Left Double-lumen Tube Research Articles

Comparison of Auscultation Method Versus Lung Ultrasound Technique to Evaluate the Accuracy of Positioning of Left Double Lumen Tube in Patients Undergoing Cardiothoracic Surgery

Comparison of Auscultation Method Versus Lung Ultrasound Technique to Evaluate the Accuracy of Positioning of Left Double Lumen Tube in Patients Undergoing Cardiothoracic Surgery

Effect of a 3D-printed reconstruction automated matching system for selecting the size of a left double-lumen tube: a study protocol for a prospective randomised controlled trial

IntroductionLung isolation is primarily accomplished using a double-lumen tube (DLT) or bronchial blocker. A precise and accurate size of the DLT is a prerequisite for ensuring its accurate placement. Three-dimensional...

Individualized rotation of left double lumen endobronchial tube to improve placement success rate: a randomized controlled trial

BackgroundIn conventional practice, the left double lumen tube (DLT) is rotated 90° counterclockwise when the endobronchial cuff passes glottis. Success rate upon the first attempt is < 80%, likely owing to varying morphology of the bronchial bifurcation.MethodsWe conducted a randomized controlled trial to compare 90° counterclockwise rotation versus individualized degree of rotation in adult patients undergoing elective thoracic surgery using left DLT. The degree of rotation in the individualized group was based on the angle of the left main bronchi as measured on computed tomography (CT). The primary outcome was the first attempt left DLT placement success rate.ResultsA total of 556 patients were enrolled: 276 in the control group and 280 in the individualized group. The average angle of the left main bronchi was 100.6±9.5° (range 72° to 119°). The first attempt left DLT placement success rate was 82.6% (228/276) in the control group versus 91.4% (256/280) in the individualized group (P=0.02, χ2 test). The rate of carina mucosal injury, as measured at 30 min after the start of surgery under fibreoptic bronchoscopy, was significantly lower in individualized group than control group (14.0% versus 19.6%, P=0.041). The individualized group also had lower rate of postoperative sore throat (29.4% versus 44.0%, P<0.001) and hoarseness (16.8% versus 24.7%, P＜0.05).ConclusionsIndividualized rotation of left DLT based on the angle of the left main bronchi on preoperative CT increased first attempt success rate in adult patients undergoing elective thoracic surgery.Trial registrationThe trial is registered at Chinese Clinical Trial Registry (ChiCTR2100053349; principal investigator Xiang Quan, date of registration November 19, 2021).

A Comparison of Arterial Oxygenation between 60% O&amp;lt;sub&amp;gt;2&amp;lt;/sub&amp;gt; CPAP and 100% O&amp;lt;sub&amp;gt;2&amp;lt;/sub&amp;gt; CPAP during One-Lung Ventilation: A Prospective Randomized Controlled Study

Background: One-lung ventilation (OLV) is generally adopted for thoracic surgery. The systemic application of a high fraction of inspiratory oxygen (F1O2) and continuous positive airway pressure (CPAP) to the non-ventilated lung is useful for preventing arterial oxygen desaturation. The adverse effects of elevated F1O2 include oxidative lung injury, resorption atelectasis and coronary and peripheral vasoconstriction. It is preferable to avoid hyperoxemia in patients with complications such as chronic obstructive pulmonary disease, idiopathic pneumonia, and bleomycin-treated lungs. We aimed to determine whether the application of 60% O2 CPAP to the non-ventilated lung is sufficient to provide adequate oxygenation with 60% O2 to the ventilated lung. Methods: A total of 70 patients scheduled to receive elective thoracic surgery requiring OLV were recruited. Left double-lumen tubes were applicable in all surgeries. Patients were randomly allocated to one of two groups, to receive either 60% O2 CPAP (60% CPAP group, n = 35), or 100% O2 CPAP (100% CPAP group, n = 35) at a setting of 2 - 3 cmH2O, applied to the non-ventilated lung. Arterial blood gas analyses were obtained at the following stages: RA, spontaneous breathing under room air (RA); TLV, during total lung ventilation (TLV) prior to the initiation of OLV; T5, 5 min after the initiation of OLV; T15, 15 min after the initiation of OLV; T30, 30 min after the initiation of OLV. Results: The PaO2 value in 60% CPAP group vs. 100% CPAP group at each measurement were as follows: RA (mean [standard deviation: SD], 89.7 [8.2] mmHg vs. 85.8 [11.9] mmHg); TLV (277.9 [52.9] mmHg vs. 269.2 [44.0] mmHg); T5 (191.4 [67.9] mmHg vs. 192.3 [66.0] mmHg); T15 (143.2 [67.3] mmHg vs. 154.7 [60.8] mmHg) and T30 (95.6 [32.0] mmHg vs. 112.5 [36.5] mmHg), respectively. Among the five measurement points, T30 was the only time point at which the 100% CPAP group showed a significantly greater PaO2 value than the 60% CPAP group (p = 0.0495). The SaO2 at T30 in the 100% CPAP group (97.4 [2.0]%) was also significantly greater than that in the 60% CPAP group (96.3 [2.2]%, p = 0.039). No differences were found between the groups regarding changes to the overall PaO2 values (p = 0.44) and SaO2 values (p = 0.23) during the study period. Conclusions: Oxygenation could be safely maintained in relatively healthy patients with 60% O2 OLV and 60% O2 CPAP. The application of 60% O2 CPAP during OLV for patients who are not suited to exposure to high F1O2 may be an alternative form of respiratory management.

ROBOTIC ASSISTED MINIMALLY INVASIVE CARDIAC SURGERY DA VINCI ROBOTIC SYSTEM. ANALYSIS OF PERIOPERATIVE CONSIDERATIONS

<h3>Introduction</h3> Robotic assisted minimally invasive cardiac surgery is a complex procedure where the anesthesiologist works in situations that require management skills. <h3>Method</h3> The study design is a retrospective observational model, which was performed with chart review. Data were collected from 104 patients who underwent minimally invasive cardiac surgery and were repaired using the Da Vinci robot-assisted minimally invasive approach from November 2019 to March 2022. The variables collected were assigned into three groups: preoperative variables, intraoperative variables and postoperative variables. The preparatory variables were age, sex, personal history of interest, Anesthetic Risk Scale (ASA), European System for Cardiac Operation Risk Evaluation II (EUROESCORE II), preoperative echocardiography, preoperative laboratory tests and diagnosis. Intraoperative variables were type of anesthesia, airway device used, invasive monitor, intraoperative transesophageal echocardiography data, complications, vasoactive drug use, blood product transfusion, extracorporeal circulation times and aortic clamping times, analgesic technique, extubation and surgical outcome. Finally, the postoperative variables were length of stay in the intensive care unit, length of hospital stay and postoperative complications. <h3>Results</h3> On the ASA 101 patients (97.1%) were in the ASA IV group and only 3 patients were in the ASA V group (2.9%). In the Euroescore II 103 patients scored less than 3 (99.03 %) and only one patient scored above 3 (0.9 %). Regarding anesthesia, 71 patients received total intravenous general anesthesia (68,3%) and 32 patients received balanced general anesthesia (30,7%) and in 1 patient this information could not be collected (0,9%)).. For airway management, a left double-lumen tube was used in 21 patients (20.8%), a Vivasight-type camera tube in 47 patients (46.6%) and a bronchial blocker through a conventional tube under fibrobronchoscopic vision in 33 patients (32.6%). In 3 patients this information could not be collected. Only 1 patient suffered serious complications during surgery (0.96 %). Vasoactive drugs were used in 81 patients (78%). Blood products were transfused in 7 patients (6.7%). The analgesic technique used consisted of locoregional blocks in 59 patients (56%), Locoregional block + patient-controlled morphine analgesia (PCA) in 14 patients (13,4%), PCA only in 29 patients (27,8%) and in 4 patients we do not know this information (3,8%). With regard to postoperative complications, 26 patients (25 %) were recorded. One patient died (0.96%). <h3>Conclusions</h3> In minimally invasive robotic-assisted cardiac surgery there are fundamental details to consider before, during and post-intervention such as the selection of the right patient, preoperative assessment, anesthetic technique, airway management, performing a good transesophageal echocardiographic study, hemodynamic behavior of the patient during the intervention, measures to take in case of complications and postoperative management, among others. Little literature exists so far and more studies are needed. ANALYSIS OF ANAESTHETIC CONSIDERATIONS

LOBAR TORSION AFTER ELECTIVE RIGHT UPPER LOBECTOMY

IntroductionLobar torsion is a rare entity, with an incidence between 0,09 an 0,3 %, but with a high mortality rate if not treated early, Postoperative middle lobe torsion following right upper lobectomy is the most common form of pulmonary torsion.Clinical caseA 72-year-old man who was a smoker and suffered from arterial hypertension and dilated cardiomyopathy, presented with a right upper lobe nodule and underwent elective right upper lobectomy. We used a 37Fr left double-lumen tube to manege one-lung ventilation and a thoracic epidural catheter was inserted to manage postoperative pain. The patient remained hemodynamically stable during the operation and right lung was re-expanded, so he was extubated in the operating room and transferred to the ICU during the first 24 hours.On postoperative day-1 chest radiography showed decreased clarity of the right middle fields, so had adopted a wait and see approach because the patient whas asymptomatic. But on postoperative day 2 chest radiography showed worsening being compatible with lobar torsion, so he was brought to the operating room emergently.DiscussionTorsion of the right middle lobe was observed without vascular or bronchial involvement. A lobe detorsion was carried out and it was fixed to the lower right lobe. Postoperative recovery was uneventful and patient was discharged 12 days after operation.In lobar torsion a delay in diagnosis and/or an improper treatment strategy can lead to serious complications. So that, the key to the patient management is an early diagnosis.The clinical presentation varies from asymptomatic to sudden dyspnea and chest pain with acute respiratory failure and hemoptysis. It can also associate serohematic debit in chest tube drainage.Radiologic findings are almost mandatory for the diagnosis. In plain radiography, we can identify a rapid opacification, collapsed lobe or positional change of the affected lobe. Computed tomography (CT) findings are more specific including lobar consolidation with ground glass attenuation and interlobular septal thickening associated with tapered obliteration of the proximal bronchus and artery of the involved lobe. Intraoperative bronchoscopy is also a very useful tool when postoperative lobar torsion is suspected.The treatment is controversial. In torsions of < 180° with incomplete obstruction of the pedicle, correction with lobar preservation (detorsion) can be considered but many authors recommend lobectomy as the treatment of choice. Lobar torsion is a rare entity, with an incidence between 0,09 an 0,3 %, but with a high mortality rate if not treated early, Postoperative middle lobe torsion following right upper lobectomy is the most common form of pulmonary torsion. A 72-year-old man who was a smoker and suffered from arterial hypertension and dilated cardiomyopathy, presented with a right upper lobe nodule and underwent elective right upper lobectomy. We used a 37Fr left double-lumen tube to manege one-lung ventilation and a thoracic epidural catheter was inserted to manage postoperative pain. The patient remained hemodynamically stable during the operation and right lung was re-expanded, so he was extubated in the operating room and transferred to the ICU during the first 24 hours. On postoperative day-1 chest radiography showed decreased clarity of the right middle fields, so had adopted a wait and see approach because the patient whas asymptomatic. But on postoperative day 2 chest radiography showed worsening being compatible with lobar torsion, so he was brought to the operating room emergently. Torsion of the right middle lobe was observed without vascular or bronchial involvement. A lobe detorsion was carried out and it was fixed to the lower right lobe. Postoperative recovery was uneventful and patient was discharged 12 days after operation. In lobar torsion a delay in diagnosis and/or an improper treatment strategy can lead to serious complications. So that, the key to the patient management is an early diagnosis. The clinical presentation varies from asymptomatic to sudden dyspnea and chest pain with acute respiratory failure and hemoptysis. It can also associate serohematic debit in chest tube drainage. Radiologic findings are almost mandatory for the diagnosis. In plain radiography, we can identify a rapid opacification, collapsed lobe or positional change of the affected lobe. Computed tomography (CT) findings are more specific including lobar consolidation with ground glass attenuation and interlobular septal thickening associated with tapered obliteration of the proximal bronchus and artery of the involved lobe. Intraoperative bronchoscopy is also a very useful tool when postoperative lobar torsion is suspected. The treatment is controversial. In torsions of < 180° with incomplete obstruction of the pedicle, correction with lobar preservation (detorsion) can be considered but many authors recommend lobectomy as the treatment of choice. Bibliography•Moreno Asencio MT, Rivo Vázquez E, Quiroga Martínez J, Moldes Rodriguez M, García Prim JM. Left upper lobar torsion after video-assisted thoracoscopic lower lobectomy. Cir Esp. 2017; 95(7):406–8.•Mansour W, Moussaly E, Abou Yassine A, Nabagiez J, Maroun R. Left Lung Torsion: Complication of Lobar Resection for an Early Stage Lung Adenocarcinoma. Case Rep Crit Care. 2016;2016:9240636. doi: 10.1155/2016/9240636. Epub 2016 May 17.

Unilateral acute lung injury in pig: a promising animal model

BackgroundAcute lung injury (ALI) occurs in 23% unilateral. Models of unilateral ALI were developed and used previously without clearly demonstrating the strictly unilateral nature and severity of lung injury by the key parameters characterizing ALI as defined by the American Thoracic Society (ATS). Thus, the use of unilateral ALI remained rare despite the innovative approach. Therefore, we developed a unilateral model of ALI and focused on the crucial parameters characterizing ALI. This model can serve for direct comparisons between the injured and intact lungs within single animals, thus, reducing the number of animals required for valid experimental conclusions.MethodsWe established the model in nine pigs, followed by an evaluation of key parameters in six pigs (main study). Pigs were ventilated using an adapted left double-lumen tube for lung separation and two ventilators. ALI was induced in the left lung with cyclic rinsing (NaCl 0.9% + Triton® X-100), after which pigs were ventilated for different time spans to test for the timing of ALI onset. Ventilatory and metabolic parameters were evaluated, and bronchoalveolar lavage (BAL) was performed for measurements of inflammatory mediators. Finally, histopathological specimens were collected and examined in respect of characteristics defining the lung injury score (LIS) as suggested by the ATS.ResultsAfter adjustments of the model (n = 9) we were able to induce strictly left unilateral ALI in all six pigs of the evaluation study. The median lung injury score was 0.72 (IQR 0.62–0.79) in the left lung vs 0.14 (IQR 0.14–0.16; p < 0.05) in the right lung, confirming unilateral ALI. A significant and sustained drop in pulmonary compliance (Cdyn) of the left lung occurred immediately, whereas Cdyn of the right lung remained unchanged (p < 0.05). BAL fluid concentrations of interleukin-6 and -8 were increased in both lungs.ConclusionsWe established a model of unilateral ALI in pigs, confirmed by histopathology, and typical changes in respiratory mechanics and an inflammatory response. This thoroughly evaluated model could serve as a basis for future studies and for comparing pathophysiological and pharmacological changes in the uninjured and injured lung within the same animal.

Right displacement of trachea to reduce right bronchial misplacement of left double lumen tube: a prospective, double-blind, randomized study

BackgroundMisplacement of double-lumen endobronchial tubes (DLTs) during bronchial intubation, especially when bronchoscopy guidance is not applicable, threatens effective lung isolation and brings about airway injury during reposition. We aimed to examine whether a novel maneuver called right tracheal displacement (RTD) can reduce left-sided DLT misplacement during first-attempt intubation without bronchoscopy guidance.MethodsPatients that underwent thoracic surgeries requiring one-lung ventilation during November 2020 to January 2021 were recruited and randomized into control and RTD group, with 54 cases in each group. The primary outcomes included the incidence of DLT misplacement and the time to complete desired bronchial intubation. The secondary outcomes included mucosal injury, sore throat and hoarseness upon emergence and at 24 h post-operatively.ResultThe incidence of DLT misplacement in RTD group was significantly lower compared to control group (0% vs. 16.7%) The time to complete bronchial intubation was also significantly shortened in RTD group compared to control (52.88 ± 9.36 s vs. 63.04 ± 20.02 s). The incidence of mucosal injury, sore throat and hoarseness were comparable between two groups.ConclusionRTD maneuver can effectively improve the success rate of first-attempt proper DLT positioning and shorten the time required by bronchial intubation.Trial registrationThis prospective, double-blind, randomized study has completed the registration of the Chinese Clinical Trial Center at 2/11/2020 with the registration number ChiCTR2000040212. It was conducted from 26/11/2020 to 31/7/2021 in third affiliated hospital of Sun Yat-sen university.

Anesthetic Management of Patient with Mediastinal Tumor Posted for Thoracotomy and Tumor Excision

Introduction: Mediastinal tumor are uncommon entity they present a major anesthetic challenges due to major airway and vascular compression. Case Report: A 60yr, old diagnosed with posterior mediastinum tumour at C7 level. Airway assessment revealed mallampatti class IV. Blood investigations were within normal limit. Pulmonary function test revealed mild obstructive disease. CT shows lesion in posterior mediastinum extending to right IJV with complete thrombosis displacing trachea and thyroid. Triple lumen CVP line was secured. Difficult intubation trolley with tracheostomy set was kept ready. Routine monitoring, left radial artery cannulation done. Patient was Preoxygenated, Premedicated and Induced. 37F Left Double lumen tube was inserted and tube position confirmed with paediatric fiberoptic bronchoscope. Patient was hemodynamically stable in the intraoperative period. Patient was reversed and extubated uneventfully. Conclusion: Mediastinal tumor resection surgery is a very complicated and requires a team effect anesthesiologists, surgeon and intensivist. A thorough pre-operative assessment of the patient should be done before the conduct of anesthesia to avoid the complications due to posterior mediastinal mass. Keywords: Thoracotomy, One-Lung Ventilation, Mediastinal Tumor. Key Messages: Anesthetic management of patient with mediastinal tumor posted for thoracotomy and tumor excision requires a double lumen ET tube for lung isolation and decrease in lung atelectasis. In this case a 60 year old male presented with mild symptoms and we highlight the usage of one lung ventilation in patient with posterior mediastinal tumor.

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

Anaesthetic Management of a Patient with Endotracheal Tuberculosis Posted for Endoscopic CSF Leak Repair

Introduction: Patient with tracheal tuberculosis with active lung infection requiring Intubation using Double lumen Endotracheal tube pose a challenge to anesthesiologist to prevent contamination of healthy lung. Case Report: 55 year female presented with complaints of nasal discharge for 2 weeks, cough with expectoration for one week. A diagnosis of CSF Rhinorrhoea was made. HRCT chest report showed tree in bud opacities suggestive of TB. General anaesthesia was planned. Preoperatively nebulized with Lignocaine with adrenaline; Patient was Pre medicated, Preoxygenation done with 100% oxygen. Induced with Inj Propofol. 35F Left Double lumen tube was inserted under fibreoptic guidance and was confirmed by chest rise and ETCO2 and Tube fixed in place. A portable ventilator was used with Tidal volume of 5ml per kg for the right lung and regular ventilator with same tidal volume to left lung. Intra operative vitals were stable throughout the procedure. The patient was extubated after adequate spontaneous efforts. After extubation the patient started desaturating, saturation went upto 70% on room air, immediately the patient was reintubated and shifted to ICU with ET tube insitu. The patient was extubated in ICU after 2 days and shifted to postoperative ward. Conclusion: In patients with active lung infection a plan for Double lumen ET tube may help in avoiding the infection spreading to healthy lung, intubation period is crucial to avoid most common problems such as malposition, airway trauma and tension pneumothorax caused by high ventilating pressure or large tidal volumes in patients.

Comparison of EZ blocker and left double-lumen endotracheal tube for one lung ventilation in minimally invasive cardiac surgery

Background/Aim: Effective lung isolation is required in minimally invasive cardiac surgery. Double lumen tubes (DLT) are most preferred for this type of operation, and data on the use of EZ blockers in cardiac surgery are limited. We aimed to compare the efficiency of the double lumen tube and EZ blockers in minimally invasive cardiac surgery with cardiopulmonary bypass performed through a right mini thoracotomy. Methods: A total of 89 patients who underwent minimally invasive cardiac surgery through right mini thoracotomy with cardiopulmonary bypass between January 1 and December 31, 2020, were included in this single-center, retrospective case control study. The group in which double lumen tubes were used for lung isolation (n = 58) was compared with that in which EZ blockers (n = 31) were used in terms of placement time, repositioning rate, lung collapse quality score, and postoperative sore throat and hoarseness. Results: The time needed to place the devices in the correct position was shorter in the DLT group (3.2 (2.7) min vs 4.6 (2.4) min, P=0.02). No significant difference was found between the prevalence of at least one repositioning and lung collapse quality scores (P=0.42, P=0.21). VAS scores for sore throat were lower and hoarseness was less encountered in the EZ blocker group (21.2 (8.8) vs 49.4 (7.6), P=0.01, 16.1% vs 48.2%, P=0.01, respectively). Conclusion: Although the EZ blocker has a longer placement time, it provides lung isolation as effective as DLT. Less sore throat and hoarseness show that EZ blocker is an important alternative for this type of surgery.

Prediction of Left Double-Lumen Tube Size by Measurement of Cricoid Cartilage Transverse Diameter by Ultrasound and CT Multi-Planar Reconstruction

Background: Currently, there is no uniform standard for selecting the left double lumen tubes (LDLT). Advantages, such as safety and convenience of the ultrasonic technology, and measurement accuracy, make it more widely applied in the clinical anesthesia, and computed tomography (CT) multi-planar reconstruction (MPR) technology will certainly provide a more accurate measurement. For better application for thoracic surgery choice LDLT, relieving the injury to patients, and reducing the complications, this study will compare the two approaches.Methods: The first part, 120 cases of patients were selected according to the height and gender; recording the patient's optimum LDLT and measurement the transverse diameter of the cricoid cartilage (TD-C) by ultrasound and CT MPR, and then obtained the TD-C range measurement by ultrasound and CT MPR corresponding to different types of LDLT. The second part, total of 102 patients were divided into the ultrasound group and the CT MPR group. In the ultrasound group, TD-C was measured by ultrasound, the corresponding size for intubation was selected based on the conclusions derived from the first part. In the CT MPR group, TD-C was measured by CT MPR, the corresponding size of LDLT based on the conclusions derived from the first part.Results: In the first part, 120 patients were no significant difference in the basic characteristics (P > 0.05). The accuracy of selecting the LDLT by conventional experience, namely height and gender was 58.3%. Ultrasonic measurement TD-C range was as follows: 32 Fr <15.88, 35 Fr: 15.88–16.80, 37 Fr: 16.75–17.81, and 39 Fr > 17.80. CT MPR measurement TD-C range was as follows: 32 Fr <15.74, 35 Fr: 15.74–16.65, 37 Fr: 16.56–17.68, and 39 Fr > 17.65. In the second part, there was no significant difference in the basic characteristics between the two groups (P > 0.05). The accuracy of intubation in the ultrasound group was 90.2% and the corresponding in the CT MPR group was 94.1% (P > 0.05).Conclusions: The accuracy of selecting the LDLT based on TD-C is significantly higher than conventional experience; it can significantly reduce the post-operative complications and there was no statistical significance in the accuracy of LDLT selected for TD-C measurement by ultrasound vs. CT, and both of them could be safely used for the evaluation before intubation under anesthesia in thoracic surgery.

One lung ventilation at high altitude (11600 ft) for video assisted thoracoscopic surgery (VATS) in a case of covid-19 sequela-empyema thoracis

Lung isolation for surgical facilitation by means of one lung ventilation (OLV) is seeing widespread use in all age groups due to increasing incidence of thoracoscopy and video-assisted thoracoscopic surgery (VATS). Lung isolation is most commonly achieved by use of double-lumen endotracheal tubes with or without a bronchial blocker. Development of intraoperative hypoxaemia (arterial oxygen saturation <90%) caused by OLV is a known hazard. In high altitude area (HAA), the lowered amount of O2 caused by a decrease in the barometric pressure (BP) leads to hypobaric hypoxia. Covid 19 directly impacts the lungs and damages the alveoli in the affected individuals exacerbating the hypoxia. Though rare, respiratory long-term sequelae of COVID-19 such as lung abscess can occur. The management of hypoxia in the course of lung isolation was a challenge especially in the high-altitude scenario with a Covid-19 background. The present report is of an adult male with high COVID-19 antibody titres who underwent video-assisted thoracoscopic surgery at a service hospital located in a high-altitude area (HAA) with altitude 11600 ft. One lung ventilation was performed with a 39 Fr left double lumen tube. Correct placement was confirmed with fiber optic bronchoscopy. The surgery was uneventful and the patient was electively ventilated postoperatively for 48 hrs. No complications were noted peri-operatively. The soldier was subsequently discharged for convalescence.

Use of bronchial blocker to facilitate left double-lumen tube placement.

Use of bronchial blocker to facilitate left double-lumen tube placement.

A randomized trial to assess the effect of cricoid displacing maneuver on the success rate of blind placement of double-lumen tube and Univent bronchial blocker.

Double lumen tube (DLT) and Univent are two commonly used lung isolation devices that often require bronchoscopy assistance. In order to facilitate blind placement for situations where bronchoscopy was unavailable, the cricoid displacing maneuver (CDM) was adopted. This study was designed to explore whether the CDM could improve the successful blind placement rate in left lung isolation esophageal surgeries. 120 ASA 1-3 patients who received left lung isolation esophageal surgeries from October 2014 to February 2016 and October 2018 to January 2020 were enrolled in this single-centered prospective assessorblinded randomized controlled trial. After anesthesia induction, patients were intubated either with DLT or Univent by applying the CDM, and the position of devices was checked by bronchoscopy. After turning into the right decubitus position, the devices were pulled back to the trachea, and placement was conducted once again. Successful placement rate for the first attempt, time needed for initial placement, malposition and reposition times by bronchoscopy during surgery, bronchus injury score, rank of lung isolation and postoperative anesthesia-related complications were recorded. At supine position, the successful placement rates for the first attempt of DLT-CDM, DLTcontrol, Univent-CDM and Univent-Control were 100%, 76.7%, 96.7% and 66.7% respectively (DLT: P=0.016; Univent: P=0.003) while at right decubitus position were 86.7%, 66.7%, 93.3% and 66.7% (DLT: P=0.067; Univent: P=0.010). There was no significant difference in the time needed for successful intubation and no severe complications. The current study provided evidence that the CDM is an effective and safe blind endobronchial placement technique for left DLT and Univent. We suggest that CDM could be applied to the endobronchial placement of left DLT and Univent.

Anesthesia for double lung transplant in a patient with confirmed COVID-19 infection: a case report

IntroductionLung transplantation has been performed in a small number of patients suffering from COVID-19 related pulmonary fibrosis or end-stage COVID-19 pneumonia. (1) There are no reports of lung transplantations to receipients with positive Covid-19-PCR at the time of the operation.MethodsA 42-year-old woman without comorbidities was hospitalized and diagnosed with COVID-19 pneumonia. After being intubated and tracheotomized, VV-ecmo support had to be initiated, no tendency of improvement ensued. Lung transplantation proceedings were made despite viral RNA test results from BAL being consistently positive (while negative culture growth suggested no active viral disease) since a small intracerebral bleeding had occurred after 45 days on ECMO. An adequate donor organ was found, double lung transplantation was performed.Two experienced anesthetists, two nurse anesthetists and a runner provided anesthesia. The OR was set to positive pressure and 26 air changes h-1, the team wore full PPE (multilayer gloves, gown/overall, FFP-3 masks, glasses, faceshield).Videolaryngoscopic intubation using a ViVaSight® (Ambu, Denmark) left double lumen tube with integrated camera was performed, TEE and bronchoscopy were avoided. We used near infrared spectropscopy and total intravenous anesthesia with Propofol 5,5mg kg-1 h-1 and Sufentanil 5mcg kg-1 h-1. Being on VV-Ecmo with 4,7l of blood and 5,5l O2 flow min-1 we used a second, centrally cannulated parallel ecmo circuit with 3l of blood and 2l of oxygen flow min-1, the VV circuit was reduced.The operation was prolonged due to adhesions, coagulopathy, rupture of the dilated right atrium. Transfusion of 30 units of packed red cells, 40 units of fresh frozen plasma, 5 units of platelets, 2000IE of PPSB, 30mcg of desmopressin acetate, 5 grams of fibrinogen concentrate guided by repetitive viscoelastic testing was performed. Bilateral pulmonary edema occurred, leading to an oxygenation index of 72 on 1l min-1 VV ecmo flow. We therefore switched to a femorally cannulated VA-ecmo circuit to minimize hemodynamic stress for the newly transplanted lungs.At the end of the operation the patient was stable with oxygenation index of 76 with 2,8l min-1 blood flow of ECMO support, sedated with Propofol 5,5mg kg-1 h-1 and Sufentanil 5mcg kg-1 h-1 and received Norepinephrine 0,06 mcg kg-1 min-1. We proned the patient immediately. COVID-19 polymerase chain reaction testing was performed in all team members and was negative in all cases.ResultsDiscussion: Double lung transplantation is possible in selective patients suffering from COVID-19 pneumonia, intraoperative care is troublesome and strains resources due to open lung surgery and airway maneuvers increasing infection risk exponentially. (2)

Severe cardiac complications of extended pleurectomy and decortication: a case report

Introduction Extended pleurectomy and decortication is a specialised procedure performed typically in elderly patients with comorbidities (1). The nature of surgery presents significant physiological stress to the cardiovascular system. Here we report an an unexplained complication of EPD that occurred in our operating theatre. Methods A 70 year-old underwent an EPD for mesothelioma, following neoadjuvant chemotherapy. He was an ex-smoker with moderate chronic obstructive airways disease, hypertensive and hyperlipidemic, and a normal preoperative electrocardiogram and echocardiogram. He had an uneventful induction of anaesthesia and the airway was secured with 41 French left double lumen tube, and maintained with desflurane and intermittent boluses of 0.25% levobupivacaine through a thoracic epidural (T4/T5 space). Routine and invasive arterial and central venous pressure monitoring were used. Surgery was uneventful with a blood loss of 250 mls and minimal dysrrhythmias during pericardectomy. At the closure of thoracotomy, sudden marked ST elevation noted was on the five-lead ECG and posterolateral ischaemic changes on a 12-lead recording (see figure 1A), associated with hypotension requiring boluses of adrenaline. No obvious precipitating event was noted. An adrenaline infusion of 0.15microg/kg/min was started to provide cardiovascular stability. Results Once transferred for angiography, the ST segments had normalized (figure 1B) and his adrenaline requirements dropped. A stable plaque in the left anterior descending artery with no flow limitation was detected. A transoesophageal echocardiogram was normal. The patient was extubated the following day on the ICU. A troponin rise (table) and persistent T wave changes (figure 1C) were detected. Discussion Intra-operative dysrhythmias are not uncommon during EPD whilst the pericardium is manipulated but rarely seen at the end of surgery (1-3), but sudden unexplained ST elevation has not to our knowledge previously been reported. Multiple breeches to the visceral pleura occur during surgery, and we speculate a small gas embolus to a coronary artery or sudden hypotension-related myocardial oxygen supply-demand mismatch may explain the severe but transient clinical and electrocardiographic findings and type two myocardial infarction, given the normal coronary angiography and post-operative echocardiography.

Prediction of Double-Lumen Tube Size By Ultrasonography for Asian Women: A Prospective Observational Study

To assess the agreement of the diameter of the cricoid cartilage by computed tomography and ultrasonography and to compare the accuracy of the left double-lumen tubes (DLTs) and right DLTs predicted by ultrasonography for Asian women. Prospective observational study. Academic, tertiary care hospital. Fifty female patients intubated with a left DLT and 50 female patients intubated with a right DLT. No intervention. A radiologist measured the transverse cricoid diameter by computed tomography (CT), and an independent echographer measured the transverse cricoid diameter using ultrasonography. The size of the DLT was selected based on the cricoid diameter by ultrasonography. The agreement of the transverse cricoid diameter was assessed by computed tomography and ultrasonography. The accuracy of the DLT, the tracheal segment, and the bronchial segment were compared between the left intubation group and right intubation group. There was a good agreement between the transverse cricoid diameter measured by ultrasonography and CT (r = 0.946, p < 0.001). The overall accuracy of the DLTs was similar between the groups (86.0% v 92.0%, p = 0.318). There were no significant differences in the accuracy of the tracheal segment (96.0% v 94.0%; p = 1.000) and the bronchial segment (90.0% v 98.0%, p = 0.056). The transverse diameter of the cricoid cartilage in most Asian women can be accurately measured by ultrasonography. The size of the DLT for Asian women can be predicted by ultrasonography measurement of the cricoid diameter.

Use of tracheal ultrasound combined with clinical parameters to select left double-lumen tube size. A prospective observational study: Erratum

Use of tracheal ultrasound combined with clinical parameters to select left double-lumen tube size. A prospective observational study: Erratum