100%, enabling prolonged jet ventilation without the risks of airway mucosal dryness and necrosis or damage to ciliary function. In addition, the mechanical jet ventilator has two alarms to protect against barotrauma and will discontinue ventilation if the set maximum airway pressure limit is reached.

Postprocedure Care

After interventional bronchoscopic procedures, patients should be transported to a standard designated recovery area with well-trained nursing staff. The recovery unit is generally equipped with wall oxygen, vital signs monitors, crash carts, and emergency intubation equipment. In patients who have undergone general anesthesia or who remain deeply sedated at the end of the procedure, supplemental oxygen should be continued via a face mask or a nasal cannula and weaned off gradually. Patients should be observed until they meet discharge criteria (i.e., for 30–45 min). Residual muscle relaxation or postprocedure respiratory failures for a variety of reasons are possible complications that may require intubation, unplanned hospital stay, and/ or likely ICU admission.

Upon discharge, all patients should be advised in writing and verbally not to drive, sign legally binding documents, or operate machinery for 24 h after the procedure. The patient should be accompanied home by a responsible adult.

Special Consideration

Anesthesia for Peripheral Diagnostic and Therapeutic Bronchoscopy

Several modalities have emerged to enable the bronchoscopist to reach peripheral lung nodules. These modalities require image guided navigation such as augmented fuoroscopy, electromagnetic navigation (ENB), radial endobronchial ultrasound (rEBUS), cone-beam computed tomography (CBCT), and most recently robotic bronchoscopy [39]. Preprocedural CT imaging is generally required to map the location of lesions and plan the navigation path. It has been noted

that the preprocedural CT images performed in an awake spontaneously ventilating patient do not mirror the imaging of the lung while the patient is under general anesthesia with muscle paralysis and mechanical ventilation. This divergence between the awake spontaneous ventilation versus asleep mechanical ventilation image has resulted in dif culty reaching the lesion and poor biopsy yield. The proposed mechanism of this divergence is the occurrence of atelectasis in the dependent areas of the lung within a few minutes of induction of general anesthesia. Additionally, suctioning of the airway secretions and installation of local anesthetic or normal saline in the airway during bronchoscopy can add to the severity of the atelectasis [40]. Noteworthy, patients with high body mass index were found to have increased risk of atelectasis. Peripheral lesions within an area of atelectasis become concealed by the surrounding collapsed lung and the airways leading to the lesion become distorted, narrowed, and shortened making the navigation dif cult [41]. The following recommendations have been described to combat the atelectasis occurring under general anesthesia and closing the gap between awake versus asleep lung radiographic images in patients with posterior or lower lobe lesions as well as obese patients undergoing peripheral bronchoscopy [42].

––Preprocedural incentive spirometry especially in obese patients.

––Preoxygenation with 80–60% fractional inspired oxygen (FiO2).

––Induction and maintenance of anesthesia with muscle paralysis.

––Postintubation lung recruitment maneuvers,

e.g., PEEP of 40 cmH2O for 40 s (adjust level and duration of PEEP to the patient’s hemodynamic tolerance as high peep of long duration causes lung hyperinfation, decrease in the venous return, and cardiac output with resultant hypotension and possibly bradycardia due to a vagal refex).

––During intraprocedural imaging requiring breath hold, the anesthesia ventilator should be set to manual mode at the peak inspiration