You are performing robotic-assisted bronchoscopy (RAB) and a transbronchial biopsy of a small right lower lobe (RLL) nodule (see image). The anesthesiologist informs you of a significant decrease in return tidal volume, a drop in end-tidal CO2 (EtCO2), and a slight increase in airway peak pressure from the high 20s to the low 30s. The patient is hemodynamically stable with SpO2 in the high 90s. Breath sounds are present but decreased bilaterally. Upon a quick fluoroscopy check, you observe no significant pneumothorax. The anesthesiologist confirms no issues with the ventilator circuit.
What would you do next? (Choose only one answer)
a. You still have a high suspicion for pneumothorax; the patient is on the ventilator, so a chest tube needs to be placed urgently before clinical deterioration.
b. Request a therapeutic bronchoscope, as you suspect bleeding into the airways.
c. Request a therapeutic bronchoscope, as you suspect a mucus plug.
d. Continue with the procedure, since the patient is stable.
e. Inform the anesthesiologist that they might not be following the ventilator protocol.
f. Perform a CBCT spin to look for a cause.
Answer:
The issue was bilateral airway obstruction caused by blood. Fluoroscopy clearly ruled out pneumothorax.
While a mucus plug is possible, it is unlikely after successful registration and navigation allowing you to proceed with the procedure.
Although a CBCT spin could help identify the cause (e.g., mucus plug, bleeding, or another issue), you would still need to address the obstruction with a conventional bronchoscope. Furthermore, 3D imaging is not widely available in all settings.
A drop in return tidal volume and low end-tidal CO2, in the absence of circuit issues, should prompt immediate airway inspection—especially when the target lesion is near a blood vessel. The therapeutic bronchoscope proved crucial in managing this situation effectively.
