Double-lumen Bronchial Tube Research Articles

Effect of postoperative ultrasound-guided internal superior laryngeal nerve block on sore throat after intubation of double-lumen bronchial tube: a randomized controlled double-blind trial

BackgroundPostoperative sore throat (POST) is one of the main adverse postoperative outcome after tracheal intubation using double-lumen endobronchial tubes (DLTs). The aim of this study was to investigate the effectiveness and safety of ultrasound (US)-guided block of the internal branch of the superior laryngeal nerve (iSLN) for alleviating POST after intubation of DLTs.MethodsPatients undergoing thoracic surgery between August 2019 and August 2021 were randomized into two groups depending on whether they received US-guided iSLN block immediately after the operation. In the control group, the patients underwent a thoracic surgery under general anesthesia (GA) with DLTs without any special treatment, while the patients in the experimental group received US-guided iSLN block bilaterally with 2 ml of 0.25% ropivacaine on either side immediately after the operation. The primary outcome was the grading of sore throat at three-time points after the operation, i.e., immediate extubation, 2 h after extubation, and 24 h after extubation. Secondary outcomes included the rate of nausea and vomiting, hoarseness, dyspnea, and choking cough after swallowing saliva at 2 h after extubation.ResultsThe incidence and severity of sore throat were significantly lower in the experimental group than the control group at all time intervals (all P < 0.01). The rate of nausea and vomiting, hoarseness, dyspnea, and choking cough after swallow saliva at 2 h after extubation had no statistical difference (all P > 0.05).ConclusionsThe use of US-guided iSLN block can be effectively and safely applied to relieve POST after intubation of DLTs on thoracic surgery.Trial registrationThe study protocol was registered at the Chinese Clinical Trial Registry (http://www.chictr.org.cn, NO. ChiCTR2000032188, 22/04/2020).

Technique of pressurized intrathoracic aerosol chemotherapy (PITAC) for malignant pleural effusion.

ObjectivesMalignant pleural effusion (MPE) is a devastating evolution of several malignancies. Pressurized intrathoracic aerosol chemotherapy (PITAC) might be a novel therapy option in MPE.MethodsPITAC is considered for patients with MPE with a performance status <2 and without other metastatic sites. General anesthesia is administered and a double-lumen bronchial tube is inserted. The patient is placed in a lateral decubitus position, and the operation is performed after ipsilateral lung exclusion. Two 12-mm balloon trocars are inserted—one in the seventh intercostal space in the mid-axillary line and one in the fifth intercostal space in the anterior axillary line. Extent of pleural disease and volume of MPE are documented. MPE is removed and parietal pleural biopsy are performed. An intrathoracic pressure of 12 mmHg CO2 is established, and a combination of Cisplatin (10.5 mg/m2 in a total volume of 150 cc NaCl 0.9%) and Doxorubicin (2.1 mg/m2 in a total volume of 50 cc NaCl 0.9%) are aerosolized via nebulizer in the pleural cavity. Vital signs and nebulization are remote-controlled. After 30 min, the remaining toxic aerosol is exhausted using a closed surgical smoke evacuation system. A 24Fr chest tube is inserted in postero-apical position with continuous negative pressure of 20 cm H2O. When needed, PITAC may be repeated every six weeks in alternate with systemic chemotherapy.ResultsIn our hands, the technique above has shown to be feasible and safe.ConclusionsFurther studies are needed to assess the potential symptomatic and oncological benefits of PITAC in MPE.

Paediatric lung isolation

### Key points Lung isolation is required for a wide variety of pathology in paediatric patients. The varying size of the paediatric airway and size limitations of each lung isolation device poses a challenge to paediatric anaesthesiologists. The need for lung isolation includes: the prevention of contamination of one lung from the other due to haemorrhage or infection, the need to control the distribution of ventilation secondary to a bronchopulmonary fistula, a lung cyst or bullae, or severe hypoxaemia from unilateral lung disease. Extensive bronchopulmonary lavage may also necessitate lung isolation. Although lung isolation can assist in surgical exposure, in the paediatric population, surgical exposure for lung resections, mediastinal exposure, and thorascopy can often be accomplished by the CO2 pneumothorax and retraction of the operative lung without the need for lung isolation. This is most common in the young patient (<2 yr of age). Slinger1 teaches that there are the ‘ABCs’ of adult lung isolation: anatomy, bronchoscopy, and chest imaging. In paediatric lung isolation, there are still all the same ‘ABC’ considerations, with the addition of ‘D’—the varying diameter of the paediatric airway with age. ### Anatomy It has been long established that there are differences between the paediatric …

Role of upper airway ultrasound in airway management.

Upper airway ultrasound is a valuable, non-invasive, simple, and portable point of care ultrasound (POCUS) for evaluation of airway management even in anatomy distorted by pathology or trauma. Ultrasound enables us to identify important sonoanatomy of the upper airway such as thyroid cartilage, epiglottis, cricoid cartilage, cricothyroid membrane, tracheal cartilages, and esophagus. Understanding this applied sonoanatomy facilitates clinician to use ultrasound in assessment of airway anatomy for difficult intubation, ETT and LMA placement and depth, assessment of airway size, ultrasound-guided invasive procedures such as percutaneous needle cricothyroidotomy and tracheostomy, prediction of postextubation stridor and left double-lumen bronchial tube size, and detecting upper airway pathologies. Widespread POCUS awareness, better technological advancements, portability, and availability of ultrasound in most critical areas facilitate upper airway ultrasound to become the potential first-line non-invasive airway assessment tool in the future.

Video-Assisted Thoracoscopic Extended Thymectomy in Myasthenic Children

Myasthenia gravis (MG) is an autoimmune disease marked by weakness of voluntary musculature. Medical and surgical therapy of adult myasthenia is well documented. There is little pediatric surgical evidence, only a few case reports being available. The aim of this paper is to verify whether the surgical and anesthesiological techniques can warrant an early and safe discharge from the operating room. The secondary aim is to assess the presence of perioperative indicators that can eventually be used as predictors of postoperative care. During the years 2006–2009, 10 pediatric patients were treated according to a surgical approach based on video assisted thoracoscopic extended thymectomy (VATET). Standard preoperative evaluation is integrated with functional respiratory tests. Anesthetic induction was made with propofol and fentanyl/remifentanyl and maintenance was obtained with sevoflurane/desflurane/propofol ± remifentanyl. A muscle relaxant was used in only one patient. Right or left double-lumen bronchial tube (Rüsch Bronchopart® Carlens) placement was performed. Six patients were transferred directly to the surgical ward while 4 were discharged to the intensive care unit (ICU); ICU stay was no longer than 24 h. Length of hospital stay was 4.4±0.51 days. No patient was readmitted to the hospital and no surgical complications were reported. Volatile and intravenous anesthetics do not affect ventilator weaning, extubation or the postoperative course. Paralyzing agents are not totally contraindicated, especially if short-lasting agents are used with neuromuscular monitoring devices and new reversal drugs. Perioperative evaluation of the myasthenic patient is mandatory to assess the need for postoperative respiratory support and also predict timely extubation with early transfer to the surgical department. Availability of new drugs and of reversal drugs, the current practice of mini-invasive surgical techniques, and the availability of post anesthesia care units are the keys to the safety and successful prognosis of patients affected by MG who undergo thymectomy.

Rescue of hemodynamic compromise in superior vena cava syndrome with transesophageal echocardiography

The anesthetic management of patients with an anterior mediastinal mass is very challenging due to the potential risk of hemodynamic and respiratory compromise. A specialized anesthetic plan should be developed for in patients with an anterior mediastinal mass based on the preoperative clinical symptoms as well as, radiographic, computed tomographic, spirometric, and echocardiographic data [1,2]. A 31-year-old man (height 173.5 cm, weight 70.4 kg) came to our emergency department with right-sided chest discom fort, dry cough, progressive dyspnea, and orthopnea for the previous 4 weeks. The initial chest X-ray evaluation revealed a large amount of right side pleural effusion and a bulky mediastinal mass. Multi directional computed tomography revealed a 12.3 cm homogenous soft tissue mass in the anterior mediastinum compressing the superior vena cava and dis placing the ascending aorta. The trachea and both main bronchi were patent, but a cross-sectional area of the right upper lobe bronchus (7.21 mm) was reduced 44% relative to the left upper lobe bronchus (12.97 mm). Right loculated pleural effusion, totally collapsed right lower lobe and subsegmental atelectasis in the right middle lobe were noted. A therapeutic and diagnostic thoracentesis was done under local anesthesia, and 1,600 ml of pleural fluid was removed. Cytology of pleural fluid revealed many lymphocytes and mesothelial cells, but these were negative for malignancy. However, because dyspnea persisted and pleural effusion was increased after admission, a mediastinoscopic biopsy and pleural decortication were performed under general anesthesia. In the operating room, the CAPIOX emergency bypass system (CAPIOX Ⓡ EBS TM , Terumo Corporation, Tokyo, Japan) was prepared in the event of cardiopulmonary collapse. Before the induction of general anesthesia, a 20-guage catheter was placed in the right radial artery for continuous blood pressure monitoring. The patient was placed in the Semi-Fowler’s position with the head elevated 30 degrees to relieve the discomfort of the supine position. Initial vital signs were blood pressure 105/65 mmHg, heart rate 100 beats/min, respiration 25 breaths/min, and O2 saturation 96%. Preoxygenation with 100% O2 was administered using a face mask, and anesthesia was induced with a continuous infusion of propofol (effect-site concentration 4.0-5.0 μg/ml and remifentanil (effect- site concentration 3.0 5.0 ng/ml using a target-controlled infusion pump (Orchestra Ⓡ Base Primea, Fresenius Vial, Brezins, France) and a bolus dose of rocuronium 50 mg via a preexisting 16-guage IV catheter in the vein on the medial surface of the right leg. Intubation was successfully achieved using the left-sided Robert-Shaw double lumen bronchial tube in the supine position. Breath sounds were heard on both sides of the chest. Mechanical ventilation was maintained with a tidal volume, respiratory rate and partial pressure of end-tidal carbon dioxide of 500 ml, 15 breaths/min, and 28-32 mmHg, respectively. After induction, the arterial blood pressure began to drop to 60/35 mmHg and the heart rate increased to 110 beats/min. Ephedrine 10 mg were administered intravenously, but the vital signs were not improved. A transesophageal echocardiography (TEE) was performed for evaluation of hemodynamic instability. It showed that a large mass compressed the right atrium

Vorgehen bei einer katheterinduzierten Pulmonalarterienperforation

A 72-year-old woman presented with progressive dyspnea on exertion. There was no chest pain. A 4/6 systolic murmur was detected on auscultation. Echocardiography demonstrated a combined aortic valve defect with severe stenosis and moderate insufficiency, additionally a persistent foramen ovale. The coronary angiography revealed coronary heart disease with severe stenosis of the left anterior descending (LAD) and the right coronary artery (RCA). The stenosis of the aortic valve was severe (Pmax 91 mm Hg, Pmean 52 mm Hg). During catheterization of the right heart iatrogenic perforation of a pulmonary artery occurred, resulting in diffuse pulmonary bleeding. The patient suffered from progredient dyspnea and hemoptysis. Catheter-induced rupture of an artery of the right inferior pulmonary lobe was diagnosed. Because of bleeding into this lobe an immediate intubation with a double-lumen bronchial tube was necessary to ensure ventilation of the contralateral lung. Several attempts to occlude the arterial leak by ballon failed. Bleeding stopped after embolisation of the vessel by injection of thrombin. Iatrogenic rupture of a pulmonary artery is a rare and life-threatening complication of the catheterization of the right heart and demands rapid therapy. The protection of the contralateral lung by intubation with a double-lumen tubes is of highest priority. Selective embolization of the affected vessel via thrombin can be a lifesaving alternative to lobectomy or conservative therapy.

Gradient of bronchial end-tidal CO2 during two-lung ventilation in lateral decubitus position is predictive of oxygenation disorder during subsequent one-lung ventilation

Hypoxemia is one of the major problems during one-lung ventilation (OLV). During two-lung ventilation (TLV) using a double-lumen bronchial tube, bronchial endtidal carbon dioxide partial pressure (ETbr(CO2)) can be determined on both sides, independently. The ETbr(CO2) is mainly dependent on the pulmonary perfusion to each lung. If the degree of oxygenation disorder during OLV were to be predictable before starting OLV, this could provide time to prepare for any subsequent hypoxemia. The aim of this study was to investigate whether the difference of ETbr(CO2) (D-ETbr(CO2)) between the dependent and the nondependent lungs during TLV in the lateral decubitus position (LP) could be a predictive factor for the severity of oxygenation disorder under subsequent OLV. Eighteen patients undergoing lung surgery were enrolled in this study. Anesthesia was induced with intravenous thiopental and fentanyl, supplemented by the inhalation of sevoflurane. A left-sided double-lumen bronchial tube was placed. The ETbr(CO2) was independently determined on each side during TLV in the supine position (SP) and at 10 min after changing the position from SP to LP. PaO2/inspiratory fraction of oxygen (FIO2) was taken at 15 min after switching from TLV to OLV in LP. The decrease of PaO2/FIO2 at 15 min during OLV in LP correlated with the reduction of the D-ETbr(CO2) predetermined during TLV in LP (r = 0.698; P < 0.01). The D-ETbr(CO2) predetermined during TLV in LP could be a predictive factor for the severity of oxygenation disorder after starting OLV in LP.

Can ultrasound be useful for predicting the size of a left double-lumen bronchial tube? Tracheal width as measured by ultrasonography versus computed tomography

Study Objective To correlate tracheal width as measured by ultrasound with width measured by computed tomography (CT), and to evaluate the possible role of ultrasound in the selection of the proper size of left-sided double-lumen endotracheal tubes (LDLTs). Design Two independent, prospective, observational clinical studies (Study 1 and Study 2). Setting University hospital. Patients Study 1 included 25 patients and Study 2 included 20 adult thoracic surgery patients who required a LDLT during anesthesia. Interventions and Measurements In Study 1, CT measurements of tracheal width were made at the coronary plane 0.5 cm above the sternoclavicular joint; CT measurements of the left main bronchus diameter were made 1 cm below the carina. Ultrasound measurement of tracheal width was performed just above the sternoclavicular joint in the transversal section. In Study 2, patients' tracheas were intubated with a LDLT based on ultrasound measurements. The frequencies of incorrect selections of LDLT and unsatisfactory lung collapse were analyzed. Main Results There was a strong correlation between tracheal width as measured by ultrasound and tracheal width ( r = 0.882, P < 0.001) and left main bronchus width ( r = 0.832, P < 0.001) as measured by CT. In 5 cases (25%), the incorrect LDLT by ultrasound was selected; and one (5%) was found to have an unsatisfactory lung collapse. Conclusion Measurement of the outer tracheal width by ultrasound can be a useful method for predicting the diameter of left main bronchus and for selecting a LDLT.

Effect of prostaglandin E1 on inflammatory responses and gas exchange in patients undergoing surgery for oesophageal cancer

Oesophageal surgery causes morbidity and mortality from respiratory complications. We tested the possibility that prostaglandin E1 (PGE1) could reduce inflammatory cytokine responses and improve gas exchange after oesophagectomy. We randomized 14 patients into two groups. One group received PGE1 20 ng kg(-1) min(-1) i.v. during anaesthesia (PGE1 group) and the other group did not (control group). Anaesthesia was maintained with sevoflurane and epidural anaesthesia. During oesophagectomy, ventilation of one lung was carried out with a double-lumen bronchial tube. The patients were extubated on or after the first postoperative day. Blood samples were taken at induction of anaesthesia, at the end of thoracotomy, at the end of the operation, 2 h after surgery and on the first day after surgery. The groups were similar for ASA physical status, age, FEV1%, operation time, duration of thoracotomy, intraoperative fluid volume and blood loss. The arterial blood gas and arterial pressure during surgery were also similar in the PGE1 and control groups. However, the PaO2/FiO2 ratio on the first day after surgery was significantly greater in the PGE1 group compared with the control group. Serum concentrations of IL-6 and IL-8 increased after surgery in both groups. IL-6 was significantly less in the PGE1 group at the end of the operation and 2 h after the operation. Intraoperative PGE1 reduced IL-6 production in patients undergoing oesophagectomy and oxygenation was better in the postoperative period.

The use of a non‐invasive method to measure intrapulmonary shunt during one‐lung anaesthesia

The Non Invasive Virtual Shunt computer program has previously been described and validated. The system has subsequently been developed to give a real time, continuous trace of virtual shunt. A portable computer connected to routine monitoring equipment displays a plot of virtual shunt updated every 10 s. A practical use of this device in the clinical setting of one-lung anaesthesia is described. The equipment was used to monitor shunt before, during and after surgery in three patients. In one case, a displaced double lumen bronchial tube was detected before there was any other indication of the problem.

Capnothorax: implications for the anaesthetist

Ten patients underwent a laparoscopic surgical technique for thoracic and cervical dissection of the oesophagus during oesophagogastrectomy. Thoracotomy was avoided with potential benefits to the patient. To facilitate surgical access the right lung was collapsed using a double-lumen bronchial tube and carbon dioxide was insufflated into the right pleural cavity to compress the lung. Changes in haemodynamic and respiratory variables occurred. In the majority of the patients airway pressure and end-tidal CO2 increased, despite alterations in ventilation. In five patients systolic blood pressure decreased suddenly by between 15 and 35 mmHg, and in four patients SpO2 decreased to 91% or less, despite an FIO2 of 1.0. If carbon dioxide was insufflated too fast, or the lung failed to deflate adequately, the clinical picture was that of a tension pneumothorax. One patient developed surgical emphysema and a contralateral pneumothorax. Postoperatively two patients had recurrent laryngeal nerve damage. Suggestions are made to minimise the changes in haemodynamic and respiratory variables during carbon dioxide insufflation into the thorax.

Differential ventilation in acute bilateral lung disease. Influence on gas exchange and central haemodynamics.

Eight patients with acute respiratory failure (ARF) due to diffuse and rather uniform lung disease were intubated with a double-lumen bronchial tube and ventilated in the lateral decubital position by two synchronized ventilators. Ventilation of each lung was individually adjusted to match the expected regional blood flow (differential ventilation). When ventilation with equal volumes (i.e. 50% of tidal volume to each lung) was performed, a 19% reduction of venous admixture (P less than 0.001) and a 22% increment in arterial oxygen tension (P less than 0.001) were seen. Comcomitantly, the cardiac output increased by 17% (P less than 0.001), to which a reduced pulmonary vascular resistance may have contributed. The net result was a 14% increment of the oxygen availability (P less than 0.001). An attempt to go further, giving 2/3 of the tidal ventilation to the dependent lung, was made on six of the patients. However, this ventilatory pattern did not further improve the gas exchange and also had detrimental effects on the haemodynamics. It is concluded that differential ventilation with equal tidal volumes in the lateral position can substantially improve gas exchange and central haemodynamics in patients with ARF due to diffuse lung disease.

PHYSIOLOGICAL CHANGES ASSOCIATED WITH UNILATERAL PULMONARY VENTILATION DURING OPERATIONS ON THE LUNG

To FACILITATE the work of the thoracic surgeon it has become accepted procedure in certain circumstances to collapse the diseased lung being operated upon. To accomplish this, the technique most frequently used by the anaesthetist in this country calls for the insertion of a double lumen bronchial tube. This makes it possible to isolate the intact dependent lung from the diseased upper one and thus to prevent contamination of the sound lung. On the other hand, collapse of the uppermost lung causes serious functional respiratory modifications which call for special compensatory measures to avoid hypoxaemia. The purpose of this report is to stress again that optimum maintenance of oxygenation is crucial to the prevention of sustained cellular hypoxia and to show how this may be achieved. METHODS Eighteen patients were studied during routine operations on the lung carried out in the full lateral position. Pertinent clinical information on the patients included in this series is listed in Table I. Premedication consisted of meperidine, 50 to 75 mg and atropine sulfate 0.4 mg administered intramuscularly one hour before the operation. After induction with thiopentone 4 to 6 mg/kg body weight, succinylcholine 2 mg/kg of body weight was given intravenously and the larynx was sprayed with 4 per cent lidocaine. After passage of the bronchial tube its position was checked by auscultation before and after posturing of the patient in the lateral position. Anaesthesia was maintained with halothane 0.5 to 1.5 per cent vapourized in 95.5 to 98.5 per cent oxygen. Nitrous oxide may be added later, depending upon Pao= levels. Muscular relaxation was maintained by intermittent doses of D-tuboeurarine. The lungs were ventilated with a volume-preset Engstrom ventilator at a frequency of 16 cycles per minutes. A tidal volume of 19. ml/kg body weight was used. Following induction, the radial artery was cannulated percutaneously with a 90-gauge teflon catheter. Evaluation of pertinent parameters was done on two occasions during the operation. The first assessment was carried out after the patient had been postured in the lateral position and the pleural cavity had been opened for more than ten minutes with both lungs ventilated and perfused. At this time three samples were collected for analysis. A sample of venous blood from the pulmonary artery was taken directly by the surgeon, one of arterial blood was drawn from the previously cannulated radial artery and a sample of mixed expired