Bronchoscopy challenges in kyphoscoliosis

1. Bronchoscopy in kyphoscoliosis
Dr Vijish Venugopal
KMCT Medical College
Calicut, Kerala

2. Case Scenario
• A 76-year-old woman had gross congenital kyphoscoliosis and cor-
pulmonale leading to type 2 respiratory failure. The patient required
assisted non invasive mechanical support in the form of nasal BIPAP.
• Recurrent bouts of respiratory infection necessitated admission to the
hospital on a nearly bimonthly basis.
• On examination she was poorly nourished but comprehending. Had a
prominent kyphoscoliosis

3. • There was auscultatory and radiologic evidence of collapse of the lower
and middle lobes of the right lung (Fig 1).
• Bronchoscopic appearance revealed complete obstruction of the
intermediate bronchus just after the takeoff of the upper lobe of the right
lung.
• Apart from evidence of infected purulent retained secretions and
associated inflammatory changes, the bronchial mucosa was undisturbed.

6. • Two expandable endobronchial metal stents (Schneider Medinvent
EndobronchialStent; Schneider Europe AG ; Zurich, Switzerland) were
inserted in both the middle lobe and intermediate bronchi.
• The patient was extubated on the next day, and the chest radiograph
showed expansion of the middle and lower lobes (Fig2).
• The patient's FEV1 and FVC prior to insertion of the stents were 0.4 and
0.5 L, respectively. Three days after insertion of the stents, the FEV1
values had increased to 0.9 L, and the FVC was 1.1 L with an average
increase of 125 %.
• During follow-up, the patient developed repeated attacks of respiratory
infection, but they did not cause respiratory failure or require intubation.
The need for hospital admission fell to three to four times pe r year.
• Subsequent bronchoscopy showed a patent bronchus over a period of 4
years

8. Case Scenario 2
• An 85 year old woman presented to the Accident & Emergency department
with a fractured neck of humerus. She had a history of severe osteoporosis
and was being treated with alendronic acid and calcium carbonate.
• Physical examination revealed marked kyphosis with a 90 degree forward
curvature of the thoracic spine. Following treatment of her humeral fracture
with a collar and cuff, she developed stridor and then a respiratory arrest
requiring resuscitation and non-invasive positive pressure ventilation.
• On further questioning the patient described previous episodes of these
attacks of stridor. They were not related to any specific triggers and resolved
spontaneously after approximately 10 minutes

10. • Initial investigation with fibreoptic bronchoscopy revealed extrinsic
compression of the mid trachea, with the lumen narrowed to less than 5
mm. Pulsation in the anterior wall of the trachea was also noted. In view
of this, a spiral CT scan was performed with the patient in a lateral
decubitus position as severe kyphosis prevented her lying supine.
• With the aid of three dimensional reconstructions, forward deviation of
the trachea by a markedly kyphotic thoracic spine was found,
compressing the airway against the brachiocephalic artery anteriorly (fig
1A and C).
• Using virtual bronchoscopy to give a ‘‘retroverted’’ view at this non-
traversable lesion, a normal tracheobronchial tree was observed distal to
the compression. There were no other lesions in the mediastinum or
lungs.

12. • In view of this, a 6 cm (18 mm) diameter Ultraflex non-covered metal
tracheobronchial stent (Boston Scientific, USA) was inserted via a rigid
bronchoscope under fluoroscopic guidance.
• A postoperative CT scan showed restoration of airway patency and
positioning of the tracheal stent (fig 1B and D).
• On subsequent follow up at 6 weeks the patient was asymptomatic and
has not suffered any further attacks of stridor or respiratory distress.

13. Scenario 3
• A 72 yr old patient with severe kyphoscoliosis presenting for urgent
laparotomy.
• Reasonable laryngeal views were obtained but intubating the trachea
proved challenging.
• The laryngeal inlet was visible, allowing a size 8.0 I.D. MallinckrodtTM
tracheal tube to be passed through the cords. However, we were
unable to advance it further than just beyond the cords.
• Subsequent attempts using a gum elastic bougie and smaller calibre
endotracheal tube were unsuccessful.

14. • A further attempt at laryngoscopy by a consultant colleague using a size 4
Macintosh blade revealed a grade 2 view. A size 6.0 mm I.D. MallinckrodtTM
tracheal tube was passed through the cords and the cuff inflated just below
the vocal cords to temporarily secure the airway. Intermittent positive
pressure ventilation was possible and oxygen saturation maintained, but
adequate ventilation necessitated high airway pressures.
• Examination using a flexible intubating fibreoptic scope (Pentax Model:F1-
10RBS, PENTAX Canada, Inc) via the tracheal tube revealed complete
occlusion of the distal lumen of the endotracheal tube by tracheal mucosa
and an airway passage was seen taking off to the right side visible through
the murphy eye of the tracheal tube.

16. What they did?
• An ultra-flexible tip guidewire from the Arndt airway exchange catheter
with rapidfit ®adapters set (COOK Medical Inc. Bloomington, IN 47402-
4195, USA) was passed via th fibreoptic scope (Pentax Model:F1-10RBS,
PENTAX Canada, Inc) through the murphy eye and into the trachea.
• The fibreoptic scope and endotracheal tube were withdrawn and a size
5.0 mm I.D. MallinckrodtTMmicrolaryngeal tube (Covidien plc, Dublin 2,
Ireland) was passed over the wire, between the vocal cords and down
the trachea.
• Tracheal tube position was confirmed by capnography trace and positive
pressure ventilation recommenced with acceptable airway pressures.

17. Approach to these patients
• Patient related risk factors
Elderly
Fraility
• Co-morbidities related risk factors
Kyphoscoliosis
Respiratory failure requiring BIPAP
• Procedure related risk factors
Fiberoptic Bronchoscopy
Rigid Bronchoscopy

26. Fasting
Sensory aids
Quality of life and EOL directives

39. Kyphoscoliosis
• Severe kyphoscoliosis is associated with respiratory complications, often
leading to respiratory failure. The progressive nature of the disease limits the
vital capacity and chest wall compliance of the patients with the effect of
normal changes with age. The reduced vital capacity and the severity of the
scoliosis are the most important predicting factors in prognosis.
• Superinfection and muscle weakness also influence the respiratory function
because of an increased work of breathing in those patients. Due to the
nature of the deformity, the respiratory failure usually is due to restrictive
elements with a decrease in the FVC. When kyphoscoliosis is severe, an
increase in the airway resistance and a decrease in lung compliance also
contribute to the observed reduction in vital capacity.
• The morphologic features of the trachea and the bronchial tree in severe
kyphoscoliosis have led to difficult intubation with endotracheal tubes or
tracheostomy tubes, and intubation often is a requirement when respiratory
failure occurs.

41. • Patients with idiopathic scoliosis treated surgically by Harrington
instrumentation aiming to correct the spinal deformity have experienced
improvement not only in the FVC but also in the FEV1 . These findings
would suggest that severe kyphoscoliosis with chest wall deformity would
affect the vital capacity of the lungs as well as cause a central airway
obstruction affecting the forced expiratory volume in some patients.
• The obstruction could be due to either compression by the vertebral bodies
or true twisting.
• Bronchial torsion or twisting was more likely in the case due to the slit-like
appearance of the bronchus and the ease with which an instrument could
be passed through it.

42. • Extrinsic compression of the tracheobronchial tree from spine and
chest wall deformities including kyphoscoliosis, pectus excavatum and
straight back syndrome can result in narrowing of the airway. This
airway narrowing is often first noted on chest CT and confirmed with
bronchoscopy. In cases of severe kyphoscoliosis, direct compression
by the deviated thoracic spine, or rotation and distortion of the
airway because of altered thoracic anatomy can result in bronchial
compression.
• Straightening of the thoracic spine can cause tracheal compression by
several mechanisms: trachea could be compressed either directly
between the sternum and the vertebral body, by the right
brachiocephalic artery crossing the trachea, or by the vertebral bodies
splaying the lower trachea at the carina

46. • The severity or the angle of the scoliosis was neither a good predictor for
the site, nor for the side of the torsion. Relief of the obstruction by
insertion of endobronchial stents has led to re-expansion of the
collapsed lobes. These results were supported by radiologic changes as
well as by improvement in the respiratory function tests which showed a
remarkable improvement in both FEV1 and FVC.
• This improvement has persisted well into the medium term.
• Although only a few cases of emphysematous changes in kyphoscoliosis
have been reported, this has been explained on the basis of prolonged
intermittent positive pressure applied to the lungs.

49. Respiratory failure on BIPAP

52. Fiberoptic Bronchoscopy
RIGID Bronchoscopy
VS

53. Pre-operative assessment
• The pre-operative investigations include the routine investigations
along with the coagulation profile in patients taking anticoagulants.
• Pulmonary function tests are done, if there is a clinical suspicion of
severe respiratory obstruction and computed axial tomography scan if
the patient has haemoptysis or there is a suspicion of a neoplasm.
• A pre-procedural blood gas is recommended in some patients for
evaluating the baseline status of the patient in terms of hypoxemia
and hypercarbia

54. • Special attention should be paid to oral cavity, jaw and neck mobility.
• Patients who are already dyspnoeic and require supportive oxygen, or are
haemodynamically unstable and hypercarbic at rest are at increased risk of
intra and post-operative complications.
• Some important factors that should be kept in mind are unstable cervical
spine, decreased movement of cervical spine especially in rheumatoid
patients, maxillofacial trauma, limited mouth opening and laryngeal
stenosis or obstruction.
• The time of the last meal should be established to assess the risk of
aspiration.
• The airway patency should be assessed. If the patient is in severe distress,
urgent bronchoscopy should be performed.

55. PREMEDICATION
• Antisialogogues – For example, injection atropine 10 µg/kg
intramuscular/intravenous and injection glycopyrrolate 5 µg/kg
intravenously/intramuscularly 30–60 min before the procedure
• Benzodiazepines – For example, injection midazolam 0.05–0.07 mg/kg
intravenously can be used as an anti-anxiety drug in selective group of
patients
• Bronchodilators – A randomised placebo controlled trial has shown that
there is no benefit of inhaled short acting beta agonists prior to
bronchoscopy in patients with chronic obstructive pulmonary disease.

56. POSITION
• Patient is usually kept in supine
position at the edge of the table
and the head is extended by
keeping a sandbag or shoulder
roll. The head is placed on a ring
with the chin pointing upwards.
This is the shaving chin position

57. INTRAOPERATIVE MONITORING
• Standard monitoring based on the Helsinki Declaration on patient safety
should be followed. This includes electrocardiogram, pulse oximetery and
non-invasive blood pressure monitoring. End tidal carbon dioxide
monitoring is usually not done.

58. VENTILATION STRATEGIES IN BRONCHOSCOPY
• Apnoeic oxygenation
• Spontaneous assisted ventilation
• Controlled ventilation
• Manual jet ventilation
• High frequency jet ventilation.

59. ANAESTHETIC CONSIDERATIONS
For rigid bronchoscopy
• Ideal anaesthesia requires hypnosis, analgesia and muscle relaxation.
• Balanced anaesthesia is usually the technique opted for rigid bronchoscopy.
• Anaesthesia may be induced with propofol, etomidate or ketamine with fentanyl
or remifentanil in adults and inhalational agents in children.
• Fentanyl boluses and short acting beta blocker can be used to avoid pressor
response.
• Vocal cords should be sprayed with 4% lignocaine to prevent post-operative
laryngospasm. Anaesthesia is maintained with remifentanil and intravenous
infusion of propofol or inhalation of sevoflurane. Nitrous oxide is contraindicated
in patients with air trapping because of the risk of over inflation. Use of short
acting muscle relaxants is recommended.

60. • Target controlled infusion as part of TIVA may also be used. Use of
TIVA may result in awareness in many patients. Deep sedation with
spontaneous breathing can also be used instead of general
anaesthesia but hypoventilation and laryngospasm may occur.
• Reversal of residual neuromuscular block is done with neostigmine
and glycopyrrolate or atropine. A complete reversal of the block is
essential because a lot of these patients lack the respiratory reserve
to tolerate any residual block.
• After completion of the procedure before reversal is given, it is
advisable to put in a cuffed endotracheal tube or a laryngeal mask
airway. Endotracheal tube is generally preferred as there may be need
for emergency flexible bronchoscopy or aspiration of secretions.

61. For flexible bronchoscopy
• Topical anaesthesia
• Sedation

64. Another Technique
• Position the patient on the trolley for administration of local anaesthetic, followed by
a semi- recumbent or supine position, depending on operator’s preference/patient
convenience, for the endoscopy and intubation.
• Identify the patient’s most patent nasal passage.
• Spray nasal mucosal with vasoconstrictor (oxymetazoline/xylometazoline)
• Nebulise 2ml 4% Lignocaine (80mg, of which 25% is typically absorbed =20mg)
• Nose and nasopharynx: Soak cotton bud (cotton applicators mounted on sticks)/pus
swab sticks/ribbon gauze in measured dose of either
Xylocaine (2% Lignocaine + 1:200000 Adrenaline) (5ml = 100mg)
or “home made” solution of 4% Lignocaine + 1:200000 or 1:100000 Adrenaline (3ml =
120mg)
• Tongue and oropharynx: 4 puffs 10% Lignocaine to throat (2 each side, tonsillar pillars
and back of throat – 40mg).

65. • Pharynx and Larynx above cords: can be anaesthetised by 1-4%
Lignocaine via metered spray or soaked swabs at increasing depths
into the mouth, using a spatula or laryngoscope as alternative.
• 4 puffs 10% Lignocaine to nose and post nasal space (40mg)
• Total dose so far = 225mg
• Subtract this from the total maximum dose (9mg/kg), and allocate the
remaining 4% Lignocaine in 1 ml aliquots to anaesthetise the larynx
below the vocal cords, and tracheo- bronchial tree, using:

66. • “Spray as you go” technique during endoscopy. If an epidural catheter is available
(16G), advance it through the working channel of the fibrescope, until it
protrudes at the end. Cut the tip containing side holes off. Attach a 2ml syringe
with 1ml 4% Lignocaine to the luer lock at the proximal end, to “drop” the local
anaesthetic onto the mucosa, as the fibrescope is advanced through the distal
airways. The tip of the epidural catheter should be advanced about 1cm distal to
the tip of the fibrescope whilst dropping the anaesthetic onto mucosa, and
retracted while advancing the fibrescope. Target the post- nasal space, back of
the throat, epiglottis, vocal cords, and trachea.
• Cricothyroid (trans-tracheal) injection, to anaesthetise subglottic region, vocal
cords and trachea. A 21-23G needle is used to pierce the crico-thyroid
membrane, aspirating whilst inserting, to confirm position. The patient is told to
exhale prior to the injection of 3-5ml of 1% – 4% Lignocaine. Remove the needle
immediately following injection, to prevent trauma of the airway when the
patient coughs. The resultant inspiration and cough aids the spread of the local
anaesthetic within the tracheo-bronchial tree.
• Alternatively, if familiar with the technique, various nerve blocks can be
performed – glossopharyngeal, superior laryngeal and recurrent laryngeal nerve
blocks

69. Summary
• with severe kyphoscoliosis, the chest wall and spine deformity can occasionally
lead to torsion of the central airways. This can be sufficiently severe to be
manifested in complete obstruction.
• Patients with kyphoscoliosis who present with progressive deterioration in
respiratory function with evidence of obstructive airway disease should be
considered for bronchoscopic examination.
• This may demonstrate endobronchial lesion, stenosis at the site of previous
tracheostomy, or bronchial torsion.
• Radiologic and clinical evidence of collapse or air trapping will support the
diagnosis.
• The use of metal stents is useful in these cases. An immediate and long-term
luminal patency can be maintained with these stents.