Bronchial intubation. A comparison between polyvinyl chloride and red rubber double lumen tubes

Red rubber and polyvinyl chloride bronchial double lumen tubes were compared. Polyvinyl chloride tubes are easier to pass quicker to position and cause less damage to the mucosa of the respiratory tract than the red rubber equivalents.     

Le tube Univent™ : un substitut aux tubes à double lumière

The Univent™ tube was designed as an alternative to double lumen endotracheal tubes. It is a conventional single lumen tube with an additional small channel within the concave anterior wall portion that houses a movable bronchial blocker used for lung isolation. A thin lumen in the blocker itself allows lung deflation and various ventilatory patterns (oxygen inflow, CPAP, jet-ventilation) in the blocked lung. Main indications for the Univent™ tube include difficult intubation, risk of aspiration and planned postoperative ventilation. The « blindinsertion of the bronchial balloon carries a high risk of primary malpositioning or secondary displacement that may cause a loss of the lung isolation or even tracheal obstruction. Initial insertion with fiberoptic bronchoscope is therefore required and this device must also be available during the whole period of one lung ventilation. High pressures generated by the bronchial cuff and higher cost than that of double lumen endotracheal tubes are two other factors that limit the use of the Univent™ tube.     

The Papworth BiVent tube: a new device for lung isolation

Provision of one lung ventilation can be technically challenging, particularly for anaesthetists who are only occasionally required to isolate one lung from the other. A new double lumen endotracheal tube, the Papworth BiVent Tube, has been designed to enable rapid and reliable lung isolation using any bronchus blocker without the need for fibreoptic endoscopic guidance. In this study, an airway-training manikin was used to assess ease of tracheal intubation and lung isolation using the Papworth BiVent tube. Ease of intubation was compared to a single lumen endotracheal tube and a conventional double lumen endobronchial tube. Ease of lung isolation when using a bronchus blocker was compared to a single lumen tube combined with a bronchial blocker. Tracheal intubation using the Papworth BiVent tube was found to be easier than when using a conventional double lumen endobronchial tube. Lung isolation using the Papworth BiVent tube used in combination with a bronchus blocker was achieved more reliably and rapidly than when using a single lumen tube and bronchus blocker.     

Difficulty in one-lung ventilation reveals tracheobronchial anomaly

A 57-year-old man with carcinoma of the esophagus was scheduled for a subtotal esophagectomy. We used a bronchial blocker tube to perform one-lung ventilation (OLV). But the OLV was not feasible because of a tracheobronchial anomaly of the right superior lobe bronchus. We replaced the bronchial blocker tube with a standard double lumen tube, and the OLV thus became complete. When we cannot perform a complete OLV with a bronchial blocker tube, we should consider the possibility of a tracheobronchial anomaly. When one is found in the right superior lobe bronchus, we should use a standard double lumen tube to perform the OLV.     

Blunt traumatic rupture of the thoracic oesophagus.

A man with a crush injury of his upper abdomen developed bilateral pulmonary empyema after repair of tears of the oesophagus and liver. Attempts to withdraw chest drains led to recurrent septicaemia, treated by reinsertion of the drains plus administration of antibiotics. The communication of the empyema space with both the bronchial tree and the oesophagus was managed successfully with intermittent positive pressure ventilation and with a double lumen endobronchial tube isolating the right lung for 10 days. Traumatic rupture of the thoracic oesophagus carries a high mortality and prompt repair is vital.     

Veno-venous extracorporeal membrane oxygenation in surgery for bronchial repair

Single-lung ventilation using a double-lumen endobronchial tube is often performed for surgical procedures involving the thorax. Tracheobronchial rupture during use of an endobronchial tube is an uncommon and serious complication. We present the case of a patient undergoing a right pneumonectomy who experienced a bronchial rupture due to a double-lumen endobronchial tube. Institution of veno-venous extracorporeal membrane oxygenation allowed removal of the endobronchial tube, and the repair was successfully performed. We hope that this information can provide further insight into the management of such a complication.     

Emergent thoracic endovascular aortic repair in a patient with hemoptysis due to bronchial fistula: a case for airway management

Bronchial fistula due to bronchial compression is a rare complication following both open surgical and endovascular repair of thoracic aortic aneurysms. We report on the airway management for a case of emergent thoracic endovascular aortic repair (TEVAR) in a patient with left bronchial obstruction due to hemoptysis. A 68-year-old man had undergone total arch replacement 8 years before, and was preoperatively diagnosed with aortobronchial fistula in the left lung. To prevent obstruction of the right lung by rebleeding in the left bronchus, we planned to exchange the single lumen endotracheal tube placed following hemoptysis to a double lumen tube prior to the operation. With assisted spontaneous breathing, bronchoscopy performed before replacing of the endotracheal tube showed obstruction of the left bronchus with many clots. With bronchoscopic assistance, clots were removed from the left bronchus and oxygenation improved significantly. We found a blue nylon suture penetrating the bronchial wall, most likely from a previous operation. However, bronchoscopy did not disclose aortobronchial fistula. Following TEVAR, the patient was diagnosed with bronchopleural fistula induced by bronchial compression due to blood vessel prosthesis and surrounding felt strips. Cooperation from surgeons and careful airway management were required to prevent life-threatening oxygenation insufficiency.     

Airtraq optical laryngoscope

BACKGROUND: We described an early experience of Airtraq laryngoscope in 20 patients receiving general anesthesia. METHODS: In all, 2 staff anesthesiologists, 3 anesthesia residents and 10 non-anesthesia residents performed endotracheal intubation with 14 polyvinyl chloride tubes with inside diameter of 7-8 mm, 5 double lumen 37-F tubes and 1 preformed nasotracheal tube. RESULTS: Every endotracheal intubation was achieved at the first trial, and the mean time to secure the airway was 46 +/- 18 seconds. CONCLUSIONS: Airtraq laryngoscope is a useful novel device for tracheal intubation.     

Iatrogenic tracheal and left bronchial stenoses. Uncommon complication of Carlens tube. Apropos of a case surgically treated in a single stage

Independent synchronized ventilation of each lung is a new form of management of severe predominantly pulmonary lesions unaliteral. Mechanical ventilatory assistance is also used via a cuffed double lumen tube (Carlens tube). Tracheal stenosis and bronchial stenosis may result from injury caused by respiratory assistance given via this tube. The etiology of the lesion appears to be direct pressure erosion of the tracheal and bronchial walls by the cuff with subsequent repair by scarformation. These lesions were present in a young man. This report describes the surgical treatment: the double stenosis was treated by resection with end-to-end anastomosis with an excellent result.     

A case report of bronchial rupture with a polyvinylchloride (PVC) double-lumen tube

The patient is a 58-year-old man with a 3-months history of painful swallowing. Endoscopy and biopsy demonstrated squamous cell carcinoma of the middle one third of the esophagus. On Sept. 13, 1987, the patient underwent surgery. The patient was intubated with the PVC double-lumen tube. After the resection of esophagus, when lymphadenectomy was performed, we noticed the herniation of a bronchial cuff through the left main bronchial tear. Surgical repair of the lesion was accomplished with a continuous suture with 3-0 vicryl. Subsequent course of the patient was uneventful. Tracheobronchial rupture is rare complication of intubation with PVC double-lumen tube. This complication results from measures such as using an inadequate tube size, malpositioning the tip of the tube, or insufflating the balloon too rapidly, which dose not allow adaptation of the balloon to the tracheobronchial wall. In our case, overinflation of the bronchial balloon was probably the etiology of rupture. This was probably secondary to diffusion of nitrous oxide, rather than initial over-distension. Meticulous cares must be emphasized to avoid such complication.     

One lung ventilation in infants and children: experience with Marraro double lumen tube

BACKGROUND: Our objective was to evaluate the efficacy of selective bronchial intubation and independent lung ventilation during thoracic surgery in children up to 3 years, using a double lumen tube. METHODS: We studied retrospective (cases 1-6) and prospective cases (7-17) between January 1996 and December 2000 at the All India Institute of Medical Sciences, New Delhi, India and at Fatebenefratelli and Ophthalmiatric Hospital, Milan, Italy. Seventeen children, 1 day to 3 years of age and weighing 2.7-12 kg, were submitted to thoracic surgery for a variety of surgical conditions. Anesthesia was conducted as usual in this type of patient and selective intubation was performed using a double lumen tube (Marraro Pediatric double lumen tube). During the operation one lung ventilation was applied and at the end of surgery the collapsed lung was reexpanded independently from the contralateral lung. RESULTS: Six children remained intubated with a double lumen tube for between 8 and 48 h and one (case no. 11) with a single lumen tube for 24 h, while 10 of the older children were extubated on the table. No serious complications during or after surgery were noted and after extubation all the children recovered completely without sequelae. CONCLUSIONS: The double lumen tube appears to be very effective in allowing one lung ventilation in this age group during thoracic surgery.     

Methods of lung separation

In the last few years, video assisted thoracoscopy, which allows a wide variety of diagnostic and therapeutic procedures, has been introduced into clinical practice. A growing enthusiasm for minimally invasive surgical approaches and improvements in video endoscopic surgical equipment has resulted in the widespread use of this technique. Most video assisted thoracoscopy procedures require a well-collapsed lung and should only be included in the absolute indication for one-lung ventilation. Following placement of a double lumen tube, it is the standard of care to check the tube is positioned correctly using fiberoptic bronchoscopy. The role of the right-sided double lumen tube is discussed in detail in this review. Finally, there are alternatives to the use of the double-lumen tube to achieve lung separation, such as the Univent tube or an independent bronchial blocker. In many situations the double-lumen tube cannot be inserted, due to a difficult airway or at the conclusion of the procedure changing the double lumen tube to a single lumen tube may result in loss of control over the airway. In such situations, it is essential for the anesthesiologists to be familiar with the existing alternatives to the double-lumen tube.     

Bloqueio lobar seletivo com um bloqueador Coopdech combinado com um tubo endotraqueal de duplo lúmen para ressecção de metástases pulmonares com laser

In recent years, laser resection of lung metastases has been established as the standard procedure worldwide. To avoid airway fire, it is necessary to collapse the surgical lung. The selective lobar bronchial blockade is a technique that allows one‐lung ventilation while the operated lobe is collapsed in patients with previous pulmonary resection requiring subsequent resection or with limited pulmonary reserve. We report a clinical case about our experience of a selective lobar bronchial blockade technique with a bronchial blocker (Coopdech endobronchial blocker) that was employed successfully with a double‐lumen endotracheal tube in a patient with previous contralateral pulmonary resection who was scheduled for atypical resections of pulmonary metastases by laser. We selectively blocked the right intermediate bronchus for management of hypoxemia during one‐lung ventilation. This technique provided adequate ventilation and oxygenation during surgery, avoiding the need of two‐lung ventilation during lung metastases resection by laser.

Prolonged per-laryngeal endotracheal intubation in children: 40 years on

Because tracheostomy has a very high complication rate in small children, prolonged mechanical ventilation was not performed satisfactorily in infants until a technique was developed that allowed prolonged per-laryngeal endotracheal intubation in children. Plastic polyvinyl chloride endotracheal tubes were introduced in the 1950s; they soften at body temperature, and are much less likely to cause subglottic stenosis than endotracheal tubes made from metal or rubber. The first account of prolonged per-laryngeal intubation of infants using polyvinyl chloride tubes was written by Dr Bernard Brandstater, and this remarkable document is reproduced here. It sets out all the important principles of endotracheal intubation in children: the tube must fit easily through the cricoid ring, it must be firmly fixed in place with the tip in the mid trachea, meticulous humidification and suction are essential, and the tube should be changed only if there are signs of obstruction.     

Treatment of acute total atelectasis

Three cases are described of complete collapse of a lung in the absence of bronchial obstruction. The condition was treated by the application of a sustained high pressure (6 kPa) to the affected lung through one limb of a double lumen bronchial tube whilst intermittent positive pressure ventilation was continued through the other limb.     

钢丝加强聚脲胺酯硬膜外导管减少硬膜外出血发生率

目的 比较钢丝加强聚脲胺酯与聚氯乙烯硬膜外导管对硬膜外腔出血发生率的影响. 方法 150例拟行连续硬膜外或蛛网膜下腔-硬膜外联合阻滞患者,按随机数字表法分为聚氯乙烯硬膜外导管组(A组,n=75)和钢丝加强聚脲胺酯硬膜外导管组(B组,n=75),以阻力消失作为判断硬膜外针到达硬膜外腔的标志,记录放置硬膜外导管遇到阻力和同抽出血情况.追踪术后1周有无硬膜外血肿发生. 结果两组间性别、年龄、体重等差异无统计学意义(P>0.05). A组和B组未遇到明显阻力分别为42.7%和78.6%,遇到轻微阻力分别为48.0%和16.0%;遇到阻力较大,放入导管困难分别为9.3%和5.4%,组间比较差异有统计学意义(P<0.01).A组无回血为82.6%,有不连续回血率为10.7%,有连续回血率为6.7%;B组无回血率为100%,组间比较差异有统计学意义(P<0.01).两组术后均无硬膜外血肿压迫症状的并发症.结论 聚氯乙烯硬膜外导管损伤硬膜外血管引起出血为常见并发症,采用钢丝加强聚脲胺酯硬膜外导管可显著减少硬膜外出血发生率.     

Lung separation in the patient with a difficult airway

During video-assisted thoracoscopy the lungs should be well collapsed to allow the surgeon an optimal view of the surgical field. The use of 'difficult tubes' such as the double lumen tube or Univent cannot be avoided despite the presence of a difficult airway. If it is only possible to place a single lumen tube, a tube exchanger can be used to switch to a double lumen tube or a Univent tube. Alternatively, a Fogarty embolectomy catheter can be passed down the single lumen tube as an independant bronchial blocker. The Bullard and the Wu laryngoscopes and the laryngeal airway mask can further assist in establishing an airway. Finally, depending on the extent and the length of the procedure, an airway, initially not classified as difficult, may become difficult and postoperative planning is a must.     

Diagnosis, procedures and conservative therapy of a bronchial rupture after intubation with double-lumen tube

Bronchial rupture is a rare but severe complication of intubation with a double-lumen tube. Cardinal symptoms are mediastinal and subcutaneous emphysema as well as pneumothorax. Larger injuries result in an air leak and the endtidal carbon dioxide decreases. The gas exchange may worsen drastically when mucosal prolapse or bronchial haemorrhagia lead to bronchial occlusion. Mediastinitis or sepsis can be the sequel of the opened mediastinum. If bronchial injury is suspected probably fibreoptic bronchoscopy is indicated. We report on a case of bronchial rupture due to overinflation of the endobronchial cuff or movement of the inflated cuff when repositioning the patient. The conservative therapy was successful in spite of the fact that surgical intervention is recommended in the literature following bronchial rupture. To avoid tracheobronchial injuries an adequate tubus size must be selected. The more flexible polyvinylchloride (PVC) tubes without a carinal hook should be preferred to the Carlens tube. An atraumatic intubation is promoted by leaving the stylet inside after the tip of the tube has passed the vocal cords. To identify the minimum occlusive pressure of the endobronchial cuff for lung isolation different methods are described and should be used. The cuff has to be deflated when the patient is repositioned and when one-lung-ventilation is not required. Tumours of the tracheobronchial tree and weakness of the bronchial wall caused by steroid hormone therapy or COPD may increase the risk of tracheobronchial laceration.     

Tracheobronchial injury

We studied 6 cases of tracheobronchial injury due to the blunt chest truma in our department. All patients were male of 19 to 60 years of age. Injured sites were main bronchus in 2, tracheobronchial portion in 2, cervical trachea and main bronchus in 1, cervical trachea in 1. In a case of cervical tracheal injury and 2 cases of tracheobronchial injury, emergent operation was performed on the day of accident. Other cases with the main bronchial injury underwent conservative treatment at first, but subsequent bronchoplasty was necessary for them due to the bronchial stenosis. After the surgery for 2 cases of tracheobronchial injury, mechanical ventilation with double lumen tube was continued to reduce the airway pressure for the anastomotic sites. In conclusion, early surgical treatment is recommended for the airway injury and the respiratory management using double lumen tube after surgery may be helpful in preventing trouble at the anastomosis.     

Bronchial complication of a closed-tube endotracheal suction catheter

Iatrogenic bronchial complications in intubated premature infants are rare. The authors present one case of rupture of a closed-tube endotracheal suction catheter. Clinical presentation was a persistent pneumothorax that required chest tube placement in several days. A foreign body was confirmed in x-ray and computed tomography (CT) scan. Flexible bronchoscopy showed a piece of catheter in the left bronchus and using a rigid bronchoscope was possible to remove. No perforation was found. There are a few reports in the literature of iatrogenic bronchial complication in premature infants caused by closed-tube endotracheal suctioning catheters. Endobronchial rupture of this catheter has never been reported. J Pediatr Surg 37:1483-1484.