Remimazolam-based anesthesia with Bougie-assisted high-frequency jet ventilation for severe central airway obstruction during rigid bronchoscopy: a case report

Central airway obstruction can present with acute respiratory distress, characterized by severe dyspnea and hypoxemia, and may require urgent intervention. Prompt endoscopic intervention is often essential for relieving the obstruction. Rigid bronchoscopy is typically performed under general anesthesia because of the profound airway stimulation associated with the procedure. However, shared airway access presents significant anesthetic challenges, including the risk of life-threatening airway collapse following induction. Remimazolam, an ultra-short-acting benzodiazepine associated with relatively limited respiratory and hemodynamic depression, may be a useful option in such settings. An 80-year-old man presented with tumor infiltration involving the carina, near-complete occlusion of the left main bronchus (luminal diameter, 2.05 mm), and approximately 70% stenosis of the right main bronchus (luminal diameter, 7.48 mm). He underwent rigid bronchoscopic tumor resection. A key component of the anesthetic strategy was preservation of spontaneous breathing until airway control was established, followed by controlled ventilation after partial restoration of airway patency. A novel approach combining remimazolam–remifentanil–propofol total intravenous anesthesia with Bougie-assisted high-frequency jet ventilation (HFJV) was employed. The modified Bougie was used to bypass the obstructed segment and deliver ventilation to the distal airway. The lowest intraoperative partial pressure of oxygen (PaO₂) was 58 mmHg while receiving 100% inspired oxygen, without hemodynamic compromise or significant cardiovascular fluctuations. This case illustrates that, in selected patients with critical central airway obstruction, a strategy combining remimazolam-based induction with Bougie-assisted HFJV may be considered when performed by an experienced multidisciplinary team with immediate access to appropriate rescue measures.