Rigid bronchoscopy in parturient: A balancing act

Mamta Dubey; Amit K Mittal; Nitesh Goel; Jitendra Dubey

doi:10.4103/joacc.JOACC_7_17

CASE REPORT

Year : 2017 | Volume : 7 | Issue : 1 | Page : 57-59

Rigid bronchoscopy in parturient: A balancing act

Mamta Dubey, Amit K Mittal, Nitesh Goel, Jitendra Dubey
Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India

Date of Web Publication

1-Jun-2017

Correspondence Address:
Mamta Dubey
Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi - 110 085
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/joacc.JOACC_7_17

Abstract

We report a case of bronchial tumour excision in a pregnant female using a combination of rigid and flexible bronchoscope under general anaesthesia. This case report highlights the anaesthetic considerations regarding airway management of the parturient during rigid bronchoscopy and measures for preservation of utero-placental perfusion. Foetal heart rate monitoring using portable ultrasonography as a point-of-care device has been emphasised.

Keywords: Bronchial tumour, foetal Doppler, general anaesthesia, pregnancy, rigid bronchoscopy

How to cite this article:
Dubey M, Mittal AK, Goel N, Dubey J. Rigid bronchoscopy in parturient: A balancing act. J Obstet Anaesth Crit Care 2017;7:57-9

How to cite this URL:
Dubey M, Mittal AK, Goel N, Dubey J. Rigid bronchoscopy in parturient: A balancing act. J Obstet Anaesth Crit Care [serial online] 2017 [cited 2023 Feb 6];7:57-9. Available from: https://www.joacc.com/text.asp?2017/7/1/57/207396

Introduction

Comprehensive anaesthetic management of rigid bronchoscopic coring of a bronchial tumour causing mass effect in a parturient has not been reported previously. Most of the available literature highlights the incidence,^[1] etiological factors,^[2] prognostic factors,^[1] diagnostic ^[3] and therapeutic ^[4] measures of lung carcinoma in a parturient. Safe conduct of anaesthesia in a pregnant female is a perplexing task. It requires expertise in airway management, precise knowledge of pathophysiological changes due to pregnancy and altered feto-maternal pharmacokinetics and pharmacodynamics. Foetal heart rate (FHR) monitoring is also recommended before and after the procedure, if the gestation is more than 20 weeks.^[5]

Case Summary

A 21-year-old, weighing 53 kg, non-smoker, 22 weeks primigravida was referred to our institute with progressive cough of 2 months duration and occasional haemoptysis. Chest Magnetic Resonance Imaging (MRI) revealed a tumour occluding the left main bronchus with consolidated left lower lung. The tumour mass resulted in dyspnoea at rest with grossly reduced air entry in left scapular and infrascapular region. Flexible fiber optic bronchoscopy under local anaesthesia revealed tumour arising from the left lower lobe bronchus, occluding left upper lobe opening and extending up to the carina [Figure 1].

Figure 1: Rigid Bronchoscopic view, showing tumour mass (broad arrow) occupying left main bronchus while small arrow show the normal right main bronchus

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Rigid bronchoscopic removal of the tumour was planned for symptomatic relief and histopathological diagnosis for further management. Written informed consent was taken for the procedure, and perioperative ultrasonography was performed to determine the foetal well-being as there existed a risk of foetal miscarriage or preterm delivery due to bronchoscopy or anaesthesia. Preoperative ultrasonography showed a single live foetus with gestational age of 21 weeks 3 days.

Her premedication included, injection (inj.) metoclopramide 10 mg and inj. ranitidine 50 mg I.V. In the operating room, standard monitoring and bispectral index score (BIS) sensor were applied. Initial vitals were heart rate (HR) 127/min, mean arterial pressure (MAP) 58 mm Hg and SpO₂ 96%. The patient was positioned supine with left lateral tilt by placing a wedge below her right buttock. The grounding plate of electrocautery was applied behind right shoulder. Inj. glycopyrollate (antisialogouge) and inj. dexamethasone (minimize airway oedema) were given. Inj. Midazolam 1 mg was given just before onset of the procedure. Infusions of dexmedetomidine and propofol were started in the dose of 0.4 mcg/kg/h and 25 mcg/kg/min, respectively. After pre-oxygenation (5 minutes), airway was secured with rigid bronchoscope under sleep dose of Inj. propofol (total 40 mg), Inj. suxamethonium 0.5 mg/kg with cricoid pressure. Anaesthesia circuit attached to the side port of bronchoscope was used for assisted ventilation coupled with intermittent jet ventilation for adequate oxygenation. Infusions of dexmedetomidine and propofol along with sevoflurane (minimum alveolar concentration, 0.5–0.8) were titrated to maintain BIS values 40–60 and to sustain haemodynamic stability (HR 122-148/min and MAP from 50–65 mm hg). Using flexible bronchoscope through rigid bronchoscope, the tumour was cauterized (electrocautery and cryocautery) and removed piecemeal uneventfully [Figure 2]. The procedure lasted 70 minutes. Patient was awakened without any awareness with stable haemodynamics. Auscultation of chest revealed equal air entry with visible left chest expansion and Spo₂ of 98%. Post-procedural fetal Doppler ultrasonography (Micromaxx™ Ultrasound system; Sonosite Inc. Bothell, WA, USA, with convex transducer) with regular rhythm [Figure 3] at the end of the procedure.

Figure 2: Piecemeal removal of tumour mass (small arrow) with cryoprobe (Broad Arrow)

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Figure 3: Doppler scanning of Fetus showing the Fetal heart Rate trace

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Discussion

Cancer complicates 1 in 1000 pregnancies,^[1] though lung tumour is a rare entity. Until recently, less than 70 cases of lung cancer have been published in the literature of various histopathological diagnosis.^[1],[6] Non-obstetrics surgery in a pregnant patient is always challenging for the anaesthesiologist. When it involves sharing of the airway, like in rigid bronchoscopy, the difficulty is compounded. The issues that need to be addressed are maintaining adequate oxygenation as there are increased chances of hypoxia due to endobronchial bleeding, slippage or migration of tumour into normal bronchus. Cautious selection of drugs and manoeuvers to prevent acid aspiration are required to ensure maternal and fetal safety. Modification of the anaesthesia techniques are necessary, considering the physiological changes of the pregnancy like measures to counteract the low apneic threshold (reduced FRC by 20%) and prevention of aortocaval compression for a favorable feto-maternal outcome.

Safe removal of endobronchial tumours through rigid bronchoscopy requires good coordination between anaesthetist and bronchoscopist. Optimal oxygenation was maintained by combining assisted ventilation (anaesthesia circuit attached to the rigid bronchoscope) with intermittent manual jet ventilation. This allowed inhalation anaesthesia, positive pressure ventilation and assessment of adequacy of ventilation through capnography. The venturi principle of jet generates airway pressure up-to 55 cm of H₂O with driving pressure of 30 Psi, thus efficiently ventilating while generating significantly higher FiO₂ in patients with lower pulmonary compliance.^[7] Continuous suctioning of the tracheobronchial tree helped to prevent soiling of the normal bronchus by blood and tumour debris.

Dexmedetomidine and propofol infusions were titrated to maintain stable haemodynamics and keep BIS value in the anaesthetic plane to prevent awareness. The addition of sevoflurane and fentanyl boluses helped to obtund stress response, suppress postoperative cough response and bronchospasm.

The use of dexmedetomidine in parturient is off label, but several reports have shown its benefits in suppressing the neuro-humoral and haemodynamic response of the surgical stimulus.^[8]

Dexmedetomidine, a selective alpha₂-adrenoceptor agonist has high placental extraction with insignificant placental barrier transfer.^[9] In doses of 0.4–0.6 mcg/kg/min, does not affect foetal birth weight, Apgar score and post-natal behavior.^[10] These favourable effects are due to presynaptic inhibition of norepinephrine release, causing modest reduction in heart rate and MAP.^[11] Propofol and opioids also possess inhibitory effects on the sympathoadrenal system due to decreased release of catecholamine from chromaffin cells.^[12] Prevention of aortocaval compression by placing wedge underneath right buttock after 20 weeks of gestation also helps to preserve uteroplacental perfusion.^[5]

Guidelines for endoscopy in pregnant patients by the American Society Of Gastroenterologist, recommends placement of grounding plate away from pelvis, because amniotic fluid is a good conductor of electricity.^[5] If the electric current crosses the pelvis, it may cause arrhythmias in the fetus, thus we placed grounding plate behind right shoulder. Although bipolar cautery is recommended, due to technical reasons we used monopolar (can be used for hemostasis) intermittently in short bursts in tandem with cryocautery, Argon plasma coagulation is an alternative that can be used.^[3] Guidelines also recommended monitoring of FHR with Doppler, before and after the procedure, if the pregnancy is more than 20 weeks. Perioperative, FHR monitoring by Doppler ultrasonography is an indispensable tool for early diagnosis and intervention. Evidence suggests that clinicians outside radiology can be quickly skilled in limited area of ultrasonography,^[13] similarly anaesthesiologist can easily adopt foetal Doppler, in routine anaesthesia practice.

Conclusion

Debulking of symptomatic lung tumour causing mass effect, using rigid bronchoscope during pregnancy can be safely conducted by maintaining feto-maternal physiology, using prudent ventilation strategies, careful titration of pharmacological agents and ensuring foetal well-being using on table Doppler monitoring.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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