Table 1.

Anesthesia for advanced guided bronchoscopy

	Step	Considerations	Recommendations
1	Preprocedure	Recruit lung volume, assess tolerance to higher PEEP, and prevent atelectasis	Perform incentive spirometry
2	Preoxygenation	Avoid absorption atelectasis	Modest FiO2 (0.6 to 0.8) as tolerated
3	Anesthesia type	Need for a completely motionless patient	TIVA with propofol and muscle paralysis
4	Intubation	Enable gas passage past the bronchoscope with the least increase in circuit pressure	Use a larger endotracheal tube (usually ≥ 8.5, but as guided by patient anatomy)
		Minimize atelectasis by avoiding traditional rapid-sequence intubation (i.e., avoid FiO2 of 1.0 and Suxamethonium)	Perform an expeditious intubation using non-depolarizing muscle relaxants
5	Post-intubation	Reverse any induction-related atelectasis and assess hemodynamic stability during higher PEEP	Conduct up to 4 recruitment maneuvers as tolerated
			Maintain FiO2 at the lowest tolerable level
		Maintain optimal lung inflation	PEEP of up to 10–12 cm H2O for upper lobe biopsies, consider higher PEEP for lower lobe lesions or obese patients
			An increase in tidal volumes may be considered
6	Breath-hold: timing	Reduce motion artifact	Breath-hold at peak inspiration (end of a normal tidal breath)
	Breath-hold: pressure	Maintain a constant circuit pressure and PEEP and reduce diaphragmatic movement	Manually adjust APL valve to maintain circuit pressure at desired PEEP level
	Breath-hold: duration	To minimize lung movement during imaging, allow time for pressure to equilibrate	Maintain breath-hold for 5–10 s before beginning imaging sweep
7	Biopsy	Ensure consistent settings between imaging and biopsy	Maintain settings at the same levels as Step 6
8	Post-procedure	Exclude pneumothorax and assess any residual atelectasis	Routine reversal and post-procedure methods. Perform chest X-ray

APL adjustable pressure-limiting valve, FiO₂ fraction of inspired oxygen, PEEP positive end-expiratory pressure, TIVA total intravenous anesthesia