Remifentanil-Propofol-Ketamine- Based Total Intravenous Anesthesia with Spontaneous Breathing for Adult Rigid Bronchoscopy

<b>Background:</b> Rigid bronchoscopy (RB) is the gold standard for managing central airway obstruction (CAO), a life-threatening condition caused by both malignant and benign etiologies. Anesthetic management is challenging as it requires balancing deep sedation with maintaining spontaneous breathing to avoid airway collapse. There is no consensus on the optimal anesthetic approach, with options including general anesthesia with neuromuscular blockers or spontaneous assisted ventilation (SAV). <b>Methods:</b> This case series presents our anesthetic protocol using remifentanil-propofol-ketamine total intravenous anesthesia (TIVA) with SAV in four patients with airway obstructions. Muscle relaxants were avoided in all cases. <b>Results:</b> Ketamine's ability to preserve respiratory drive and airway reflexes, along with its bronchodilating properties, made it ideal for managing CAO. All procedures successfully restored airway patency without complications or drug-related side effects. <b>Conclusions:</b> Our findings suggest that remifentanil-propofol-ketamine TIVA combined with SAV is a viable anesthetic approach for therapeutic RB, offering effective sedation, maintaining airway patency, and minimizing perioperative complications.