Lung isolation during port-access cardiac surgery: double-lumen endotracheal tube versus single-lumen endotracheal tube with a bronchial blocker

OBJECTIVE: The purpose of this study was to compare the use of a double-lumen endotracheal tube to a single-lumen tube combined with a bronchial blocker for lung isolation during Port-Access cardiac surgery. DESIGN: Prospective, randomized, controlled trial. SETTING: Tertiary care university hospital. PARTICIPANTS: Thirty-two patients undergoing Port-Access cardiac surgery via a right minithoracotomy. INTERVENTIONS: Patients were randomized to intubation with either a left-sided double-lumen tube (double-lumen group) or a single-lumen tube with concomitant use of a bronchial blocker (blocker group). Comparisons between groups included (1) intubation time, (2) number of laryngoscopy attempts, (3) time required for tube exchange at the end of the operation, and (4) surgical satisfaction with the lung deflation (1-5 scale: 5 = excellent). MEASUREMENTS AND MAIN RESULTS: The initial intubation time was similar between groups (118 +/- 82 seconds, double-lumen v 144 +/- 32 seconds, blocker; p = 0.2781). An additional 105 +/- 37 seconds was needed to exchange the double-lumen tube at the end of the operation. The double-lumen group also required more laryngoscopy attempts compared with the blocker group (2.3 +/- 0.6, double-lumen v 1.1 +/- 0.4, blocker; p = 0.0001). The lung deflation was better in the double-lumen group (5 [4-5], double-lumen v 4 [3-5], blocker, p = 0.0414). CONCLUSIONS: Compared with a single-lumen tube/bronchial blocker combination the double-lumen endotracheal tube required more laryngoscopy attempts and additional time to replace the tube at the end of the case but resulted in slightly better overall lung deflation.     

Use of the laryngeal mask for placement of a bronchial blocker in children

For one-lind ventilation in children, a bronchial blocker (e.g. Fogarty catheter) is often used, but its insertion may not be easy. We report a new method of placement of a bronchial blocker in an infant, using the laryngeal mask.     

Sequential lobar-lung-lobar isolation using a deflecting tip bronchial blocker

This case report describes the use of a bronchial blocker (BB) with a wheel-controlled tip (Cohen flexitip endobronchial blocker) to provide initially middle and lower right lobe isolation and then right lung isolation (RLI) during right lower lobectomy in a patient with compromised pulmonary function preoperatively. As predicted, RLI and one-lung ventilation were associated with worsening oxygenation. Toward the end of the surgery, RLI was converted back to middle and lower right lobe isolation and oxygenation returned to normal levels. The BB design made lobar isolation easier and enabled repositioning of the BB during surgery. The techniques used for BB insertion as well as lobar and lung separation are described.     

Single lung ventilation in children using a new paediatric bronchial blocker

As video-assisted thoracoscopic surgery has become more common in paediatric patients, the use of single lung ventilation in children has also increased. Single lung ventilation in young children is performed by either advancing a tracheal tube into the mainstem bronchus opposite the side of surgery or by positioning a bronchial blocker into the mainstem bronchus on the operative side. Techniques for placing a variety of bronchial blockers outside the tracheal tube have been described. We describe a technique for placement of a new bronchial blocker through an indwelling tracheal tube using a multiport adaptor and a fibreoptic bronchoscope.     

Con: The New Bronchial Blockers Are Not Preferable to Double-Lumen Tubes for Lung Isolation

The advantages and disadvantages of BBs versus DLTs are listed in Table 5. Whatever method of lung isolation is used, the following “ABCs” of lung isolation apply:

1 A: anatomy. Know the tracheobronchial anatomy. One of the major problems that many anesthesiologists have achieving satisfactory lung isolation is the lack of familiarity with distal airway anatomy.

2 B: bronchoscopy. Whenever possible, use a fiberoptic bronchoscope to position endobronchial tubes and blockers. The ability to perform fiberoptic bronchoscopy is now a fundamental skill needed by all anesthesiologists providing anesthesia for thoracic surgery. An online bronchoscopy simulator has been developed to help train anesthesiologists in positioning DLTs and blockers. This simulator, which uses real-time video, is available without cost at www.thoracicanesthesia.com.

3 C: chest imaging. The anesthesiologist should always look at the chest imaging before placement of a DLT or blocker. Abnormalities of the lower airway can often be identified in advance, and this will have an impact on the selection of the optimal method of lung isolation for a specific case.

喉罩联合支气管封堵器单肺通气对学龄患儿呼吸功能的影响

目的探讨喉罩联合支气管封堵器对单肺通气学龄患儿呼吸功能的影响。方法选择择期行胸腔镜手术患儿60例,男37例,女23例,年龄6～10岁,BMI 20～25 kg/m~2,ASAⅡ级,将患儿随机分为两组:喉罩组和气管插管组,每组30例。全麻诱导后采用压力控制模式机械通气,压力(P) 16 cmH_2O,RR 16次/分,PEEP 0 cmH_2O,I∶E 1∶2。记录麻醉前(T_0)、单肺通气开始(T_1)和单肺通气45 min(T_2)时的SBP、DBP及HR及T_2时的V_T、P_(ET)CO_2和肺顺应性(C_L),并采集T_2时桡动脉血进行血气分析。记录高碳酸血症、低氧血症、咽喉痛、喉痉挛和误吸等术后并发症的发生情况。结果T_1时喉罩组SBP、DBP明显低于气管插管组(P0.05)。T_2时两组SBP、DBP和HR差异无统计学意义。T_2时喉罩组PaO_2明显高于气管插管组,PaCO_2明显低于气管插管组(P0.05)。喉罩组V_(T )、C_L明显高于气管插管组,P_(ET)CO_2明显低于气管插管组(P0.05)。喉罩组高碳酸血症发生率明显低于气管插管组(P0.05)。结论在患儿胸腔镜术中,喉罩联合支气管封堵器单肺通气较气管插管加封堵器可获得更大的V_T,改善通气,促进CO_2排出,降低高碳酸血症发生率,更有利于气体交换。     

Differential lung ventilation using laryngeal mask airway and a bronchial blocker tube for a patient with unanticipated difficult intubation

We experienced differential lung ventilation using laryngeal mask airway (LMA) and a bronchial blocker tube for a patient with unanticipated difficult intubation. A 27-year-old man was diagnosed as the left spontaneous pneumothorax and scheduled for bulla excision with video-assisted thoracic surgery. Because of failure in tracheal intubation of the usual double lumen tube, we inserted LMAProseal #4 and accomplished differential lung ventilation using a bronchial blocker tube through LMA. This method will be effective in differential lung ventilation of the patient with difficult airway.     

单肺通气中应用支气管封堵器与双腔支气管导管的比较

目的比较支气管封堵器与双腔支气管导管在胸腔镜下肺大疱切除术中的应用。方法择期80例行胸腔镜下肺大疱切除术患者,随机均分为支气管封堵器组(Ⅰ组)和双腔支气管导管组(Ⅱ组)。Ⅰ组通过支气管封堵器实现单肺通气,Ⅱ组通过插入双腔支气管导管实现单肺通气,所有气管插管均由同一个熟练的麻醉医师完成。观察两组插管时间、定位时间、外科术野暴露程度和术后咽喉疼痛发生情况。结果Ⅰ组插管时间明显短于Ⅱ组(P<0.05),两组定位时间、外科术野暴露程度差异无统计学意义;Ⅰ组术后咽喉痛评分明显低于Ⅱ组(P<0.05)。结论支气管封堵器与双腔支气管导管均能有效应用在胸腔镜下肺大疱切除术患者单肺通气中,应用支气管封堵器可缩短插管时间及减轻患者术后咽喉疼痛。     

SaCo可视喉罩联合支气管封堵器在微创胸腔镜手术患者中的应用

目的 探讨SaCo可视喉罩联合支气管封堵器在微创胸腔镜手术患者中的应用.方法 选择2019年2月至2020年4月择期行微创胸腔镜手术患者77例,男52例,女25例,年龄18～80岁,BMI 19～24 kg/m2,ASAⅠ或Ⅱ级.采用随机数字表法将患者分为两组:喉罩组(LM组,n=39)和气管导管组(ET组,n=38)...     

The ProSeal laryngeal mask airway in children

BACKGROUND: The ProSeal (PLMA) is a new laryngeal mask device with a modified cuff to improve the seal and a drain tube to provide access to the gastrointestinal tract. We assessed the performance of the size 2 (which has no dorsal cuff) and size 3 (which has a dorsal cuff) in terms of insertion success, efficacy of seal, tidal volume, gas exchange, fiberoptic position, gastric tube placement and frequency of problems. METHODS: Eighty children undergoing minor surgery were studied (n = 40, size 2 PLMA, weight 10-25 kg; n = 40, size 3 PLMA, weight >25-50 kg). Induction was with remifentanil and propofol. Insertion was with the introducer tool and by experienced users. Maintenance was with propofol or sevoflurane and pressure controlled ventilation. RESULTS: The first-time and overall insertion success rate was 84 and 100%, respectively. Oropharyngeal leak pressure was 31 +/- 5 cmH2O. There were no gastric or drain tube air leaks. Tidal volume and gas exchange was adequate in all patients, other than two brief episodes of hypoxia because of airway reflex activation. The vocal cords and epiglottis were visible in 99 and 80%, respectively, via the airway tube. The first-time and overall insertion success rate for gastric tube insertion was 87 and 100%, respectively. During maintenance, the PLMA was removed in one patient with airway reflex activation and another required epinephrine for bronchospasm. There were no differences in performance between the sizes 2 and 3 PLMA. CONCLUSION: The PLMA is an effective airway device in children and isolates the glottis from the esophagus when correctly positioned. Despite the lack of a dorsal cuff, the performance of the size 2 was similar to the size 3 PLMA in the age groups tested.     

The airway management using laryngeal mask airway and tracheal fiberscopy in a pediatric patient with tracheal stenosis after tracheostomy

A 9-year-old boy was scheduled for excision of tracheal granuloma which had developed at the tip of a tracheostomy tube. Instead of a tracheostomy tube, a 4 mm ID tracheal tube was inserted via the tracheostomy beyond the tracheal constriction because of rapid development of respiratory failure. General anesthesia was induced and maintained with sevoflurane and oxygen via the tube, and a size 2.5 laryngeal mask airway (LMA) was inserted without muscle relaxant. Spontaneous respiration remained. Under monitoring by fiberoptic tracheoscopy via the LMA, the tracheal tube was extubated carefully. An 8 Fr. suction tube was indwelled via the tracheostomy beyond the stenosis for oxygen supply. After sealing the tracheostomy, he could breath spontaneously through the LMA. During the excision of tracheal granuloma by holmium:YAG laser, fiberoptic observation was continued via the LMA, and the procedure was performed without any complication. We conclude that the tracheal stenosis can be managed using the LMA, continuous fiberoptic monitoring and additional option of keeping spontaneous ventilation.     

Ultrasound-guided percutaneous dilatational tracheostomy with laryngeal mask airway control in a morbidly obese patient

Percutaneous dilatational tracheostomy (PDT) is a widely used and accepted method of long-term ventilation of critically ill patients in many intensive care units. However, it has certain contraindications that must be taken into account; for example, difficult anatomy and short, bull neck that are so often seen in morbidly obese persons. We present a case of a morbidly obese female patient in whom ultrasound-guided PDT was performed and in whom the airway was controlled by Laryngeal Mask Airway (LMA) during the procedure. Possible advantages of an ultrasonography-guided method and LMA control in morbidly obese patients also are discussed.     

Selective lobar bronchial blockade using a double-lumen endotracheal tube and bronchial blocker

We report our experience of a selective lobar bronchial blockade (SLBB) technique with a bronchial blocker (BB) which was employed successfully with a routine double-lumen endotracheal tube (DLT) in three patients. For the first case, we selectively blocked the infected left lower lobe in a surgical patient with a lung abscess in a DLT setting. For the second case, we applied this method to block the right middle and lower lobes in order to assess air leakage from the upper lobe during video-assisted thoracic surgery (VATS). For the third case, selective continuous positive airway pressure (CPAP) to the blocked lobes on the operative side resulted in oxygenation improvement with one-lung ventilation (OLV) in a DLT. This novel technique provides benefits during general thoracic surgery by preventing contamination, providing a better operative field, and improving oxygenation with lobar CPAP.