Bronchoscopy is most often performed with a fiberoptic bronchoscope that easily passes through a tracheal tube with an internal diameter of 8.0 to 8.5 mm.
Insertion of an endoscope into the thoracic cavity and pleural space is used for the diagnosis of pleural disease, effusions, and infectious diseases (especially acquired immunodeficiency syndrome) and for staging procedures and lung biopsy.
Anesthesia can be provided using local, regional, or general anesthesia depending on the expected duration of the procedure and the physical status of the patient.
If general anesthesia is required, either a single-lumen tube or a DLT may be used. Positive pressure ventilation interferes with visualization via the endoscope; therefore, a DLT is preferred.
The spontaneous partial pneumothorax that occurs when the endoscope is inserted results in improved surgical visualization. The spontaneous pneumothorax is usually well tolerated even in awake patients because the skin and chest wall form a seal around the thoracoscope and limit the degree of lung collapse.
Video-assisted thoracoscopic surgery (VATS) entails making small incisions in the chest wall, which allows the introduction of a video camera and surgical instruments into the thoracic cavity.
Anesthesia Considerations
As with traditional thoracotomy, for VATS, the patient needs to be positioned in the lateral decubitus position, and lung collapse is needed for adequate surgical exposure.
The need for OLV is greater with VATS than with open thoracotomy because it is not possible to retract the lung during a VATS as it is during an open thoracotomy.
The operated lung should be deflated as soon as possible after tracheal intubation because it may take as long as 30 minutes for complete lung collapse to occur.
Carbon dioxide insufflation into the pleural cavity to facilitate visualization. Insufflation pressures should be kept low (<5 mm Hg) because high pressures can cause mediastinal shift and hemodynamic compromise.
CPAP as commonly used to treat arterial hypoxemia during OLV for an open thoracotomy will be unacceptable during VATS because of interference with the surgical procedure. During VATS, PEEP to the nonoperated (dependent) lung should be used.
Postoperative Concerns
Pain after VATS is less than after an open thoracotomy.
Respiratory function is better preserved after VATS.