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.     

Use of the Arndt wire-guided endobronchial blocker via nasal for one-lung ventilation in patient with anticipated restricted mouth opening for esophagectomy.

Functional separation of the lungs may be accomplished by several methods. Patient with restricted mouth opening has limited options for one-lung ventilation. We report the use of wire-guided endobronchial blockade, a new tool for achieving one-lung ventilation in a patient with restricted mouth opening requiring nasotracheal, fiberoptic intubation for esophagectomy and reconstruction with gastric tube substitution.     

Experience with the Arndt paediatric bronchial blocker

Previously reported techniques for single lung ventilation inchildren have failed to provide consistent, single lung ventilationwith relative ease and reliability. We report our experiencewith the use of a new device, the Arndt 5 French (Fr) paediatricendobronchial blocker, for single lung ventilation in a seriesof 24 children. We were able to achieve single lung ventilationin 23 of the 24 patients (aged 2–16 yr). Placement requiredapproximately 5–15 min. Attempts at placement were abortedin one patient who was unable to tolerate even short periodsof apnoea because of lung pathology. Although it has some limitations,our experience suggests that the paediatric bronchial blockercan be used as a consistent, safe method of single lung ventilationin most young children.     

Devices for lung isolation used by anesthesiologists with limited thoracic experience: comparison of double-lumen endotracheal tube, Univent torque control blocker, and Arndt wire-guided endobronchial blocker

BACKGROUND: Lung isolation is accomplished with a double-lumen tube or a bronchial blocker. Previous studies comparing lung isolation methods were performed by experienced anesthesiologists in thoracic anesthesia. Therefore, the results of these studies may not be relevant to the anesthesiologist with limited experience. This study compared the success rates of lung isolation devices among anesthesiologists with limited experience in thoracic anesthesia. METHODS: A prospective, randomized trial was designed to determine the success and time required for proper placement of the left-sided double-lumen tube (n = 22), the Univent tube (Vitaid Ltd., Lewiston, NY; n = 22), and the Arndt Blocker (Cook Critical Care, Bloomington, IN; n = 22). Anesthesiologists with less than two lung isolation cases per month were included (faculty n = 17 and senior residents n = 11). Variables recorded included (1) successful placement (as determined by an independent observer), (2) time of placement, and (3) the number of times the fiberoptic bronchoscope was used. RESULTS: Participants failed to place or position their assigned device in 25 of 66 patients (failure was 39% among faculty and 36% among senior residents). The failure rate did not differ among the three devices (P = 0.65). The median (25th-75th percentile) times to complete the placement procedures were as follows: (1) double-lumen tube: 6.1 min (4.6-9.5 min), (2) Univent tube: 6.7 min (4.9-8.8 min), and (3) Arndt Blocker: 8.6 min (5.8-17.5 min) (P = 0.45 comparing all devices). After device malposition was identified, it took 1 min or less for the investigating anesthesiologist to achieve optimal position. CONCLUSIONS: Anesthesiologists with limited experience in thoracic anesthesia frequently fail to successfully place lung isolation devices. Rapid successful device placement by an experienced anesthesiologist excluded any contribution of uniquely difficult anatomy. The nature of the malpositions suggests that the most critical factor in successful placement was the anesthesiologist's knowledge of endoscopic bronchial anatomy.     

气管导管外放置Arndt支气管内阻断器与二氧化碳人工气胸用于婴幼儿单肺通气的比较

目的:比较气管导管外放置Arndt支气管内阻断器与CO 2人工气胸用于婴幼儿单肺通气的通气效果。方法:择期行胸腔镜手术的婴幼儿28例,年龄6~36个月,ASA分级Ⅰ、Ⅱ级。两组患儿在全身麻醉诱导后行Arndt支气管内阻断器或单腔支气管导管置入,术中根据需要行单肺通气。根据患侧肺萎陷方法不同按照随机数字表法分为两组(每组14例):Arndt支气管内阻断器组(A组)和CO 2人工气胸组(C组)。观察记录患儿插管前(T 1)、插管后(T 2)、单肺通气开始时(T 3)、单肺通气结束时(T 4)、拔管时(T 5)MAP、心率、气道压力(airway pressure,Paw)变化及术中重要时间点血气分析中PaO 2、PaCO 2情况。记录、肺萎陷程度、单肺通气时间、拔管时间及术中低氧情况(SpO 2低于90%)。结果:所有患儿均顺利完成手术。A组T 2、T 4、T 5时MAP及T 4、T 5时Paw高于C组(P<0.05),T 3时点的Paw低于C组(P<0.05)。A组肺萎陷即刻评分、肺萎陷20 min评分高于C组(P<0.05)。两组患儿心率、PaCO 2、PaO 2、单肺通气时间、拔管时间及低氧发生率差异无统计学意义(P>0.05)。A组患儿有1例导管移位导致低氧,C组有2例患儿由于长时间胸腔压力过大导致低氧发生,均未导致严重不良后果。结论:气管导管外放置Arndt支气管内阻断器相比CO 2人工气胸应用于婴幼儿单肺通气时,患侧肺萎陷效果更佳,血流动力学更稳定。     

High-frequency jet ventilation using the Arndt bronchial blocker for refractory hypoxemia during one-lung ventilation in a myasthenic patient with asthma

A novel method in the management of refractory severe hypoxemia during one-lung ventilation (OLV) in a patient who presented with myasthenia gravis, asthma, a symptomatic mediastinal mass, hiatal hernia, and a moderate pericardial effusion is presented. The patient was scheduled for excision of a large anterior mediastinal mass and creation of a pericardial window through a left thoracotomy. One-lung ventilation was achieved using an Arndt bronchial blocker. High-frequency jet ventilation (HFJV) was applied to the surgical nondependent lung through the lumen of the Arndt endobronchial blocker with titration of positive end-expiratory pressure to the dependent lung. Oxygenation improved significantly. The use of HFJV through the Arndt blocker offers an effective method for treatment of refractory hypoxemia during OLV.     

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.     

One-lung ventilation when intubation is difficult--presentation of a new endobronchial blocker

BACKGROUND: One-lung ventilation utilizing a double-lumen endotracheal tube may be technically difficult or inappropriate in morbidly obese or critically ill patients. In patients requiring awake fiberoptic intubation, double-lumen tube placement may be impossible. Wire-guided endobronchial blockade through a conventional endotracheal tube is a new alternative for these patients. METHODS: A 44-year-old, 133 kg female patient was scheduled to undergo a thoracotomy for transthoracic fundoplication. A wire-guided endobronchial blocker (WEB) was placed following rapid-sequence induction and intubation with an 8.0 OD single-lumen endotracheal tube with the aid of a pediatric bronchoscope. RESULTS: The WEB, using a guiding loop, was placed with ease and allowed effective one-lung ventilation. CONCLUSION: The WEB system allows one-lung ventilation to be achieved with a conventional endotracheal tube. The need for reintubation at the end of surgery is eliminated and endotracheal tube cross-sectional area is conserved.     

支气管封堵器在电视胸腔镜手术单肺通气中的应用研究

目的 评估支气管封堵器(endobronchial blocker,EBB)在电视胸腔镜手术中的应用效果. 方法 选择100例拟行择期电视胸腔镜手术(video assisted thoracoscopic surgery,VATS),完全随机分为EBB组(E组)和双腔支气管导管(double-lumen tube,DLT)组(D组),每组50例.观察比较两组患者的定位时间、肺塌陷时间、导管或EBB移位次数、肺隔离效果、气道压及下气道损伤情况. 结果 与D组比较,E组定位时间和肺隔离效果差异无统计学意义(P＞0.05).E组和D组肺塌陷时间分别为(8.5±3.5)、(4.5±2.9) min,套囊移位次数分别为23和5次,两组比较差异有统计学意义(P＜0.05);而D组患者单肺通气(one-lung ventilation,OLV)时压力显著高于E组,分别为(26±4)、(22±3) cm H20(1 cm H20=0.098 kPa);且其下气道中重度损伤例数也显著高于E组,分别为25和12例差异有统计学意义(P＜0.05). 结论 与DLT比较,EBB OLV术中肺萎陷时间长、位置易移动,但气道损伤小,能安全顺利地完成OLV,是满足VATS较好的OLV方法之一.     

Effectiveness of Arndt endobronchial blockers in pediatric scoliosis surgery: a case series

BACKGROUND: Pediatric scoliosis surgery may require single lung ventilation for surgical access. Current methods of lung isolation are inadequate for some or all of these children. The Arndt endobronchial blocker (EBB) has been described for use in pediatric thoracic surgery to enable single lung ventilation (SLV). There are few data on its use in pediatric spinal deformity surgery. We report the successful use of the Arndt EBB in a series of these patients. METHODS: Any patient undergoing surgical correction of scoliosis involving a lateral thoracotomy for an anterior approach was managed with an Arndt EBB (5, 7 and 9 Fr gauge) to facilitate SLV. All cases were undertaken by a pediatric anesthetist trained in pediatric bronchoscopy; a 2.2 or 2.8 mm pediatric fiberoptic scope was used for placement and positional confirmation. RESULTS: Patients' ages and weights ranged from 18 months to 18 years, and from 9.4 to 71 kg. All had idiopathic or congenital scoliosis; one underwent a vertical expansion prosthetic titanium rib (VEPTR) procedure. In all 20 patients, placement was easily and quickly achieved with no incorrect placements. There was one displacement after inflation, quickly corrected. Right upper lobe deflation proved difficult in one patient with high take-off of the right upper lobe bronchus. The surgical field was excellent in all cases. CONCLUSIONS: In our case series, Arndt EBB provided a safe and highly effective means of single lung isolation for children undergoing pediatric scoliosis surgery.