, GERD, and motility disorders.
• Treatment goals can be curative or palliative.
• Pulmonary aspiration risk should be addressed with premedications like metoclopramide, sodium citrate, or a proton pump inhibitor (PPI); rapid sequence induction (RSI) may be required.
• Scleroderma can be associated with kidney, heart, and lung disease.
• Lung isolation with a double-lumen tube (DLT) is necessary if thoracoscopy or thoracotomy is required.
• Exercise caution with esophageal bougie placement.

Anesthetic management for common thoracic procedures like bronchoscopy and VATS requires careful ventilation, positioning, and monitoring. Bronchoscopy can be performed under awake or general anesthesia. VATS is a minimally invasive surgery useful for diagnosing and managing pleural and lung disease.