Journal of Bronchology
8:36–43 © 2001 Lippincott Williams & Wilkins, Inc., Philadelphia
Review
Anesthetic Considerations for Bronchoscopic Procedures in
Patients with Central-Airway Obstruction
Jay B. Brodsky, M.D.
Downloaded from https://journals.lww.com/bronchology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD36tKOuhuKL2xDPV1/zCj3ZjknDQDt5KYKyk4N8uOEPaIH6oWe55czvA== on 02/20/2020
Department of Anesthesia, Stanford University School of Medicine, California, U.S.A.
Abstract: Symptomatic obstruction of the central airways
(trachea, carina, main bronchi) can be relieved by a variety
of bronchoscopic interventions. This review focuses on the
anesthetic considerations for these procedures including Nd-
YAG laser ablation, balloon dilation, cryotherapy, photody-
namic therapy, brachytherapy, and airway stenting in patients
with central airway stenosis. Key Words: Anesthesia—
Symptomatic obstruction of the central airways (tra-
chea, carina, main bronchi) can be the result of a variety
of benign and malignant processes (Table 1).
Bronchoscopic interventions to relieve central-airway
obstruction include surgical resection or core-out, Nd-
YAG laser ablation, balloon dilation, brachytherapy,
cryotherapy, photodynamic therapy, and airway stent-
ing.1 This review focuses on airway management during
bronchoscopic procedures for central-airway obstruction.
ANESTHESIA FOR
BRONCHOSCOPIC PROCEDURES
Preoperative Evaluation
Every patient must have a full preoperative medical
assessment. Pertinent information is obtained from the
medical history, physical examination, discussions with
the endoscopist, diagnostic imaging studies, and pulmo-
nary function testing. The foremost concern is the nature
and degree of the airway disease. Many patients have had
serial procedures, and past medical records can provide
information about airway access, previous anesthetic
management strategies, and complications. It is impor-
Address reprint requests to Dr. Jay B. Brodsky, Department of An-
esthesia, Stanford University School of Medicine, Stanford, CA 94305
U.S.A; e-mail: Jbrodsky@leland.stanford.edu
36
Techniques—Ventilation equipment—Bronchoscopy—Flexi-
ble—Rigid
Journal of Bronchology 8:36–43, 2001.
ETT, endotracheal tube; FFB, flexible bronchoscope;
HFJV, high-frequency jet ventilation.
tant to note what size endotracheal tube (ETT) and bron-
choscope have been used for prior procedures.
Patients may be experiencing respiratory distress with
dyspnea, coughing, and wheezing. Inspiratory stridor
suggests extrathoracic airway obstruction whereas expi-
ratory stridor may be the result of intrathoracic obstruc-
tion. Many patients also have underlying acute and
chronic pulmonary disease. Bronchospasm and other re-
versible lung conditions should be treated before bron-
choscopy.
Potential problems with tracheal intubation must be
evaluated. No single test is completely accurate in pre-
dicting intubation difficulties. Many attempts have been
made to identify risk factors.2,3 Patients in whom the
posterior pharyngeal wall cannot be visualized below the
soft palate and who have a short neck are usually more
difficult to intubate than patients with normal anatomy.4
The ability to open the mouth adequately and to extend
the neck fully may also determine the ease of tracheal
intubation and whether a rigid bronchoscope or a flexible
bronchoscope (FFB) can be used for the procedure.
The location, size, and extent of the mass and/or the
degree of airway obstruction should be established accu-
rately preoperatively if possible. Conventional radiogra-
phy may not be accurate. Chest computed tomography
and/or magnetic resonance studies should be performed.5
This information can help determine what size ETT to
 ANESTHESIA FOR BRONCHOSCOPIC AIRWAY PROCEDURES 37

TABLE 1. Causes of central-airway obstruction Many patients with a malignancy may have undergone
Benign
chemotherapy or radiation therapy. These therapies may
Congenital be associated with systemic toxicity, cardiomyopathy,
Vascular pulmonary damage, and additional alteration of airway
Vascular rings
Dilated aorta
anatomy.
Enlarged thymus
Enlarged thyroid Premedication
Tracheogenic cyst
Tracheal stenosis Sedative premedication should only be considered for
Tracheomalacia the very anxious patient because of the potential for hy-
Acquired poventilation and additional airway compromise. Pa-
Traumatic
Complication of tracheal intubation/tracheostomy tients with marked airway obstruction should not be se-
Burn/smoke injury dated or left alone in an unmonitored environment.
Airway hematoma An anticholinergic drying agent (atropine, glycopyr-
Anastomotic
Lung transplantation rolate) may be helpful, especially in the presence of ex-
Sleeve resection of trachea or bronchus cessive airway secretions which can impair the effective-
Inflammatory ness of topical anesthesia. A drying agent reduces the
Wegener’s Granulomatosis
Relapsing Polychondritis need for frequent suctioning during the procedure. This
Amyloidosis is important because suctioning may interfere with gas
Infectious exchange, causing hypoxemia.
Tuberculosis
Papillomas
Rhinoscleroma Monitoring
Viral tracheobronchitis
Bacterial tracheitis Whenever bronchoscopy is performed under general,
Other regional, or monitored anesthetic care, the American So-
Aortic aneurysm ciety of Anesthesiologists standards require that quali-
Retrosternal goiter
Lymphadenopathy fied anesthesia personnel be present to monitor continu-
Malignant ously oxygenation, ventilation, circulation, and tempera-
Intraluminal obstruction ture (Table 2).
Extraluminal compression

TABLE 2. American Society of Anesthesiologists standards for

basic monitoring
use, how far that tube may be safely advanced, or wheth-
er an ETT can be used at all. Standard 1
Qualified anesthesia personnel shall be present in the room
A dynamic flow–volume loop study can differentiate throughout the conduct of all general anesthetics, regional, and
between variable or fixed intra- and extrathoracic airway monitored anesthesia care.
obstructions. With a variable extrathoracic obstruction Standard 2
Oxygenation, ventilation, circulation, and temperature shall be
there is flow limitation and a plateau during inspiration, continually evaluated.
whereas with a variable intrathoracic obstruction the re- 1. Oxygenation
verse occurs and there is limitation of airflow during Oxygen analyzer for inspired gases
Observation of the patient
expiration.6 With a fixed intra- or extrathoracic obstruc- Pulse oximetry
tion (e.g., tracheal stenosis), the plateau and limitation of 2. Ventilation
airflow is seen in both the expiratory and inspiratory Auscultation of the lungs
Observation of the patient
flow–volume loops. This information is important to the Observation of the reservoir bag
anesthesiologist because the nature of the airway ob- End-tidal carbon dioxide or transcutaneous carbon dixoide
struction may determine the method of anesthesia induc- analysis
3. Circulation
tion and airway management. Continuous ECG monitoring
Spirometric testing may also be helpful in assessing Heart rate and blood pressure recorder every 5 minutes
pulmonary function as well as the ability to reverse bron- Auscultation of heart sounds, palpation of pulse, pulse
plethysmography, pulse oximetry, intra-arterial pressure
chospasm pharmacologically. If possible, an arterial tracing
blood gas reading with the patient breathing room air 4. Temperature
should be obtained. The presence of arterial hypoxemia Core temperature and/or skin temperature
and hypercarbia increases the likelihood of anesthetic Practice Standard from the American Society of Anesthesiologists,
management problems during or after the procedure. Park Ridge, IL.

Journal of Bronchology, Vol. 8, No. 1, January 2001

38 J. B. BRODSKY
Anesthetic Induction
The method of achieving airway control depends on
the nature of the patient’s airway disease. One can pro-
ceed with an “awake” intubation under topical anesthe-
sia, an inhalation anesthetic induction preserving spon-
taneous ventilation, or a routine induction using intrave-
nous agents and a muscle relaxant to facilitate ETT
placement.
One must always be careful when advancing the ETT
down the trachea because it can cause bleeding and ag-
gravate an intraluminal obstruction. Fiberoptic intubation
and placement of the ETT under direct vision is the
technique of choice for many patients with central air-
way lesions.
An inhalation anesthetic induction with the patient
breathing sevoflurane can avoid the need for a muscle
relaxant and is indicated in patients with a variable in-
trathoracic obstruction caused by an anterior mediastinal
mass. For fixed obstructions, an intravenous anesthetic
induction using muscle relaxants is more appropriate.
The special anesthetic considerations for patients with
anterior mediastinal tumors are reviewed elsewhere.7
Choice of Anesthetic
Bronchoscopy normally poses special problems for
the anesthesiologist because the airway must be shared
with the endoscopist. These problems are magnified in a
patient with an obstructed airway. The endoscopist re-
quires good visibility and adequate space for instru-
ments, whereas the anesthesiologist is concerned about
gas exchange and hemodynamic stability. The diversity
of anesthetic techniques used for these procedures means
that no single technique meets all requirements for all
patients.
Local anesthesia plus intravenous sedation is often
used but may be a poor choice if patient movement could
jeopardize the procedure. Many procedures require an
immobile field for precise airway measurement or for
accurate direction of a laser beam. The need for the pa-
tient to be completely still mandates general anesthesia
and often the use of a muscle relaxant. Short-acting neu-
romuscular relaxants (succinylcholine, mivacurium)
should be used, and paralysis must be fully reversed
before tracheal extubation.8
Many general anesthetic techniques combine inhala-
tional and intravenous agents. All commonly used inha-
lation anesthetic agents (halothane, isoflurane, sevoflu-
rane, desflurane) have bronchodilatory effects that may
be helpful because of the frequent presence of reactive
airway disease. Intravenous agents (barbiturates, propo-
fol, opioids, ketamine) can maintain anesthesia during
Journal of Bronchology, Vol. 8, No. 1, January 2001
suctioning, bronchial dilatation, or stenting when venti-
lation with an inhalational agent is interrupted. Whatever
anesthetic technique is used, a fast-acting intravenous
agent should be available in case the patient moves. Only
short-acting opioids (remifentanil, alfentanil) should be
used. Because there is minimal pain after these proce-
dures and postoperative respiratory depression is danger-
ous, long-acting opioids (morphine, Dilaudid, meperi-
dine) are avoided.
Once the trachea is intubated there is the possibility
that the airway distal to the ETT can collapse or remain
obstructed. A rigid bronchoscope should always be avail-
able to reestablish a patent airway.
Method of Ventilation
Several techniques can be used for ventilation during
rigid and flexible bronchoscopy, including spontaneous
breathing, intermittent positive-pressure ventilation, use
of the Sanders injection system, and high-frequency jet
ventilation (HFJV).9 For FFB, intermittent positive-
pressure ventilation through an ETT is the usual choice.
The FFB is placed through the self-sealing diaphragm of
a bronchoscope adaptor attached to the ETT. The FFB
within the ETT reduces the available cross-sectional area
and increases resistance to gas flow. An ETT with an
internal diameter of at least 8.0 mm is required for adults.
The rigid ventilating bronchoscope incorporates a
side-arm adaptor that is attached to the anesthetic breath-
ing system. Occlusion of the proximal end of the bron-
choscope with an eyepiece allows controlled ventilation
through the lumen of the bronchoscope. There is always
a gas leak around the bronchoscope, and ventilation is
interrupted whenever the eyepiece is removed. Contin-
ued ventilation with an anesthetic agent while the eye-
piece is removed will result in gas inhalation by the
endoscopist.
HFJV allows uninterrupted ventilatory support during
rigid bronchoscopy. High-frequency positive-pressure
ventilation through catheters with internal diameters as
small as 2.0 mm can provide safe levels of oxygenation
as long as an adequate expiratory passage is present.10 A
technique using a 14-Fr nasal insufflation catheter with
HFJV to avoid an ETT has been used for FFB placement
of tracheal stents.9 In cases of tracheal obstruction, the
HFJV catheter is placed beyond the stenosis.
The Sanders technique uses the Venturi principle to
deliver positive-pressure ventilation through an open
rigid bronchoscope. Intermittent bursts of high-pressure
oxygen are delivered through a cannula attached to the
proximal end of the bronchoscope. The jet of oxygen
entrains large volumes of room air, and adequate tidal
 ANESTHESIA FOR BRONCHOSCOPIC AIRWAY PROCEDURES
volumes can be achieved. This technique is particularly
useful because it allows the endoscopist to work through
the open rigid bronchoscope without interruptions of
ventilation. PaCO2 levels are generally acceptable, and
adequate oxygenation is maintained.11
Emergence
Bronchoscopic airway procedures require that the pa-
tient remain adequately anesthetized until the very end of
the procedure. The time required for the return of airway
reflexes, complete reversal of muscle relaxant, and emer-
gence from anesthesia depends on the agents used and
the duration of the anesthesia.
Airway patency may actually worsen as the patient
recovers from anesthesia. Edema in the upper airway
may manifest itself once the bronchoscope is removed.
During emergence, coughing may increase bleeding. If a
rigid bronchoscope has been used, a decision must be
made whether to replace it with an ETT.
At the completion of the procedure the patient should
be fully awake. If the patient is obtunded and not breath-
ing adequately, or if the airway has been traumatized and
airway patency is a concern, the trachea should remain
intubated. A tube exchanger can be placed in the trachea
through the rigid bronchoscope or the ETT before extu-
bation. If reintubation becomes necessary, the tube
changer is used as a guide for placement of a new ETT.12
Although most patients have their trachea extubated at
the completion of the bronchoscopic procedure, the an-
esthesiologist must be prepared for emergency reintuba-
tion and have all the necessary airway equipment avail-
able. The endoscopist and the bronchoscopic equipment
should also be available until the patient has fully
emerged from anesthesia and airway patency has been
ensured.
All patients should receive supplemental oxygen after
extubation, during transport to, and while in the postan-
esthesia care unit. Stridor after the procedure may require
treatment with humidified oxygen, nebulized epineph-
rine, steroids, or even reintubation.
Complications
The anesthesiologist must be prepared to deal with
complications while working in a confined, unfamiliar
environment. The complication rate depends on the op-
erator’s skill, the method of bronchoscopy, the anesthetic
technique, the condition of the patient, and the location
and extent of the tumor.13
Even in patients without airway pathology, pulmonary
function is decreased immediately after bronchoscopy.
39
The decrement in postoperative pulmonary function may
be the result of premedication with antisialagogues and
sedatives, the topical anesthetic, or the result of mechani-
cal obstruction by the lesion.14
Complications of bronchoscopy can include laryngeal
and bronchial spasm. Damage to teeth is common. Direct
trauma to the airway can cause bleeding, edema, and
tumor fragmentation. Mucosal perforation or barotrauma
may lead to subcutaneous emphysema and tension pneu-
mothorax. There is always a possibility of massive hem-
orrhage with the need for emergency thoracotomy.15 For
procedures with a very high likelihood of serious com-
plications, an operating room should be available and
prepared even when the actual procedure is performed at
a distant location such as the radiology suite.
Cardiovascular instability (hypertension, hypotension,
arrhythmias) is common. Bradycardia occurs as a vagally
mediated response to insertion of the bronchoscope but
may be avoided with the use of an anticholinergic agent.
Light anesthesia with the release of catecholamines, hyp-
oxia, and hypercapnia all contribute to arrhythmias.
Complications associated with bronchoscopic relief of
airway obstruction include hypoxemia, bleeding, bron-
chospasm, and perforation of the airway.
There may be marked resistance to ventilation from a
misplaced stent or dislodged tumor material.16 Aspira-
tion of resected material is also a possibility. A postop-
erative chest radiograph should be obtained because air-
way instrumentation carries the risk of pneumothorax or
segmental lung collapse. Delayed massive hemoptysis
may occur after any of these therapies if pulmonary ar-
tery–bronchial fistulae develop.17 A rigid bronchoscope
and equipment for tracheostomy or cricothyroidotomy
should be readily available for airway emergencies.
SPECIAL PROCEDURES FOR
CENTRAL-AIRWAY OBSTRUCTION
Airway Stenting
A metal or silicone rubber stent in the trachea or bron-
chus can be an effective means of providing structural
support for select patients with intraluminal obstructions,
malacia, or extrinsic airway compression.16 Successful
stenting can provide immediate, symptomatic relief of
life-threatening dyspnea.
Airway stents are particularly useful after pulmonary
transplantation complicated with graft rejection or infec-
tion,18 after tracheobronchial injury,19 and for intrinsic
tumors of the airways.20 Stenting procedures can be per-
formed in adults and children.21 Although alternative
Journal of Bronchology, Vol. 8, No. 1, January 2001
40 J. B. BRODSKY
therapies (balloon dilation, Nd-YAG laser ablation,
brachytherapy, cryotherapy) can be used for intrinsic ob-
structions, only stenting is effective for malacia and ex-
trinsic airway compression. Stents are also used for
esophageal airway fistulae.
Most patients experience immediate symptomatic im-
provement. Mean forced vital capacity, mean peak expi-
ratory flow, mean forced expiratory volume in 1 second,
and PaO2 all increase after successful stent place-
ment.22,23 Patients with airway obstructions requiring
ventilatory support can be separated from the ventilator
and have their trachea extubated after the stenting pro-
cedure.24,25
Expandable metal stents are easier to insert and have a
wider internal lumen than silicone stents. Metal stents do
not impair the drainage of sputum because ciliary move-
ment is not interrupted. Expandable metal stents are in-
dicated for unresectable malignant airway disease be-
cause, once placed, they are considered permanent. Be-
cause they are so difficult to remove they are also less
likely than silicone stents to become displaced and mi-
grate distally.26 Their flexibility allows them to be bent
so they conform better to tortuous airways than rigid
silicone stents.
Over a period of just a few weeks the metal stent is
incorporated into the airway wall and its mesh becomes
covered with mucosa. Therefore, metal stents are only
temporarily effective for transbronchial stenosis result-
ing from intraluminal tumor or granulation tissue be-
cause both can eventually grow between the wire
mesh.27
A metal stent can be placed under topical anesthesia
with or without intravenous sedation. If an immobile
patient is essential for airway measurement, dilation, and
accurate stent positioning, then general anesthesia with
or without a muscle relaxant is a better choice.
Tracheostomy may not be feasible through a metal
tracheal stent. However, because the stainless steel stent
is mesh with large spaces between the wires, cricothy-
roidotomy may be possible. Stent displacement, mucus
impaction, and granulation tissue formation are potential
long-term complications.
Silicone stents are inserted via a rigid bronchoscope
under general anesthesia. They are not permanent and
can be removed or displaced easily, thus they are used in
situations when stenting is intended to be temporary. A
silicone stent can be removed when the stenosing airway
disease subsides, so they are indicated for obstruction
resulting from inflammation and infection.28 The anes-
thesiologist must be aware that the position of a previ-
ously placed silicone stent, especially one in the trachea,
may change during subsequent tracheal intubation.
Journal of Bronchology, Vol. 8, No. 1, January 2001
Nd-YAG Laser Therapy
Nd-YAG laser therapy is used for resection of airway
malignancies29 or granulation tissue.30 The laser can tun-
nel through a complete obstruction or widen a narrowed
lumen, providing immediate relief of symptoms.31
The Nd-YAG laser is conducted through a flexible
quartz monofilament that can be passed down either an
FFB or a rigid bronchoscope. The laser penetrates deeply
and destroys tissue by a coagulation–vaporization se-
quence. The Nd-YAG laser photocoagulates the margins
of the tumor, and then sections of the devascularized
tumor must be removed physically from the airway. A
continuous 3-L/min flow of air is passed simultaneously
through a co-axial Teflon sheath to cool the fiber tip and
keep it free of debris.
A rigid bronchoscope is preferred because it provides
better visibility and better suctioning conditions, and al-
lows easier retrieval of blood, mucus, and tumor de-
bris.32 A rigid bronchoscope also maintains the patency
of the airway. Unlike the FFB, a rigid metal broncho-
scope is nonflammable.33 However, the metal can reflect
a laser beam, resulting in tissue damage.
An FFB can reach distal airways beyond the reach of
a rigid bronchoscope. The Nd-YAG laser can be passed
down an FFB directly into the airway in an awake but
sedated patient. However, if the patient moves, the laser
beam can be misdirected, resulting in serious complica-
tions.
General anesthesia including a muscle relaxant is usu-
ally a better choice than topical anesthesia and intrave-
nous sedation.34 For Nd-YAG therapy, a conventional
plastic ETT with an internal diameter of at least 8.0 mm
is needed to accommodate the FFB and still allow suf-
ficient space to ventilate the lungs. The laser must be
fired beyond the tip of the tube to avoid ignition of the
tube material. Saline inflation of the airway’s cuff may
reduce the risk of fire from a misaimed laser.
It is important to avoid using nitrous oxide because
that gas supports combustion. An air–oxygen mixture
limiting the FiO2 to less than 0.4 should be used. The
problems of oxygenating a patient with severe airway
obstruction are compounded by this requirement to ven-
tilate with such a low FiO2. A premixed helium–oxygen
mixture (Heliox; 70%/30%) has been used to prevent
combustion with the carbon dioxide laser.35 In addition
to protecting against fire, helium may improve ventila-
tion beyond an obstructing airway lesion because its den-
sity is less than that of nitrogen. Helium is expensive, not
readily available, and may interfere with oxygen analyz-
ers in the system and give erroneous values.
Whichever anesthetic technique (sedation or general
 ANESTHESIA FOR BRONCHOSCOPIC AIRWAY PROCEDURES
anesthesia) is used, there is usually an increase in PaCO2
and a decrease in pH and PaO2 after Nd-YAG proce-
dures.36 Because the laser beam can pass through the
cornea and cause retinal damage, special blue–green eye-
glasses are required to protect the eyes. Some colored
anesthesia monitor displays are difficult to read with
these glasses. The patient’s eyes should be covered with
moist pads.37 The windows of the operating room or
bronchoscopy suite should be covered and there should
be a sign on the outside of the door warning that a laser
is in use. The plume (products of the tissue combustion)
released during laser resection can be noxious to breathe
or even hazardous to the health.38,39 Effective smoke
evacuation can help control deleterious effects.
With the Nd-YAG laser only the surface of the af-
fected tissue is visibly changed, but underlying edema
formation can result in additional obstruction or hemor-
rhage hours after laser therapy.40 Prophylactic dexameth-
asone or methylprednisolone is sometimes recommended
to reduce tissue swelling.
Bleeding usually is minimal and can be controlled by
epinephrine-soaked gauze pledgets. However, if the laser
strikes a vascular structure, severe hemorrhage can re-
sult.41 Major bleeding complications occur most often
when a main-stem bronchus is totally occluded. Because
the direction of the lumen is unknown, perforation of the
wall of the bronchus is more likely to occur with perfo-
ration of vessels.42 Airway perforation may result in tra-
cheo- or bronchoesophageal fistulae and pneumotho-
rax.43
Balloon Dilation of the Airway
Balloon dilation is a safe and effective palliative pro-
cedure for airway narrowing in adults,44 and for congen-
ital and acquired stenosis of the trachea and bronchi in
children.45 A balloon catheter is threaded over a guide
wire and is positioned across the stenotic airway.46,47
Under direct vision with an FFB or a rigid bronchoscope,
the balloon is inflated for 30 to 120 seconds. Repeat
inflation–deflation sequences are performed if airway
narrowing persists. Usually there is immediate improve-
ment, with an increase in airway dimensions and relief of
symptoms.47 However, improvement is usually tempo-
rary and many patients require serial dilatations, place-
ment of an airway stent, or laser therapy.46
The actual physical dilation is very stimulating, and
the patient may cough vigorously. When performed un-
der general anesthesia, either a short-acting muscle re-
laxant should be used or a rapid-acting intravenous an-
esthetic should be available to control coughing.
41
Cryotherapy
Cryotherapy is another bronchoscopic procedure for
upper airway obstruction. Benign obstructions are first
dilated with a balloon, followed by cryotherapy using
nitrous oxide as a cryogen applied through an FFB.
As an alternative to the Nd-YAG laser, cryotherapy is
inexpensive and safe for the operator and other members
present. There is no danger of bronchial wall perforation
or endobronchial fire.48
Cryotherapy is usually performed under topical anes-
thesia and conscious sedation in a bronchoscopy suite
without the presence of an anesthesiologist. The anes-
thesiologist may be called for an acute airway crisis.
Brachytherapy
Bronchoscopic brachytherapy is the direct application
of a radioactive isotope into a tumor bed within the air-
way using a bronchoscope. A highly localized dose of
radiation can be delivered to the tumor while sparing the
surrounding healthy tissue.49 Brachytherapy is effective
as a palliative treatment of dyspnea, hemoptysis, intrac-
table cough, postobstructive atelectasis, and pneumonia
from tracheal and bronchial malignancies.50 Brachy-
therapy has also been used to relieve benign airway ob-
struction from hyperplastic tissue when other interven-
tions have failed.51
Originally the radioactive source was applied directly
to the tumor through a rigid bronchoscope. Intraluminal
placement of the radioactive substance is now performed
through a polyethylene after-loading catheter using an
FFB.52
Photodynamic Therapy
Before commencing phototherapy, a hematoporphyrin
derivative is administered intravenously 3 to 5 days be-
fore the start date.53 When a laser light is shown through
an FFB, target neoplastic tissue will fluoresce. In the
presence of a sensitizer, selective photon absorption by
the tumor occurs, and the concomitant use of a laser
beam results in a chemical reaction that causes tumor cell
death whereas normal tissue is not harmed.
Combustion is not a problem, so the lungs can be
ventilated with 100% oxygen. Delayed complications as-
sociated with phototherapy include bleeding and airway
obstruction from tissue necrosis.
SUMMARY
The patient with central-airway obstruction undergo-
ing an endoscopic procedure is a challenge to the anes-
thesiologist. One must be familiar with the basics of
anesthesia for flexible and rigid bronchoscopy, and also
Journal of Bronchology, Vol. 8, No. 1, January 2001
42 J. B. BRODSKY
with the special considerations of each of the different
therapeutic interventions currently used in treating cen-
tral-airway obstruction.
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