A Prospective, Randomized Trial Comparing Respiratory Status During Anesthesia for Airway Stenting: Spontaneous Respiration Versus Controlled Ventilation With Muscle Relaxants

Abstract

BACKGROUND: Airway stenting is a procedure in which a stent is inserted into a stenotic site of the airway. The safest method of ventilation for airway stenting is controversial. A prospective randomized interventional study was conducted on airway stenting. We conducted this study to investigate whether controlled ventilation with muscle relaxants (MR) during airway stenting reduces the incidence of desaturation events (percutaneous oxygen saturation [Spo 2] <95%) in comparison with spontaneous respiration (SP). METHODS: Sixty-four patients were enrolled at our hospital between April 2016 and August 2018, and were randomly assigned to the controlled ventilation with MR group or SP group. For anesthesia, total intravenous anesthesia with propofol target-controlled infusion and remifentanil was performed. In the SP group, SP was maintained. In the MR group, a rigid bronchoscope was inserted after the administration of MR to perform controlled ventilation. The incidence of desaturation events was analyzed by logistic regression adjusted by the preoperative respiratory state and stenotic site of the airway. RESULTS: The incidence of desaturation events in the SP and MR groups was 75.0% (24/32) and 9.7% (3/31), respectively, with an odds ratio of 0.04 (95% confidence interval, 0.01–0.16, reference = SP group; P < .001). In the SP group, the mean intraoperative pH was lower than that in the MR group (7.2 ± 0.1 vs 7.4 ± 0.1, respectively; P < .001). In this group, the mean partial pressure of arterial carbon dioxide (Paco 2) was higher (70.2 ± 17.0 mm Hg vs 40.5 ± 8.0 mm Hg, respectively; P < .001) and the mean partial pressure of oxygen in the arterial blood/fraction of the inspiratory oxygen ratio was lower (263.1 ± 64.2 mm Hg vs 396.4 ± 69.4 mm Hg, respectively; P < .001). CONCLUSIONS: Controlled ventilation with MR during airway stenting reduced the incidence of desaturation events, maintaining a favorable respiratory status.

Anesthetic management of tracheal stent extraction using a double gum elastic bougie technique

“…Although there is no evidence regarding how general anesthesia should be managed and whether or not muscle relaxants should be used during stent placement [ 14 ], stent removal should be performed using a rigid bronchoscope under general anesthesia [ 15 ]. There have been reports of restenosis caused by granulation after stent removal, stent rupture during removal, and tracheal injury, although these occurred during metal stent removal.…”

Safety application of muscle relaxants and the traditional low-frequency ventilation during the flexible or rigid bronchoscopy in patients with central airway obstruction: a retrospective observational study

“…There are some debates as which one is better than the other, and whether the use of muscle relaxants is safe and indispensable in this procedure [15][16][17][18][19][20]. In some articles, the authors are in favor of the non-use of muscle relaxants in rigid or flexible bronchoscopy for the safe factor [17,21], but a recent research showed that controlled ventilation with muscle relaxants during stenting reduced the incidence of desaturation events, maintaining a favorable respiratory status [22]. A rigid bronchoscope can be placed under deep sedation without muscle relaxants, but that required high doses of analgesic and hypnotic agents, which may lead to cardiovascular instability or residual drug effects harming pulmonary function after the operation, and if the depth of anesthesia is not enough, it may causes the trauma of the vocal cords and larynx, even accidental airway perforation, due to the significant response to tracheal manipulation.…”

Anesthetic considerations in interventional pulmonology

“…These interventions may be performed with controlled ventilation using a laryngeal mask airway (LMA) or endotracheal tube with a flexible bronchoscope, or by using rigid bronchoscopy. Conventional ventilation, with or without neuromuscular blockade, or jet ventilation may be used for oxygenation and ventilation [10,11]. When using thermal ablative modalities, it is important to keep the fraction of inspired oxygen (FIO 2 ) <0.4 during application to prevent airway fires [12].…”