Anesthetic considerations for bronchial thermoplasty in patients of severe asthma: A case series

The role of anesthesiologist in nonoperating room procedures including pulmonary interventions is expanding. Bronchial thermoplasty (BT) is a minimally invasive bronchoscopic intervention for patients with severe asthma refractory to conventional pharmacotherapy. It involves the application of controlled radiofrequency thermal energy to large- and medium-sized airways. We report our experience for perioperative anesthetic management of patients scheduled for BT. Three patients with severe asthma were planned for BT under general anesthesia. After standard monitoring and intravenous cannula insertion, anesthesia was induced with propofol, fentanyl, and rocuronium after preoxygenation and maintained with propofol target-controlled infusion. The ventilation was controlled mechanically with I-gel used for airway management. The oxygen concentration was titrated to 40% or less at the time of thermal activation delivery. The procedure was performed using a thin bronchoscope inserted through the I-gel working port of the catheter mount. The procedures lasted for around 1 h. After completion of the procedure, the residual neuromuscular blockade was reversed, and I-gel was removed. BT requires three separate procedure sessions performed 2–3 weeks apart, and each session sequentially targets right lower lobe, left lower lobe, and bilateral upper lobes. The challenge involved in BT is due to the airway sharing between anesthesiologists and pulmonologists and anesthesia in a nonoperating room setting in patient with uncontrolled severe asthma. A meticulous preoperative evaluation, perioperative anesthetic plan, and periprocedural monitoring can reduce the complications.