Background 
Bronchial thermoplasty (BT) is a rapidly emerging bronchoscopic treatment for patients who suffer from refractory asthma despite optimal therapy.  It involves delivery of radio frecuency thermal energy to the airway walls with a Bronchial Alair TM probe, to reduce the smooth muscle mass. The procedure is divided into three sessions, each 45 minutes long, interspersed with three weeks.

Besides the anesthetic peculiarities of any bronchoscopy technique, the complexity of these patients and the limited literature available for BT makes this procedure challenging for the anesthesiologist.

Case Report 
The patient is a 59-year-old man with a severe refractory asthma and a serious functional limitation despite maximum medical treatment.
After verifying stable disease,  the patient received 50 mg/d oral prednisone during the three days before the procedure, the day of the treatment and the first post-procedural day to minimize inflammation. 
Once in the bronchoscopy room, after standard monitoring and peripheral cannulation, 0,15 ml/kg nebulized salbutamol and antisialogogue premedication with 0,4 mg glycopyrrolate was administrated.  Subsequently, topical anesthesia was performed with lidocaine 1.5-2% from the supraglottic region, down to the bronchial distal tree. Additional doses could be necessary, up to a maximum dose of 8 mg/kg.
To ensure comfort and inmobility of the patient, a conscious sedation was maintained combining TCI of propofol 2 μg/ml and remifentanil 0.15 μg/kg/min, with supplemental oxygen.

The procedure was complited with no incidents. In the PACU bronchospasm ocurred and was treated successfully with inhaled salbutamol and intravenous steroids.The patient was discharged from hospital after 24 hours.
At 12 months, the mean rate of severe exacerbations was reduced by over 90%. 

Discussion  
There is limited literature on anesthetic management in bronchial thermoplasty.  The severity of these patients require an individual evaluation to determine the suitability.
We opted for a conscious sedation to reduce stimuli that may induce bronchospasm. Premedication with corticosteroids is essential to reduce the peribronchial edema. We prefered glycopyrrolate over atropine because it offers a superior antisialogogue effect and less tachycardia.

References:
  Selzer, Angela Roberts; Murrell, Matthew; Shostak, Eugene. New trends in interventional -pulmonology. Current Opinion in Anesthesiology:2017; 30:17-22.
2 Mayse, Martin L. MD*; Laviolette, Michel MD†; Rubin, Adalberto S. MD‡; et al. Clinical Pearls for Bronchial Thermoplasty. Journal of Bronchology & Interventional 2007; 14:115-123.
3 Jagroop S. Saran; Melissa Kreso; Sandhya Khurana; et al. Anesthetic Considerations for Patients Undergoing Bronchial Thermoplasty. Anesth Analg. 2017; XXX: 00-00.

Learning points 
We believe that the success of our case is based on an adequate patient selection and preoperative preparation, requiring an optimal local anesthesia under conscious sedation to ensure patient comfort and immobility, minimizing airway manipulation.


09 / Bronchial thermoplasty under conscious sedation in the ambulatory bronchoscopy procedure room