Double-lumen Tube Research Articles

Current approaches to anesthetic management in thoracic surgery-An evaluation from the German Thoracic Registry

While many hospitals in Germany perform thoracic surgery, anesthetic techniques and methods that are actually used are usually only known for individual departments. This study describes the general anesthetic management of three typical thoracic surgical procedures across multiple institutions. The German Thoracic Registry recorded 4614patients in 5 institutions between 2016 and 2019. Hospitals with aminimum number of more than 50 thoracic procedures per year are eligible for inclusion in the registry. To analyze the anesthetic management, amatching process yielded three comparable patient groups (n = 1506) that differed solely in the surgical procedure. Three surgical procedures with varying degrees of invasiveness were selected: Group A = video-assisted thoracoscopic surgery (VATS) with wedge resection, group B = VATS with lobectomy, group C = open thoracotomy. Statistical analysis was performed descriptively using relative and absolute frequencies. Dichotomous variables were compared using the χ2-test. The study enrolled patients with amedian age of 65.6years. The mean value of the American Society of Anesthesiologists (ASA) classification was 2.8. One lung ventilation was most commonly performed (group A = 98.2%, group B = 99.4%, group C = 98.0%) with double lumen tubes (DLT). Bronchial blockers (group A = 0.2%, group B = 0.4%, group C = 0%) were rarely used. Primary bronchoscopy was used to control double lumen tubes after insertion in the majority of cases (groupA = 77.5%, groupB = 73.1%, group C= 79.7%). Continuous positive airway pressure (CPAP, group A = 1.2%, group B = 1.4%, group C = 5.1%) and jet ventilation (group A = 1.6%, group B = 1.6%, group C = 1.4%) were rarely used intraoperatively. In group C, the administration of avasopressor was also more frequently required (group A = 59.9%, group B = 77.8%, group C = 86%). Acentral venous catheter was established in 30.1% of all patients in groupA, 39.8% in groupB and 73.3% in groupC. Patients in groupA received an arterial catheter less frequently (71.7%) when compared to groupsB (96.4%) andC (95.2%). Total intravenous anesthesia with propofol was used in most patients (group A = 67.7%, groupB61.6%, groupC 75.7%). Propofol supplemented by volatile anesthetics was used less frequently (group A = 28.5%, group B = 35.5%, group C = 23.7%). With increasing invasiveness of the surgical procedure, placement of an epidural catheter was preferred (group A = 18.9%, group B = 29.5%, group C = 64.1%). Paravertebral catheters (group A = 7.6%, group B = 4.4%, group C = 4.8%) or asingle infiltration of the paravertebral space were performed less frequently (group A = 7.8%, group B = 17.7%, group C = 11.6%). Postoperatively, some patients (3.4-25.7%) were transferred to the general ward. The largest proportion of patients transferred to ageneral ward underwent less invasive thoracic procedures (groupA). When the extent of resection was greater (groupB and groupC) patients were mostly transferred to an intermediate care unit (IMC) or an intensive care unit (ICU). The insertion of invasive catheters was neither associated with the patients' ASA classification nor preoperative pathologic pulmonary function. Our data indicate that less invasive thoracic operations are associated with areduction of invasive anesthetic procedures. As the presented data are descriptive, further studies are required to determine the impact of invasive anesthetic procedures on patient-related outcomes. This evaluation of the anesthetic management in experienced thoracic anesthesiology departments represents the next step towards establishing national quality standards and promoting structural quality in thoracic anesthesia.

Airway Management of a Giant Thoracic Ganglioneuroma Causing Airway Obstruction in a 3-Year-Old Child

Large tumours occupying one half of the thoracic cavity are rare and may cause life-threatening complications by compression or invasion of vital structures that results in cardiovascular and/or respiratory insufficiency. In-depth preoperative planning is necessary after assessment of perioperative risk of hemithoracic masses. By providing lung isolation, one-lung ventilation technique provides improved surgical conditions compared to conventional dual-lung ventilation for thoracic surgery. As double-lumen tubes are not available for smaller children, balloon-tipped bronchial blockers remain the technique of choice, especially under the age of 6 years. Huge intrathoracic masses in small children with radiological and clinical findings suggesting airway compression are high risk for airway complications. Fibreoptic bronchoscope-guided intubation should be preferred in view of tracheobronchial compression by the mass and placement of an endobronchial blocker helps in one-lung ventilation in small children. The management of these tumours is challenging and should be performed only in specialised centres.

General anaesthesia with double-lumen intubation compared to opioid-sparing strategies with laryngeal mask for thoracoscopic surgery: A randomised trial

BackgroundGeneral anaesthesia for thoracoscopic lung surgery can be performed with the opioid-sparing strategies without intubation and may reduce the risk of glottic injury and enhance recovery after surgery. We therefore tested the primary hypothesis that avoiding intubation reduces glottic injury. MethodsAdults having elective thoracoscopic lung resections were randomised to: (1) intubated group: routine general anaesthesia with a double-lumen tube intubation; or, (2) non-intubated group: a bundle of opioid-sparing strategies, which included paravertebral blocks and total intravenous anaesthesia with minimal remifentanil infusion from 0.05 to 1.0 ng/mL (avoid sufentanil unless the respiratory rate exceeds 25/min or the systolic blood pressure exceeds 30% of the baseline value), no muscle relaxation, and spontaneous ventilation through a laryngeal mask. The primary outcome was glottal injury as determined by transnasal bronchoscopy one hour after removal of the laryngeal mask or double-lumen tube. ResultsTwo hundred seventeen patients were assessed for the primary outcome. Sufentanil use was reduced 96% and remifentanil was reduced 40% in non-intubated opioid-sparing patients. The incidence of glottal injury was 9% (10/109) in the non-intubated vs. 37% (40/108) in the intubated patients (RR: 0.25; 95%CI: 0.13–0.47, P < 0.001). The non-intubated group also had less postoperative sore throat (8% vs. 39%; P < 0.001) and hoarseness (3% vs. 19%; P < 0.001). Postoperative pulmonary complications and lung injury biomarkers did not differ between the groups. Compared to the intubated group, the non-intubated group had less postoperative pain, faster recovery, and improved quality-of-life scores. ConclusionsNon-intubated opioid-sparing strategies for video-assisted lung resections reduce airway injury and promote postoperative recovery. Clinical trial number and registry URLChiCTR1800018198https://www.chictr.org.cn/showproj.aspx?proj=30780

Effects of Thermal Softening of Double-Lumen Endobronchial Tubes on the Prevention of Postoperative Sore Throat in Smokers: A Randomized Controlled Trial

Tracheal intubation-related complications, such as postoperative sore throat (POST), hoarseness, and vocal cords injuries, are not uncommon. It is well known that thermal softening of double-lumen endobronchial tubes (DLTs) has been used to prevent these events from happening in non-smokers; however, no study has ever assessed the effects of thermal softening of DLTs in smokers undergoing one-lung anesthesia. The authors aimed to investigate whether thermal softening of DLT can achieve a better effect in preventing POST. A total of 258 smokers scheduled for one-lung anesthesia were randomly assigned to 1 of the following 2 groups: (1) group C (non-thermal softening group) and (2) group T (DLTs were placed in 40°C 0.9% saline for 10 minutes). Incidence and severity of POST and hoarseness were assessed until 48 hours after surgery. Vocal cords were examined using laryngoscope before intubation and immediately after extubation. Patients' hemodynamic change at intubation and extubation was recorded. The primary outcomes were the incidence and severity of POST. The secondary outcomes were the incidence and severity of hoarseness, vocal cords injuries, and patients' hemodynamic change at intubation and extubation. Sore throat and vocal cord injuries occurred less frequently in the thermal softening group than in the control group (31/129 v 60/129, p < 0.01; 21/129 v 49/129, p < 0.001; 12/129 v 35/129, p < 0.001 for sore throat; 14/70 v 27/70, risk ratio (95% confidence interval): 0.52 (0.30-0.90), p=0.025 for sore throat; 5/129 v 52/129, p < 0.05 for vocal cord injuries). Thermal softening of DLTs significantly reduced the incidence and severity of DLTs intubation-related POST within 72 hours after extubation.

Dilutional acidosis during whole lung lavage under general anesthesia due to excessive absorption of normal saline

BackgroundWhole lung lavage (WLL) is an effective therapy for pulmonary alveolar proteinosis. We report a rare dilutional acidosis following WLL in a female patient.Case presentationUnder general anesthesia, a left-sided double-lumen tube was inserted with its bronchial lumen connected to the saline delivery system. Preoperatively, arterial blood gases were within normal limits. During 14 l of fluid was instilled into the lung for 2.5 hours, a decrease in pH, K+, and base excess, alongside an increase in Na+ and Cl−, indicated a strong ion difference; the diagnosis was dilutional hyperchloremic metabolic acidosis. Although she remained hemodynamically stable and had no indicators of massive absorption, she stayed in the ICU for mechanical ventilation for one night out of concern of pulmonary edema.ConclusionsInappropriate irrigating fluid pressure might lead to absorption of normal saline. Continuous monitoring and careful observation during WLL can help prevent intraoperative dilutional acidosis.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

Robotic-assisted minimally invasive thymectomy for myasthenia gravis with thymoma.

Comparison of left double lumen tube and y-shaped and double-ended bronchial blocker for one lung ventilation in thoracic surgery\u2014a randomised controlled clinical trial

BackgroundDouble lumen tube (DLT) intubation is the most commonly used technique for one lung ventilation. Bronchial blockers (BB) are an alternative, especially for difficult airways. The EZ-bronchial blocker (EZB) is an innovative y-shaped and double-ended device of the BB family.MethodsA randomised, controlled trial was conducted in 80 patients undergoing elective thoracic surgery using DLT or EZB for one lung ventilation (German Clinical Trial Register DRKS00014816). The objective of the study was to compare the clinical performance of EZB with DLT. Primary endpoint was total time to obtain successful one lung ventilation. Secondary endpoints were time subsections, quality of lung collapse, difficulty of intubation, any complications during the procedure, incidence of objective trauma of the oropharynx and supraglottic space and intubation-related subjective symptoms.Results74 patients were included, DLT group (n = 38), EZB group (n = 36). Median total time to obtain one lung ventilation [IQR] in the DLT group was 234 s [207 to 294] versus 298 s [243 to 369] in the EZB group (P = 0.007). Median total time was relevantly influenced by different preparation times. Quality of lung collapse was equal in both groups, DLT group 89.5% were excellent vs. 83.3% in the EZB group (P = 0.444). Inadequate lung collapse in five patients of the EZB group resulted in unsuccessful repositioning attempts and secondary DLT placement. Endoscopic examinations revealed significantly more carina trauma (P = 0.047) and subglottic haemorrhage (P = 0.047) in the DLT group. Postoperative subjective symptoms (sore throat, hoarseness) were more common in the DLT group, as were speech problems.ConclusionsUsing EZB prima facie results in prolonged time to obtain one lung ventilation with equal quality of lung collapse for the thoracic surgeon. If preparation times are omitted in the analysis, the time difference is statistically and clinically not relevant. Our data showed only little evidence for reducing objective airway trauma as well as subjective complaints. In summary both procedures were comparable in terms of times and clinical applicability. Therefore decisions for DLT or EZB should depend more on individual experience, in-house equipment and the individual patient, than on any times that are neither clinically significant nor relevant.Trial registrationGerman Clinical Trial Register DRKS00014816, prospectively registered on 07.06.2018

Use of Fogarty catheter as bronchial blocker for lung isolation in children undergoing thoracic surgery: A single centre experience of 15 cases.

Background and Aim:Various devices such as single lumen tubes, balloon-tipped bronchial blockers, and double-lumen tubes can be used for lung isolation in children, but no particular device is ideal. As such, there is a wide variation in lung isolation techniques employed by anaesthesiologists in this cohort of patients. This study aims to describe our experience with Fogarty catheters for lung isolation in children.Methods:This was a single centre, retrospective review of 15 children, below the age of 8 years, undergoing thoracic surgeries and requiring lung isolation. Demographic details, clinical parameters, complications during Fogarty catheter placement, number of attempts for placement, time taken for satisfactory lung isolation, and intraoperative complications were collected.Results:Successful lung isolation was achieved in all 15 children with Fogarty catheters of various sizes with the help of flexible bronchoscopy. Desaturation and bradycardia were the commonest complications seen during placement of the catheters but resolved with bag-mask ventilation. On average, 2 attempts were required for successful Fogarty placement. The mean time for successful lung isolation was 6.9 ± 1.3 minutes. The commonest intraoperative complication noted was desaturation, which resolved with an increase in FiO2and positive end expiratory pressure. 2 children had migration of the device proximally to the trachea causing airway obstruction. The devices were successfully repositioned in both cases.Conclusion:Fogarty catheters can be used for successful lung isolation in children less than 8 years of age, undergoing thoracic surgery.

Sequential Double-Lung Transplantation in Kartagener Syndrome: A Case Report

<h3>Introduction</h3> Kartagener syndrome (KS) is a rare congenital disorder, characterized by sinusitis, bronchiectasis and situs inversus. Lung transplantation is an effective treatment for end-stage lung failure. Main surgical difficulties found in these patients are due to dextrocardia and differences between left and right hilar structures and pulmonary lobes, which may cause the need to adapt the usual surgical technique. Only few technical reports were made for lung transplantation in situs inversus. <h3>Case Report</h3> We present a 48-year-old male patient with KS. He was 1,69m and had a TLC of 7,32L. When first evaluated for transplantation in 2019, he had a FEV1 and DLCO of 32% (1.1L) and 38% (3.7L), respectively, with a need of supplemental O2 (2L-rest; 4L-effort). He remained clinical and functionally stable for 2 years and was transplanted in 2021 (donor: 1,75cm, TLC 6,9L). Patient ventilation was performed with left sided double lumen tube that made selective ventilation quite difficult, therefore, an endobronchial blocker was used. A Clamshell incision was made with identification of left-right structure rotation. Without extracorporeal circulation, sequential double-lung transplantation was performed. Despite the evident anatomical changes, donor and recipient ipsilateral lungs had a good morphometric matching. Different anatomic relationships were taken into consideration. Since left recipient hilus had a right anatomy and right recipient hilus had a left anatomy, to provide an end-to-end arterial and bronchial anastomosis, we had to preserve a longer donor PA in both sides, and a longer donor right main bronchus. No technical alterations were made in the auricular cuff. There was no need to perform wedge resection of the right inferior lobe and left residual cardiac chamber wasn't verified. Left and right lung ischemic time were 4h12min and 6h22min, respectively. Patient was extubated 14h post-op and discharged 32 days after surgery with no complications. <h3>Summary</h3> We performed sequential double-lung transplantation in a patient with KS. Due to anatomic relations, longer donor pulmonary arteries and main right bronchus were necessary. There was no need for plastic maneuvers and the surgery was performed in the usual operative time.

Haemorrhage post biopsy of a bronchial carcinoid

Background: Bronchial carcinoid tumours are rare, indolent, malignant neuroendocrine tumours derived from Kulchitsky cells and are not related to smoking. As these tumours can be asymptomatic or present with nonspecific symptoms, a high index of suspicion is essential to make an early diagnosis which determines the prognosis. Surgery is curative and remains the mainstay of treatment.&#x0D; Case presentation: A 41-year-old female with no background medical illness first presented with a spontaneous left sided pneumothorax requiring a chest tube insertion. High-resolution CT (HRCT) thorax detected an incidental solitary pulmonary nodule. Bronchoscopy revealed a smooth round tumour sitting at the ostium of the basal right lower lobe bronchus. Endobronchial biopsy was complicated with massive bleeding requiring emergency exploration via rigid bronchoscopy. Multiple attempts to secure haemostasis using Watanabe spigot and argon plasma coagulation failed. She was intubated with a double lumen tube to isolate the healthy left lung. An urgent CT pulmonary angiogram (CTA) was performed to look for collaterals and feasibility of embolization, but no collaterals were seen. She was then referred to the cardiothoracic surgeon for an emergency right lobectomy. Histopathological examination revealed typical carcinoid tumour. She was discharged from the hospital in a stable condition.&#x0D; Discussion: Bronchial carcinoids embryologically originate from the foregut and patients rarely present with features suggestive of carcinoid syndrome and crisis. Mostly are asymptomatic resulting in late presentation and diagnosis. Majority of the typical carcinoids are centrally located and may present with obstructive symptoms and recurrent pneumonia. Bronchoscopists may face massive bleeding following endobronchial biopsy in bronchial carcinoids.&#x0D; Conclusion: Massive bleeding after endobronchial biopsy can occur and therefore the bronchoscopist should have anaesthesia, interventional radiology, and cardiothoracic support to handle this complication. Using tumour markers may obviate the need for biopsy in typical bronchial carcinoids to prevent massive bleeding after endobronchial biopsy.&#x0D;

Effects of rhomboid intercostal plane block for postoperative analgesia after thoracoscopic surgery compared with local anesthetic infiltration: A randomized clinical trial

ABSTRACT Background The efficacy of pain control is a crucial element of improved recovery following thoracic surgery. Inadequate analgesia may extend the interval of hospitalization, besides raising medical costs. Fascial plane blocks are quickly becoming a feasible as well as a safe alternative to epidural analgesia for abdominal and thoracic pain. Rhomboid intercostal block (RIB) is a novel, simple block utilized in a region that is described as a triangle of auscultation on the scapula’s medial edge. This study attempted to determine the impact of RIB on postoperative pain following thoracoscopic surgery compared to local anesthetic (LA) infiltration. Methods The current research is a randomized, controlled trial on 60 subjects undergoing video-assisted thoracic surgery. Participants were randomly divided into two groups. All subjects received standard general anesthesia protocol, which included the insertion of a double-lumen endotracheal tube as well as mechanical ventilation. At the end of the operation in the RIB group, an injection of 20 ml bupivacaine (0.25%) was administered below the rhomboid major muscle guided by ultrasound. In the LA group, patients received local wound infiltration. Visual analog scores for pain during coughing and at rest, total postoperative analgesic consumption, adverse effects, and hospital stay were recorded. Results The study group demonstrated diminished visual analog scores during coughing as well as at rest with less overall consumption of analgesia compared to the local infiltration group. Conclusion Our study showed that ultrasound guided RIB provides better pain relief and less postoperative opioid consumption after thoracoscopic surgeries compared to local anesthetic infiltration.

Cohen’s Comprehensive Thoracic Anesthesia

Cohen’s Comprehensive Thoracic Anesthesia

Challenge of Lung Isolation in Patients with Vocal Cord Implants.

Glottic closure insufficiency increases the risk of aspiration and pneumonia, particularly in the elderly. Medialization thyroplasty is an open surgical procedure for treating glottic incompetency by approximating both vocal folds. The vocal fold medialization is achieved by inserting an implant to bring the nonmobile fold to the unaffected side. Lung isolation in patients with vocal cord implantation poses a unique challenge. Understanding the risks of different modalities of lung isolation and their impacts on the vocal cord implant is crucial to implementing a specifically tailored plan. Preoperative bronchoscopy, intraoperative video laryngoscopy, and bronchoscopy are ideal methods for assessing the vocal fold implants and guiding the lung isolation technique. Bronchial blocker through a single-lumen endotracheal tube may be the preferred choice to avoid the injury of the stretched vocal cords and dislodgement of the implant by a larger diameter double-lumen tube.

Double-lumen tube versus bronchial blocker in lymphadenectomy along the left recurrent laryngeal nerve for esophageal cancer: a propensity-matched analysis.

Lymph node (LN) dissection along left recurrent laryngeal nerve (RLN) is challenging in esophagectomy for esophageal cancer, and double-lumen endotracheal tube (DLT) impedes the exposure of this area. The aim of this study was to determine whether bronchial blockers (BB) could be a better choice for this procedure. The clinical characteristics of patients who received McKeown esophagectomy with radical lymph node dissection in Wuhan Tongji Hospital between August 2017 and July 2019 were retrospectively analyzed. The 1:1 propensity score match analysis was performed to compare the short-term effectiveness, the numbers of lymph nodes dissected, and the patterns of recurrence and survival between the two groups. A total of 294 patients (192 and 102 in the DLT and BB group, respectively) were enrolled in the study. After matching, 204 patients (102 pairs) who underwent one-lung ventilation with DLT or BB displayed no significant variance in baseline characteristics. The BB group had higher number of LNs resected along left RLN (1.8 ± 2.3 vs. 2.5 ± 2.5, P = 0.001). For patients with metastatic left RLN LN, the BB group had longer medium survival time (15 vs. 32months, P = 0.045), and tended to have longer medium recurrence-free survival time (6 vs. 15months, P = 0.079), and lower rate of upper mediastinal and cervical LN recurrence (30.00% vs. 66.67%, P = 0.198). The postoperative complications were similar in both groups. Compared with DLT, using BB in esophagectomy may allow more radical lymphadenectomy along left RLN.

Abstract No. : ABS0814: Comparison of lung ultrasound technique versus clinical method to evaluate the accuracy of positioning of left endobronchial double lumen tube in patients undergoing elective thoracic surgery- a prospective observational study

Background & Aims:Clinical methods like height and gender were found to be inaccurate in predicting the size of double-lumen tube (DLT).Tracheal ultrasonography (TUS) reliably predicts the size of DLT by measuring tracheal diameter. The aim wasto check theaccuracy of ultrasound over clinical methods.Methods:This study was conducted on 68 patients undergoing elective thoracic surgery requiring one-lung ventilation (OLV) withDLT. The subjects were divided into two groups depending on the prediction of size of DLT by either clinical (Group1) orultrasound method. (Group 2). The transducer was placed perpendicular to skin over cricoid cartilage to measure the transversediameter of the column of air in the cricoid cartilage which denoted the size of the DLT. The primary objective of the study was to assess the accuracy in prediction of size and placement of DLT through various parameters in both clinical andultrasound groups.Results:The accuracy of predicted DLT size between the Group U and Group C was found to be statistically significant (p=0.044). In Group 1, 56% of patients showed a mismatch between the predicted DLT size and the actual size required, while in Group 2, the mismatch was only 32.4%. The accuracy of placement of DLT in the first attempt suggested by adequate lung isolation was also significantly higher (p=0.028) in the ultrasound group compared to the clinical group.Conclusion:The size of DLT can be predicted by using clinical parameters but have low accuracy. In our study, the size of DLT was calculated by measuring tracheal diameter using TUS, which significantly improved the selection of appropriate DLT size, avoiding complications.Actual DLT usedGroup 1Group 2Z test No.%No.%Same as predicted1544.02367.6Z=-2.01, P=0.044*Higher that predicted823.5514.7Lower than predicted1132.5617.6Total34100.034100.0

Surprise evidence of a bronchial rent in a case of pulmonary Koch’s posted for lung decortication using the one-lung ventilation protocol

Tracheobronchial injury is a potentially life-threatening clinical scenario. In the case of surprise evidence of bronchial wall tear while doing lung surgery, tracheal tube extubation and post-operative management pose a challenge to the anaesthesiologist. We present a case of a 16-year-old girl, a known case of pulmonary Koch’s taking anti-Koch’s treatment, admitted with hydropneumothorax, who was posted for left lung decortication. She presented with complaints of left-sided chest pain and cough since 3 months and a weight loss of 13 kg in 3 months. An inter-costal drain was inserted on the left side.Her high-resolution computed tomography thorax showed multiple cavitatory lesions with ground glass opacities in right lung parenchyma,Hydropneumothorax from the upper lobe to lower lobe of the left lung; consolidation, calcification in the left lower lobe; mediastinal shift toward the right.In the Operation theatre, the patient was pre-oxygenated, induced with Inj Propofol + Inj Fentanyl + Inj Suxamethonium according to the patient’s weight, and intubated with a 28 Fr’ left-sided double lumen tube (DLT). Left-sided decortication was performed uneventfully. On conclusion of surgery, while checking for leaks, it was noted that the exhaled tidal volume was unacceptably low and a rent on the left main bronchus of around 2 x 2 cm with scarred borders was detected, which was repaired with tissue patch suturing by the surgeons. After closure, the DLT was removed and re-intubation was performed with endotracheal tube no. 6. The patient was shifted to the intensive care unit, electively ventilated, and gradually weaned off in 2 days. Then, the patient was discharged in a week.To conclude, meticulous planning, vigilant monitoring of vital parameters, and close communication between the surgeons and the anaesthesiologists are essential to timely manage a life-threatening complication.

The 12 steps to a thoracoscopic anterior segment segmentectomy: Oncologically safe and sound.

The 12 steps to a thoracoscopic anterior segment segmentectomy: Oncologically safe and sound.

Dental Strain on Maxillary Incisors During Tracheal Intubation With Double-Lumen Tubes and Different Laryngoscopy Techniques - A Blinded Mannequin Study

To quantify dental forces during double-lumen tube intubations with different laryngoscopy techniques. Experimental biomechanical mannequin study. Two German university hospitals. One hundred four anesthesiologists with varying levels of experience. Participants performed a sequence of intubations on a mannequin equipped with hidden forces sensors in the maxillary incisors. Different laryngoscopy techniques were evaluated under normal and difficult airway conditions. Direct laryngoscopy was compared with different videolaryngoscopy techniques: the C-MAC with a Macintosh blade, the GlideScope, and the KingVision with hyperangulated blades. A total of 624 intubations were evaluated. In normal airway conditions, the median (interquartile range [range]) peak forces were significantly lower when the GlideScope (15.7 (11.3-22.0 [2.1-110.5]) N) was used compared with direct laryngoscopy (21.0 (14.1-28.5[4.7-168.6]) N) (p=0.007). In difficult airways, resulting forces were reduced using hyperangulated videolaryngoscopes (GlideScope: -13.7 N [p < 0.001]; KingVision: -11.9 N [p < 0.001]) compared with direct laryngoscopy, respectively. The time to intubation was prolonged with the use of the KingVision (25.5 (17.1-41.9[9.2-275.0])s [p < 0.001]) in comparison to direct laryngoscopy (20.8 (15.9-27.4[8.7-198.6]) s). The C-MAC demonstrated the shortest time to intubation. Although hyperangulated videolaryngoscopes improve dental strain, clinicians also should consider the time to intubation, which is shortest with nonhyperangulated videoblades, when choosing a laryngoscopy technique on an individual patient basis.

Whole lung lavage in pulmonary alveolar proteinosis: anesthetic management and challenges

BackgroundPulmonary alveolar proteinosis is a rare disorder characterized by alveolar obstruction secondary to the collection of lipoproteinaceous material in the alveoli leading to a spectrum of respiratory illness ranging from mild to severe respiratory failure. Whole lung lavage considered the gold standard for the treatment of PAP is performed under general anesthesia and presents a unique set of challenges to the anesthesiologist. The procedure involves manually removing the lipoproteinacious material by repeating aliquots of fluids and draining periodically after percussion. When done effectively it is quite effective and life-saving procedure.Case presentationA 39-year-old female presented with history of gradually progressive shortness of breath, diagnosed to have primary pulmonary alveolar proteinosis for which bilateral whole lung lavage was planned. During the lavage cycles, patient had episodes of desaturation to 60% during which the double lung ventilation was resumed. Her serial ABG revealed a deteriorating oxygenation. In view of increased oxygen requirements, the procedure was carried out in two stages. She made a complete recovery after the procedure.ConclusionsA multidisciplinary team working with good communication, use of adequate back up plans, meticulous lung separation with double lumen tube, vigilant intraoperative monitoring, short-term postoperative ventilation go a long way in achieving adequate gas exchange in patients with respiratory failure due to pulmonary alveolar proteinosis.

Video laryngoscopy-guided double-lumen tube insertion: Do we have enough evidence yet?

Video laryngoscopy-guided double-lumen tube insertion: Do we have enough evidence yet?