Management Of Central Airway Obstruction Research Articles

Management of central airway obstruction.

Management of central airway obstruction.

Ventilation challenge in rigid bronchoscopy: Laser tube as an alternative management in patients with lung cancer and central airway obstruction.

Central airway tumors involving the trachea and main-stem bronchi are a common cause of airway obstruction and a significant cause of mortality among the patients of thoracic diseases with respiratory failure. Debulking in rigid bronchoscopy is quick, safe, and effective. It can be complex and hard in patients with severe bronchial or tracheal obstruction and/or with intraluminal bleeding tumors because of inadequate distal airway control. We have used laser tube as a new technique of ventilation for severe central airway obstruction. Forty-six patients with severe airway obstruction undergoing rigid bronchoscopy from September 2020 to June 2022 at the Thoracic Surgery Department of the University L. Vanvitelli of Naples underwent placement of laser tube. In all patients who underwent rigid bronchoscopy with the use of the laser tube, a reduction of obstruction of more than 50% was obtained and in all patients no hypoxia (saturation < 88%), nor hypercapnia, nor significant bleeding were reported. The results of this study suggest that rigid bronchoscopic debulking with the use of laser tube is a safe and effective technique in the management of central airway obstruction. The use of the laser tube allows the monitoring of gas exchange, which controls hypoxemia. Thanks to the double cuff putdistally to the tracheal obstruction or in the contralateralbronchus to the obstructed one, the laser tube prevents the flooding of blood from debulking below the stenosis. Rigid bronchoscopy with laser tube will expand its use in the future.

Current practices in the management of central airway obstruction.

Airway obstruction continues to cause substantial pulmonary morbidity and mortality. We present a review of classic, current, and evolving management techniques, highlighting recently published studies on the topic. Recommendations have historically been primarily based on anecdotal experience, case reports, and retrospective studies, but more solid evidence has emerged in the last decade. Novel endobronchial stents are being developed to mitigate the issues of stent migration, mucus plugging, fracture, and granulation tissue formation. Endobronchial drug delivery has become an active area of translational and clinical research, especially with regards to antineoplastic agents used for malignant airway stenosis. Even classic or updated techniques such as spray cryotherapy, injections of mitomycin-c, and balloon dilation have recently been examined in methodologically sound studies. Finally, recently published data have confirmed that patient breathlessness and quality of life improve significantly with therapeutic airway interventions. A multimodal and multidisciplinary approach to patient care is key to achieving the best outcomes. The treatment of central airway stenosis is often multimodal and should focus on patient-centric factors, taking into account risks and benefits of the procedure, operator, and center expertise, and always occur in the context of a multidisciplinary approach. Evidence-based clinical research is increasingly driving patient management.

The mechanical characteristics and performance evaluation of a newly developed silicone airway stent (GINA stent)

Central airway obstruction (CAO) can be attributed to several benign or malignant conditions. Although surgery is the preferred therapeutic option for the management of CAO, bronchoscopic treatment can be performed in scenarios where the surgical procedure is not possible. Recent years have witnessed several improvements in the field of bronchoscopic treatment, especially with regard to airway stents. Current research involves new attempts to overcome the existing shortcomings pertaining to the stents (migration, mucostasis, and granulation tissue formation). The authors have recently developed a new silicone airway stent (GINA stent) with an anti-migration design, dynamic structure that enables the reduction of stent cross-sectional area, and radio-opacity. The present study aimed to evaluate the mechanical characteristics and performance of the novel GINA stent using a porcine tracheal stenosis model. In the current study, all the tests involved the comparison of the GINA stent [outer diameter (OD, mm): 14; length (L, mm): 55] with the Dumon stent (OD: 14; L: 50). The mechanical tests were performed using a digital force gauge, in order to determine the anti-migration force, expansion force, and flexibility. The present study evaluated the short-term (3 weeks) performance of the two stents after implantation [GINA (n = 4) vs. Dumon (n = 3)] in the porcine tracheal stenosis model. The results pertaining to the comparison of the mechanical properties of the GINA and Dumon stents are stated as follows: anti-migration force (18.4 vs. 12.8 N, P = 0.008); expansion force (11.9 vs. 14.5 N, P = 0.008); and flexibility (3.1 vs. 4.5 N, P = 0.008). The results pertaining to the comparison of the short-term performance of the GINA and Dumon stents are stated as follows: mucus retention (0/4 vs. 0/3); granulation tissue formation (0/4 vs. 0/3); and migration (1/4 vs. 2/3). The GINA stent displayed better mechanical properties and comparable short-term performance, compared to the Dumon stent.

The Role of Bronchoscopic Cryoablation in Management of Central Airway Obstruction

Central airway obstruction is one of respiratory emergency manifested as dyspnea, stridor and obstructive pneumonia. Most of central airway obstruction cases were treated with resection and surgery. Bronchoscopy is an initial modality to diagnose, stabilize the airway obstruction and evaluate for palliative treatment. Cryoablation is an evolving therapeutic bronchoscopic methods. Through rapid freeze–thaw cycles, cryoablation causes cell death and tissue necrosis or tissue adherence that can be used via the flexible or rigid bronchoscope. Cryoablation can safely restore airway patency and improve symptoms in patients with central airways obstruction from exophytic tumours. It is also used in the treatment of granulation tissue and benign strictures. Clinical studies showed improvement of dyspnea, cough, and hemoptysis with non-significant complications.

The role of rigid bronchoscopy in complex airway disorders

Rigid bronchoscopy is a diagnostic and therapeutic tool used to treat complex airways disorders. It plays a central role in the management of central airway obstruction caused by benign or malignant diseases; and requires close cooperation between the bronchoscopist and the anesthesiologist as they share the same operative field. Rigid bronchoscopy requires deep sedation or general anesthesia, intubation with the rigid bronchoscope and adequate oxygenation and ventilation during the procedure. The choice of ventilation techniques include apneic oxygenation, spontaneous assisted ventilation, controlled ventilation and jet ventilation. Rigid bronchoscopy is used to relieve respiratory symptoms due to airway obstruction by dilation for a tracheal stenosis or the mechanical debulking of endoluminal tumours, and supporting the airway by the placement of an endoluminal stent. Two types of stents are currently in use: silicone stents and metal stents with different lengths, diameters and shape configurations. They can significantly improve patients symptoms and their quality of life. Therapeutic rigid bronchoscopy, performed in appropriately selected patients and by skilled operators is effective and has a low morbidity rate.

High-flow nasal cannula for oxygenation during emergency tracheal stenting under flexible bronchoscopy guidance

Central airway obstruction is a common complication of advanced esophageal carcinoma requiring bronchoscopic evaluation and intervention by a pulmonologist. Airway assessment by flexible bronchoscopy is crucial for the selection of the most suitable modality for the management of central airway obstruction. In such situations, flexible bronchoscopy may however be complicated by the development of hypoxemia. Oxygen therapy by high-flow nasal cannula (HFNC) has been used for the correction of hypoxemia for a number of conditions, including diagnostic bronchoscopy. This case report describes a successful use of HFNC for correction of severe hypoxemia during the placement of a metallic stent in a patient with tracheal obstruction due to esophageal carcinoma.

POST-PNEUMONECTOMY CENTRAL AIRWAY OBSTRUCTION: MANAGEMENT CHALLENGES

SESSION TITLE: Fellows Procedures Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Management of central airway obstruction (CAO) is challenging post-pneumonectomy due to limited respiratory reserve and the potential for life-threatening intraprocedural complications. We present a case of malignant CAO in a patient with a single lung that has been treated bronchoscopically with success for 3 years. CASE PRESENTATION: A 73-year-old man with pT2bN1M0 squamous cell carcinoma of the right lung 6 years ago s/p chemotherapy, radiation, and right pneumonectomy presented to the hospital for one week of exertional dyspnea and blood-tinged sputum. He was in no acute distress but had stridor. Computed tomography showed thickening of the tracheal mucosa and narrowing of the tracheal lumen. Fiberoptic bronchoscopy revealed friable, polypoid lesions extending the length of the trachea narrowing the lumen to 4 mm in the most affected region. Rigid bronchoscopy was performed with jet ventilation. The endotracheal tumor was devitalized using neodymium-doped yttrium aluminum garnet (Nd:YAG) laser. Pathology revealed squamous cell carcinoma consistent with metastatic disease from the former right lung. The patient completed radiation and chemotherapy but had recurrent dyspnea from CAO. 12 rigid bronchoscopies with laser tumor destruction have been performed to-date over 3 years. The patient continues to walk 30 minutes per day and maintains an active lifestyle. DISCUSSION: Bronchoscopic management of CAO with laser resection can improve quality of life, functional status, and prolong survival (1). The Nd:YAG laser is particularly advantageous because of its deep penetration, superior coagulation characteristics, resecting ability, and versatility to be utilized through a flexible or rigid bronchscope (1). We chose rigid bronchoscopy for airway security, the ability to tamponade a hemorrhage, and superior oxygenation with jet ventilation. Laser therapy is useful for lesions in the trachea or mainstem bronchi that are polypoid, less than 4 cm, and have a visible distal airway lumen with functional lung (1). Complications include perforation of the mediastinum, vascular structures, or esophagus which is why lesions that obliterate anatomical boundaries are not usually amenable to laser therapy. Essential elements of tumor debulking in complex cases like this one include the following: deep sedation and muscle relaxation, proper estimation of bronchoscope size, atraumatic rigid intubation, use of the Nd:YAG laser conforming to established technical standards (2) with intermittent exposures (0.5 to 1 second) not higher than 45 Watts (3), use of hemostatic agents such as Surgicel and cottonoids, and an anesthesia team experienced in jet ventilation. CONCLUSIONS: Endotracheal tumor resection can be safely performed in single lung patients. The Nd:YAG laser is especially advantageous for tumor debulking and hemostasis with the ability to improve quality of life and extend survival. Reference #1: Angel LF, Levine DJ. Basic Therapeutic Techniques. In: Introduction to Bronchoscopy. Ernst A, Herth FJF, editors. Cambridge: Cambridge University Press; 2017. pp. 184. Reference #2: Hoag JB. Use of Medical Lasers for Airway Disease. In: Principles and Practice of Interventional Pulmonology. Ernst A, Herth FJF, editors. Berlin: Springer; 2013. pp.364. Reference #3: Dumon JF, Shapshay S, Bourcereau J, et al. Principles for safety in application of neodymium-YAG laser in bronchology. Chest. 1984;86(2):163-168. DISCLOSURES: No relevant relationships by Brian Cody Adkinson, source=Web Response No relevant relationships by Sisir Akkineni, source=Web Response No relevant relationships by Sixto Arias, source=Web Response

Real‐time confirmation of tracheal decompression

The primary objective was to highlight the role of intraoperative bronchoscopic guidance during the management of central airway obstruction. A 6-month-old child presented with recurrent chest infections due to innominate artery compression of distal trachea. Aortopexy was performed under real-time bronchoscopic guidance. Intraoperative bronchoscopic guidance helped in confirm a successful release of the central airway obstruction. When operations similar to aortopexy are performed for release of airway obstructions, intraoperative bronchoscopic guidance is a valuable tool for confirming a successful outcome. The successful surgical management of central airway obstruction due to an innominate artery compression of the distal trachea under real-time bronchoscopic guidance in a 6-month-old child is described.

Airway stents: a retrospective evaluation of indications, results and complications in our 10-year experience.

Tracheobronchial stents (TBS) are the principal modalities in the management of central airway obstruction with intrinsic tracheobronchial pathology and extrinsic airway compression. The aim of the study is to assess the indications, surveillance management, complications, and long-term outcomes of the TBS managed by rigid bronchoscopy (RB) in our 10-year experience. The files of all patients who underwent stenting in two centers from November 2008 to September 2018 were reviewed for background data, type of disease, and indication for the placement of stents, symptoms, treatment, complications and outcome. 305 patients were stented with 342 TBS. TBS were placed in both malignant (n= 223) and benign airway diseases (n= 82). The median length of stent stay was 88 (34-280) days in patients with malignancies and 775 (228-2085) days in benign diseases. There was no stent-related mortality. Mucostasis (19%) and granulation tissue formation (17%) were the most common stentrelated complications. Benign nature of the disease, tumors metastatic to tracheobronchial tree, lenght of stent stay, and shape of stent were associated with the development of complications. TBS offer a safe and effective therapy for patients with both benign and malign tracheobronchial pathologies.

ACUTE ON COPD

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Central Airway Obstruction (CAO) is pathologic obstruction of air flow in the trachea and main stem bronchi. The most common cause of CAO is non-small cell lung cancer, but other common causes are tracheobronchomalacia, tracheal strictures, and other malignancies. Less commonly, primary tumors of the trachea and metastatic cancers can also cause central airway obstruction. CASE PRESENTATION: A 68 year old female with a prior medical history of hypertension, hyperlipidemia, past alcohol dependence, and COPD due to a 45 pack year smoking history presented to the emergency department via EMS. She was intubated for acute hypoxic and hypercapnic respiratory failure and was admitted to the ICU where she underwent treatment for COPD exacerbation, community-acquired pneumonia, and urinary tract infection with azithromycin, methylprednisolone, and ceftriaxone. A review of the patient’s chart showed a screening CT had been completed two days prior to admission and showed a paratracheal mass with invasion into the trachea and right main bronchus. Given the patient’s lack of response to maximal medical therapy, bronchoscopic evaluation was pursued. During bronchoscopy, a mass was found protruding from the right main stem bronchus, occluding 80-90% of the trachea. The bronchoscope could not be passed around the mass, however biopsies were taken before the procedure was aborted. Interventional Pulmonology was consulted with plans for further evaluation and management. The patient underwent a second bronchoscopic evaluation, which showed near occlusion of the trachea due to tumor in the left main stem bronchus. Debulking provided rapid improvement in oxygen saturation. Further debulking of the trachea and right main stem bronchus were completed with rigid bronchoscopy and a stent was placed at the entrance of the right main stem to prevent further airway collapse. The following day, the patient was successfully extubated without further respiratory difficulties. She was transferred from the ICU to the general medical floor and ultimately to a rehabilitation facility with Oncology follow up. The patient has quit smoking, follows at UW medicine for her sarcoma, and is handling her symptoms well. DISCUSSION: Pathology on the specimens obtained showed poorly differentiated synovial sarcoma. Synovial sarcoma most commonly affects children and young adults. It routinely affects the knees and ankles but can involve other joints. It is normally found proximal to tendons and bursae without invasion of surrounding tissues, joint space, or synovial membranes. Case reports have described synovial sarcoma in almost all anatomical locations despite its predilection for synovial joints. CONCLUSIONS: Obstructive lung disease can have multiple causes, therefore it is important to consider that respiratory failure may be secondary to more than just a patient’s known underlying lung pathology. Reference #1: Herth, Felix JF. (2018). Clinical Presentation, diagnostic Evaluation, and management of central airway obstruction in adults. G. Finlay (Ed.), UpToDate. Retrieved March 10, 2019, from https://www.uptodate.com/contents/clinical-presentation-diagnostic-evaluation-and-management-of-central-airway-obstruction-in-adults Reference #2: Goldblum, John R. Rosai and Ackerman’s Surgical Pathology, 11th ed. Elsevier Inc. C2018. Chapter 41, Soft Tissues; p. 1810-1914. Reference #3: David Feller-Kopman, Atul C. Mehta and Momen M. Wahidi. Murray and Nadel's Textbook of Respiratory Medicine. 6th ed. Saunders. c2016. Chapter 23, Therapeutic Bronchoscopy; p. 383-392. DISCLOSURES: no disclosure on file for Jonathan Danaraj; No relevant relationships by Matthew Strohmeyer, source=Web Response

A Single Center Experience of Feasibility of a Novel Self-Expanding Metallic Airway Stent (Bonastent): A Case Series.

Central airway obstruction (CAO) is defined as obstruction of the airway lumen in the trachea or mainstem bronchi, most commonly due to primary or metastatic malignancy; and is classified as extraluminal, endoluminal, or mixed. The majority of malignant CAO are advanced stage and require a multimodality palliative approach, including stent placement. We describe a retrospective review of a novel self-expandable metallic stent, the Bonastent; a fully covered, nitinol-braided airway stent which conforms to airway tortuosity without loss of diameter in the management of CAO. We performed a retrospective chart review of patients with CAO who underwent Bonastent placement at a single center between February 2017 and March 2018. Ease of stent placement, short-term complications (within 24 h of stent placement) and long-term complications (within 3 mo of stent placement) were recorded. Eleven patients were identified, reviewed and included in the study. Thirteen stents in 11 patients were placed for predominantly malignant CAO. One patient had a short-term complication of stent migration. Four patients had long-term complications; of which 3 patients had in-stent mucus impaction requiring bronchoscopy. In our study, the stent-related complication rates were comparable to the reported literature. In our experience, Bonastent is an easy to use option which adds to the armamentarium of the self-expandable metallic stent to treat malignant CAO.

Airway Procedures

There has been a marked increase in the number and complexity of airway procedures performed both in the operating room and procedural areas. The anesthesiologist is challenged with establishing a patent shared airway and maintaining adequate gas exchange in patients with compromised airways and/or respiratory function. This review presents a general approach to the patient presenting for an airway procedure and highlights the commonly occurring complications. Airway fire, bleeding, and airway disruption or obstruction may occur. Some of the newer interventional bronchoscopic procedures are introduced, with emphasis on anesthetic implications. A more detailed discussion surrounds the anesthetic management of central airway obstruction and airway stenting. This review contains 8 figures, 5 tables, 30 references. Key Words: anesthesia for flexible bronchoscopy, anesthesia for rigid bronchoscopy, airway stenting, bronchoscopy, central airway obstruction, interventional pulmonology, total intravenous anesthesia, ventilation

Airway Procedures

There has been a marked increase in the number and complexity of airway procedures performed both in the operating room and procedural areas. The anesthesiologist is challenged with establishing a patent shared airway and maintaining adequate gas exchange in patients with compromised airways and/or respiratory function. This review presents a general approach to the patient presenting for an airway procedure and highlights the commonly occurring complications. Airway fire, bleeding, and airway disruption or obstruction may occur. Some of the newer interventional bronchoscopic procedures are introduced, with emphasis on anesthetic implications. A more detailed discussion surrounds the anesthetic management of central airway obstruction and airway stenting. This review contains 8 figures, 5 tables, 30 references. Key Words: anesthesia for flexible bronchoscopy, anesthesia for rigid bronchoscopy, airway stenting, bronchoscopy, central airway obstruction, interventional pulmonology, total intravenous anesthesia, ventilation

Interventional Bronchoscopy: What is Possible and What Makes Sense?

Interventional bronchoscopy plays a significant role in the treatment of various pulmonary diseases. Different endoscopic therapeutic modalities are available for the management of central airway obstruction (CAO) that represent a common indication for interventional bronchoscopy. The latest development in the field of CAO management are biodegradable stents, that would maintain the airway patency over time, then gradually degrade and vanish from the airway. Other indications for interventional bronchoscopy are chronic obstructive pulmonary disease (COPD), emphysema, asthma and chronic bronchitis. Thereby, various techniques of endoscopic lung volume reduction (ELVR) that address at hyperinflation reduction extend the therapeutic spectrum of patients with severe emphysema. Targeted lung denervation that aims a persistent bronchodilation present an area of current research in the field of COPD and asthma. In patients with chronic bronchitis, cryospray therapy that is performed within clinical trials may reduce the amount of secretion.

150: Experience of Carina/Y-stent use in management of central airway obstruction

150: Experience of Carina/Y-stent use in management of central airway obstruction

Electrocautery and bronchoscopy as a first step for the management of central airway obstruction and associated hemoptysis

Central airway obstruction caused by malignant or benign lesions, associated in some cases with hemoptysis, is a condition with high morbidity and mortality. The use of electrocautery by flexible bronchoscopy is an initial treatment option with immediate improvement of obstruction symptoms. It is as effective as Nd: YAG laser. To describe the usefulness of electrocautery in the management of central obstruction of the airway and hemoptysis. A retrospective, descriptive study of patients referred for management of central airway obstruction or associated hemoptysis. Diagnoses, symptoms (dyspnea, cough, and hemoptysis) and radiology before and after the procedures were analyzed. Eighteen patients aged 59 ± 12 years (66% males) were evaluated, registering 25 endoscopic procedures. Three conditions were found: partial or complete airway obstruction, hemoptysis and post lung transplant bronchial stenosis. Seventy two percent presented with dyspnea, 61% with cough and 33% with hemoptysis. Sixty six percent of patients had airway obstruction caused by malignant metastatic lesions. After electrocautery, 17 patients (94.4%) improved their symptoms and achieved complete airway clearing. Three patients had significant bronchial stenosis after lung transplant achieving subsequent clearing after electrocautery. Electrocautery during flexible bronchoscopy is an effective and safe procedure for the management of central airway obstruction and associated hemoptysis.

Rigid bronchoscopy and silicone stents in the management of central airway obstruction.

The field of interventional pulmonology has grown significantly over the past several decades now including the diagnosis and therapeutic treatment of complex airway disease. Rigid bronchoscopy is an invaluable tool in the diagnosis and management of several malignant and non-malignant causes of central airway obstruction (CAO) and has become integral after the inception of airway stenting. The management of CAO can be a complicated endeavor with significant risks making the understanding of basic rigid bronchoscopy techniques, ablative technologies, anesthetic care and stenting of utmost importance in the care of these complex patients. This review article will focus on the history of rigid bronchoscopy, the technical aspects of performing a rigid bronchoscopy as well as the use of silicone stents their indications, complications and placement techniques.

Usefulness of Rigid Bronchoscopic Intervention Using Argon Plasma Coagulation for Central Airway Tumors.

ObjectivesArgon plasma coagulation (APC) is a noncontact form of electrocautery that utilizes ionized argon as the electrical current. A rigid bronchoscopic use of APC for the management of central airway obstruction could be safe and rapidly effective. This study evaluated the usefulness of rigid bronchoscopy with APC for the management of central airway obstructions due to benign or malignant tumors.MethodsTwenty patients with obstructing central airway tumors were retrospectively reviewed from February 2008 to February 2013 at Chonnam National University Hospital. All patients received rigid bronchoscopic tumor removal under general anesthesia. APC was applied before and after tumor removal.ResultsThe median age of patients was 59 years (interquartile range [IQR], 51 to 67 years) and 70% were female. The causes of airway obstruction included malignancy (n=8) and benign tumor (n=12). Airway tumors comprised intraluminal lesions (n=11, 55%) and mixed intraluminal/extraluminal lesions (n=9, 45%). The median tumor size was 15 mm (IQR, 10 to 18 mm). The median degree of airway obstruction was significantly reduced after intervention (90% [IQR, 88% to 96%] vs. 10% [IQR, 0% to 20%], P<0.001). The median American Thoracic Society dyspnea grade (3 [IQR, 1 to 4] vs. 1 [IQR, 0 to 1], P<0.001) and forced expiratory volume in one second (1.03 L [IQR, 0.52 to 1.36 L] vs. 1.98 L [IQR, 1.57 to 2.64 L], P=0.004) were significantly improved after intervention. There were no procedure-related acute complications and deaths.ConclusionRigid bronchoscopy with APC is an effective and safe procedure to alleviate central airway obstruction caused by tumors.

Ventilation and Anesthetic Approaches for Rigid Bronchoscopy

Due to growing interest in management of central airway obstruction, rigid bronchoscopy is undergoing a resurgence in popularity among pulmonologists. Performing rigid bronchoscopy requires use of deep sedation or general anesthesia to achieve adequate patient comfort, whereas maintaining oxygenation and ventilation via an uncuffed and often open rigid bronchoscope requires use of ventilation strategies that may be unfamiliar to most pulmonologists. Available approaches include apneic oxygenation, spontaneous assisted ventilation, controlled ventilation, manual jet, and high-frequency jet ventilation. Anesthetic technique is partially dictated by the selected ventilation strategy but most often relies on a total intravenous anesthetic approach using ultra-short-acting sedatives and hypnotics for a rapid offset of action in this patient population with underlying respiratory compromise. Gas anesthetic may be used with the rigid bronchoscope, minimizing leaks with fenestrated caps placed over the ports, although persistent circuit leaks can make this approach challenging. Jet ventilation, the most commonly used ventilatory approach, may be delivered manually using a Sanders valve or via an automated ventilator at supraphysiologic respiratory rates, allowing for an open rigid bronchoscope to facilitate ease of moving tools in and out of the airway. Despite a patient population that often suffers from significant respiratory compromise, major complications with rigid bronchoscopy are uncommon and are similar among modern ventilation approaches. Choice of ventilation technique should be determined by local expertise and equipment availability. Appropriate patient selection and recognition of limitations associated with a given ventilation strategy are critical to avoid procedural-related complications.