Endobronchial tubes - a case for re-evaluation

An endobronchial tube (Macintosh-Leatherdale) was used to secure the airway for a tracheal resection and end-to-end anastomosis. This lung separation device enabled insertion of both a fibreoptic bronchoscope and a tube exchange catheter. These were required after the trachea was transected and re-anastomosis proved surgically difficult. The airway exchange catheter allowed for jet ventilation and later a tube change when an emergency occurred. Options and management issues for tracheal surgery and lung separators are discussed. A case is made for a re-evaluation of endobronchial tubes both as a useful conduit for modern airway instruments and as an alternative to small double-lumen tubes for the increasing population of obese patients weighing > 100 kg, requiring thoracic surgery.     

One-lung ventilation using a new original connector: with a bronchial blocker and a single lumen tracheal tube

We experienced 22 consecutive anaesthetic managements requiring one-lung ventilation for thoracotomy. We used our original connector, which enabled us to insert a bronchial blocker cut from Univent tube and fibreoptic bronchoscope into the single lumen tracheal tube without air leakage and instability. The bronchial blocker was easily introduced into the mainstem bronchus of the non-dependent lung. The pulmonary alveoli were well collapsed through air-vent inside the bronchial blocker, and we could offer good surgical field. When one-lung ventilation was finished during surgery, we removed the bronchial blocker with connector, and could insert a larger fibreoptic bronchoscope and a suction catheter into the single lumen tracheal tube. We could detach or exchange the bronchial blocker, when they are not functioning well. This method was excellent in the airway management for usual thoracotomy.     

Acquired symptomatic bronchial stenosis in infants: successful management using an argon laser

Acquired bronchial stenosis following prolonged endotracheal intubation is uncommon, but in infants it is associated with significant morbidity. A variety of endobronchial techniques including forceps or cautery resection and balloon dilatation have been used with inconsistent results. Laser therapy seems attractive, but pediatric applications have been very limited. We report the first series of infants with life-threatening acquired bronchial stenosis treated with an argon laser. Eight infants, age 3 weeks to 2 years, presented with symptomatic bronchial obstruction following prolonged intubation. Seven of these patients had at least 90% obstruction of a lobar or mainstem bronchus. Under general anesthesia a 300 or 600 micron quartz laser fiber was passed through the suction channel of a 3.5-mm flexible or 3-mm rigid bronchoscope. The laser was operated at 2.5 to 3.5 W in 0.5-second pulses, to ablate the obstructing tissue. Multiple procedures, spaced no closer than 10 days, were required in three of eight infants. Follow-up bronchoscopy after 2 to 30 months revealed normal findings in five of eight infants. All but one child, who has persistent collapse of the bronchus intermedius due to bronchomalacia at the site of the obstruction, had satisfactory results. The only complication was a pneumothorax in a 1,300 g infant, which developed eight hours after treatment. Our experience suggests that the argon laser is effective in the management of endobronchial lesions in infants and is superior to the CO2 and Neo-dymium-yttrium aluminum garnet (Nd-YAG) lasers for this purpose.(ABSTRACT TRUNCATED AT 250 WORDS)     

Fibreoptic bronchoscopy under general anaesthesia using the laryngeal mask airway

The laryngeal mask airway was used to facilitate fibreoptic bronchoscopy under general anaesthesia in 140 adult patients. Following placement, the position of the mask was observed through the fibreoptic bronchoscope. Three different positions were identified. In 120 patients (86%) the concave surface of the mask faced the larynx directly with or without some unfolding of the epiglottis. In 17 patients (12%) the laryngeal mask appeared to be at an angle facing one pyriform fossa and in two patients the tip of the mask lay anterior to the arytenoids. No problems with ventilation or maintenance of an acceptable airway were encountered. In one patient repositioning of the laryngeal mask was necessary to allow the passage of the bronchoscope. One patient developed laryngospasm and required tracheal intubation.     

Laryngeal mask airway for ventilation during diagnostic and interventional fibreoptic bronchoscopy in children

BACKGROUND: The use of the flexible fibreoptic bronchoscope in infants and children has expanded to include both interventional and diagnostic bronchoscopy. The present report utilizes the laryngeal mask airway (LMATM) for ventilation and anaesthesia administration in children during fibreoptic bronchoscopy using an adult bronchoscope. METHODS: The technique was used in 10 children; their age ranged between 1.2 and 5 years. Six of these children had a history of foreign body aspiration and underwent interventional bronchoscopy, while four children underwent diagnostic bronchoscopy. Anaesthesia was induced by facemask using sevoflurane 6-8% followed by the insertion of a LMA size 2 or 2.5. A swivel adapter connected the proximal end of the LMA to the T-piece anaesthesia system. Anaesthesia was then maintained with spontaneous breathing of sevoflurane 2-4% in oxygen, delivered via the LMA. A flexible adult fibreoptic bronchoscope (outer diameter 4.9 mm) was inserted via the swivel adapter. RESULTS: The procedure could be accomplished successfully in the 10 patients. However, one child developed laryngospasm that was easily relieved by deepening the level of anaesthesia. In a second child hypoxia and hypercarbia occurred and were relieved by intermittent withdrawal of the fibreoptic bronchoscope. CONCLUSIONS: Laryngeal mask airway is a safe and effective adjunct to fibreoptic bronchoscopy under general anaesthesia in children. Its larger internal diameter compared with a tracheal tube permits the use of relatively large fibreoptic bronchoscope without a significant increase in airway resistance.     

Placement of left-sided double-lumen endobronchial tubes: comparison of clinical and fibreoptic-guided placement

We have compared a new intubation manoeuvre using a fibreoptic bronchoscope with conventional blind placement of a double-lumen tube. Thirty adult patients who presented for thoracoscopy requiring one-lung ventilation underwent endobronchial intubation with a double-lumen tube inserted either in the conventional blind way or using a fibreoptic bronchoscope. There were four misplacements of the double-lumen tube using the conventional method but none using the bronchoscope. In addition, the bronchoscope allowed more rapid intubation (mean 106 vs 347 s). The results suggest that the fibreoptic-guided method of inserting the double-lumen tube was a satisfactory alternative to the conventional one.      

Microlaryngoscopy-airway management with anaesthetic techniques for CO(2) laser

Carbon dioxide laser microlaryngoscopy requires planning and cooperation of both the anaesthesiologist and surgeon. While there are potentially significant complications, such as fire and difficulty ventilating the patient, laser microlaryngoscopy techniques provide the benefit of allowing for precise management of a wide range of upper airway conditions. Laryngoscopy and bronchoscopy require that the surgeon and anaesthesiologist cooperate in order to maximize exposure for the surgeon and allow for adequate ventilation of the patient. The type of airway the anaesthesiologist may use is dictated by whether access is needed to the hypopharynx, supraglottis, larynx, or subglottis. When the carbon dioxide laser is used for airway surgery, ventilation techniques that may be used include jet ventilation (subglottic or supraglottic) and intermittent or continuous endotracheal intubation, with a variety of tubes. The major complication to be avoided is airway fire. Each technique has advantages and disadvantages for avoiding fire and providing adequate ventilation. Fire is not a concern when the carbon dioxide laser bronchoscope is used, but the humidifier must be eliminated from the anaesthesia circuit to avoid vapour obstructing the bronchoscope coupler.     

Fibreoptic bronchoscopy for tracheal and endobronchial intubation with a double-lumen tube

A 68-year-old patient was scheduled for a thoracotomy. A double-lumen endobronchial tube was requested by the surgeon to facilitate operating conditions. Initial attempts at intubation by conventional methods were unsuccessful. The proximal ends of a 37F double-lumen tube were then shortened and a 4-mm fibreoptic bronchoscope was passed through the bronchial lumen. The patient's larynx was easily visualized and the bronchoscope was passed into the trachea. The double lumen tube was then advanced over the bronchoscope and correctly positioned. Shortening a double-lumen tube allows the use of a fibreoptic bronchoscope to aid in tracheal intubation in a patient whose larynx is difficult to visualize by conventional methods.     

The airway endoscopy mask: useful device for fibreoptic evaluation and intubation of the paediatric airway

A mask is presented which allows the administration of 100% oxygen, inhalational anaesthetics, continuous positive airway pressure and intermittent positive pressure ventilation during diagnostic airway endoscopy and difficult intubation with a fibreoptic bronchoscope in paediatric patients. The mask is particularly useful in small or critically ill patients. It may also have its place in teaching situations.     

Laryngeal mask airway facilitated fibreoptic bronchoscopy in infants

Purpose

To assess the efficacy of the laryngeal mask airway (LMA) for fibreoptic bronchoscopy (FOB) and bronchoalveolar lavage (BAL) in infants.

Methods

Observations were made in 19 consecutive infants undergoing FOB under general anaesthesia (GA) plus topical local anaesthesia. Anaesthesia was induced with N₂O, O₂, and halothane or sevoflurane except in two patients who received propofol and one who received thiopentone. Anaesthesia was maintained with oxygen and either sevoflurane, halothane, desflurane, or propofol infusion. No neuromuscular blockers were used. Size #1 or #2 LMAs were used through which a 3.5 mm fibreoptic bronchoscope was introduced. ECG, noninvasive blood pressure, pulse oximetry and, P_ETCO₂ were measured. Intra-and post-procedural complications were recorded.

Results

Mean age was 6 months; mean weight was 6.6 kg. Chronic wheezing was the indication for FOB in eight patients. Minor complications occurred in five patients: difficult LMA placement in one patient required changing size from #2 to #1; two patients had laryngospasm and bronchospasm that resolved with deepened anaesthesia and nebulised bronchodilator; one patient had transient arterial O₂ desaturation responding to increased FIO₂, and one patient required tracheal intubation because ventilation via LMA became inadequate.

Conclusion

The minor complications observed were similar to other series and did not result in morbidity or mortality. We feel that GA via LMA facilitates safe FOB in infants. It affords excellent airway management, a quiet patient, and passage of a larger fibreoptic bronchoscope for better imaging and suction channel required for BAL.     

An evaluation of one method of ventilation for laser therapy to the tracheobronchial tree

Laser therapy has been used extensively for surgery to the respiratory tract since its first application in 1971. At this hospital, the surgeon's preferred technique for laser surgery to the tracheobronchial tree is to use the Nd-YAG laser through a fibreoptic bronchoscope passed through a rigid bronchoscope. General anaesthesia is employed and ventilation is controlled using jet-ventilation by the Sanders technique. Review of the literature failed to locate adequate information on the effect of manoeuvres such as insertion of instruments and the presence of a tracheal obstruction distal to the bronchoscope on the quality of ventilation using this technique. A bench study was undertaken, therefore, in an attempt to mimic such clinical situations and to assess the effect of such manoeuvres on the adequacy and pattern of ventilation. Under all conditions tested 'end-tidal' CO2 concentrations accurately reflected distal 'tracheal' concentrations. The lowest inspired O2 concentration was 50% while entraining air through the bronchoscope. The highest was 86% while entraining oxygen.     

The effectiveness of ARNDT endobronchial blockers in paediatric scoliosis surgery

Introduction: Although described for paediatric thoracic surgery (1), there is little data on the use of the Arndt endobronchial blocker in paediatric spinal deformity surgery. We present its successful application in these patients. Methods: Thirteen patients undergoing surgical correction of scoliosis involving a lateral thoracotomy anterior approach were suitable for lung isolation using an Arndt endobronchial blocker. Placement was via an armoured tracheal tube; the endobronchial blockers were 5 or 9 FG with low‐volume low‐pressure cuffs (spherical or elliptical balloons). Placement was by a paediatric anaesthetist trained in paediatric bronchoscopy and required a 2.2 or a 2.8 mm paediatric fibreoptic bronchoscope. Results: Patient ages ranged from 18 months to 18 years and weights from 9 kg to 71 kg. All had idiopathic or congenital scoliosis; one patient underwent a VEPTR procedure. In all 13 patients, placement was easily and promptly achieved with no incorrect placements, displacements (including after patient repositioning), or failures to isolate one lung. Median time of insertion was 5 min (with checks), speed of insertion increasing as experience improved. Inflation times for the blocker balloon ranged from 1.5 h to 5 h. There was no airway trauma; direct bronchial inspection revealed local erythema only. Saturations were supported with 5 cm CPAP to the isolated lung and one‐lung ventilation was well tolerated in all but one patient with acceptable airway pressures (<35 cm water); this one patient required partial lung inflation (blocker in place, balloon not inflated) to maintain adequate saturations and airway pressures. The surgical field was excellent in all cases. Discussion: Complex paediatric spinal surgery may require lung collapse to improve spinal access, and is traditionally achieved using a double‐lumen tracheal tube. Difficulties can arise as the children are often small for age with potentially distorted airway anatomy and there are a limited number of double lumen tube sizes. This can lead to inadequate isolation, a poor surgical field, endobronchial cuff herniation or obstruction of left upper lobe (tube too small or too long). The careful use of the Arndt endobronchial blocker avoids all these problems and enables easy reliable and safe isolation. Potential complications include malposition, migration, and direct airway trauma, allied to the usual complications of one lung anaesthesia. In our series, there were no complications relating to its use and insertion was quick and straightforward. Conclusions: Lung isolation with the Arndt endobronchial blocker is both safe and very effective in paediatric spinal deformity surgery. Reference 1 Wald SH, Mahajan A, Kaplan MB et al. Experience with the Arndt paediatric bronchial blocker. Br J Anaesth 2005; 94 : 92–94.     

Fluoroscopic guidance of Arndt endobronchial blocker placement for single-lung ventilation in small children

Background: Thoracoscopic surgery may require single-lung ventilation (SLV) in infants and small children. A variety of balloon-tipped endobronchial blockers exist but the placement is technically challenging if the size of the tracheal tube does not allow the simultaneous passage of the fibreoptic scope and the endobronchial blocker. This report describes a technique for endobronchial blocker insertion using fluoroscopic guidance in children undergoing SLV.
Methods: After approval from the local Medical Ethics Committee and parental consent, 18 patients aged 2 years or younger scheduled for thoracic surgery requiring SLV were prospectively included. Following induction of anesthesia, a 5 Fr endobronchial blocker (Cook^® Arndt endobronchial blocker) was inserted first into the trachea under direct laryngoscopy. Correct placement in the main bronchus was assessed by fluoroscopy and tracheal intubation next to the endobronchial blocker. Optimal position and balloon inflation was verified using a fibreoptic scope. The duration and number of insertion attempts as well as age, weight and size of the tracheal tube were recorded.
Results: Eighteen patients were studied. Median (range) age and weight were 12 (0.2–24) months and 11.2 (4–15) kg, respectively. SLV was successfully achieved in all patients using a 5 Fr endobronchial blocker outside a 3.5–4.5 mm ID tracheal tube within 11.2 (±2.2) min. No side effects were observed during the procedure.
Conclusion: Fluoroscopic-guided insertion of extraluminal endobronchial blocker is an effective and reliable tool to place Arndt endobronchial blockers in small children.     

Univent导管在胸腔镜手术气道管理中应用的评价

目的探讨支气管堵塞器Univent导管进行单肺通气气道管理的价值。方法40例因气胸而需要行胸腔镜手术患者按随机数字表随机分为2组:一组为Univent组(U组);一组为双腔气管导管组(D组),使用Robertshaw导管。U组在纤维支气管镜引导下进行插管和定位,D组完成插管后用纤维支气管镜检查确认导管位置。记录2组成功放置导管所需要的时间;摆好体位后,导管移位需要用纤维支气管镜再进行检查和调整位置的次数;肺萎陷的程度;单肺通气期间的气道峰压;单肺通气后30min血气分析的结果。结果成功放置Univent导管的时间长于成功放置双腔气管导管的时间[(6.18±1.26)minvs(3.26±0.82)min,t=8.654,P=0.000]。U组术中导管移位镜检7人次,D组为5人次,差异无显著性(U=187.500,P=0.663)。2组肺萎陷程度差异无显著性(U组肺萎陷程度好15例,中3例,差2例;D组肺萎陷程度好17例,中2例,差1例;U=179.500,P=0.583)。U组的单肺通气气道峰压明显低于D组[(15.3±3.5)cmH2Ovs(21.4±6.6)cmH2O,t=-3.649,P=0.001];...     

Equipment for airway management

Airway management provides gas exchange, protects the lungs from injury and permits treatment. This requires safe, effective and reliable use of equipment, often using several items in combination. An airway management plan with backup plans is vital, and correct equipment use needs correct knowledge, skill and attitudes to form an airway management strategy; a sequence of logical plans. There are five approaches to airway management in which equipment is used: facemask ventilation with or without adjuncts, airway clearance with suction or foreign body removal, use of supraglottic airway devices, tracheal intubation with a variety of laryngoscopes (including the flexible fibreoptic bronchoscope (FFOB)), and transtracheal access using cricothyroidotomy or tracheostomy. Tracheal tubes and aids for placement are described.     

One way to ventilate patients during fibreoptic intubation

Occasionally anaesthesiologists find themselves in situations where ventilation during intubation with a fibreoptic bronchoscope (FOB) is desirable. In order to ventilate the patient during the FOB intubation, we used a 90 degree angle swivel connector, normally used for fibreoptic bronchoscopia in an intubated patient. After a nasotracheal tube is placed with the tip in the oropharynx, ventilation of the patient is possible via this tube by closing the mouth and other nostril. The fibrescopic procedure is done through the right-angle connector with suction port and the tube is used to guide the tip of the FOB to the aditus laryngis. The method has been used in 7 patients who were impossible to intubate with a conventional procedure. In all patients ventilation was possible and intubation was performed in 5 min (range 1-15).     

Awake fibrecapnic intubation in head and neck cancer patients with difficult airways: new findings and refinements to the technique

Recently, we described an adaptation of awake fibreoptic intubation that we call awake fibrecapnic intubation. The aim of this study was to evaluate the efficacy and risk of complications with this novel technique in a consecutive case series of head and neck cancer patients known to have difficult airways. We prospectively studied 40 consecutive intubations in head and neck cancer patients prior to a diagnostic or surgical procedure. Following topical anaesthesia, a flexible bronchoscope was introduced into the pharynx; spontaneous respiration was maintained in all patients. A special suction catheter was advanced into the airway through the suction channel of the bronchoscope for carbon dioxide measurements. When four capnograms were obtained, the bronchoscope was railroaded over the catheter and a tracheal tube was placed. All adverse events and complications were recorded. There were no complications associated with the technique. The median (range) time to intubation was 3 min (1.5-15 min). All patients were intubated successfully, 39 (98%) of them using awake fibrecapnic intubation. There was one patient with severe tumour bleeding and acute airway obstruction caused by advancement of the tube over the bronchoscope. This was not considered to be a complication of the fibrecapnic technique. Awake fibrecapnic intubation is a safe and valuable technique in head and neck cancer patients with a difficult airway.     

Equipment for airway management

Airway management provides gas exchange, protects the lungs from injury and permits treatment. This requires safe, effective and reliable use of equipment, often in combination. A management plan with backups is essential, but a sequence of logical plans forming an airway management strategy is better. Correct equipment use needs correct knowledge, skill and attitudes. There are five approaches to airway management in which equipment is used: facemask ventilation with adjuncts, use of supraglottic airway devices, tracheal intubation with a variety of laryngoscopes (including the flexible fibreoptic bronchoscope), front of neck (transtracheal) access using cricothyroidotomy or tracheostomy and airway clearance with suction or foreign body removal. Tracheal tubes and aids for placement are described.     

Equipment for airway management

Airway management provides gas exchange, protects the lungs from injury and permits treatment. This requires safe, effective and reliable use of equipment, often in combination. A management plan with backups is essential, but a sequence of logical plans forming an airway management strategy is better. Correct equipment use needs correct knowledge, skill and attitudes. There are five approaches to airway management in which equipment is used: facemask ventilation with adjuncts, use of supraglottic airway devices, tracheal intubation with a variety of laryngoscopes (including the flexible fibreoptic bronchoscope), front of neck (transtracheal) access using cricothyroidotomy or tracheostomy and airway clearance with suction or foreign body removal. Tracheal tubes and aids for placement are described.     

High-frequency jet ventilation through a fibreoptic bronchoscope channel during lung lavage

Simple manual ventilation facilitates removal of intra-alveolar accumulations. High-frequency jet ventilation can be performed through a narrow lumen like that of a fibreoptic bronchoscope. Accordingly, we expected that high frequency jet ventilation through a fibreoptic bronchoscope channel would facilitate lung lavage, and we developed a new bronchoalveolar lavage system, in which high-frequency jet ventilation through the channel of a fibreoptic bronchoscope was combined with conventional bronchoalveolar lavage. We describe a case in which this new lavage system, unlike conventional bronchoalveolar lavage, successfully removed the lipid material in the alveoli associated with pulmonary alveolar proteinosis.