Lung Isolation Research Articles

Comparison of the effect of double-lumen endotracheal tubes and bronchial blockers on lung collapse in video-assisted thoracoscopic surgery: a systematic review and meta-analysis

ObjectiveThis meta-analysis compared the quality of lung collapse and the resultant adverse reactions between the use of double-lumen endotracheal tubes (DLT) and bronchial blockers (BB) in minimally invasive thoracic surgery.MethodsA search was performed in five bibliographic databases, namely PubMed, Springer, Medline, EMBASE, and Cochrane Library ignoring the original language, which identified five randomized controlled trials (RCTs) published on or before December 31, 2021. These studies were subsequently analyzed. All included studies compared the efficacy and safety of DLT and BB as a lung isolation technique in surgery. The methodological quality of each study was assessed by the Cochrane Collaboration’s risk of bias tool. The quality of lung collapse and the malposition rate were adopted as the main outcome indicators. Alternatively, the intubation time and the incidence of postoperative sore throat were adopted as secondary indicators.ResultsWhen either DLT or BB were utilized in minimally invasive thoracic surgery, no differences were observed in the quality of lung collapse (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.63 to 1.58), the intubation time (mean difference [MD], 0.06; 95% CI, -1.02 to 1.14), or the malposition rate (OR, 0.88; 95% CI, 0.37 to 2.06). However, the incidence of postoperative sore throat among patients treated with BB was significantly lower than that among patients treated with DLT (OR, 5.25; 95% CI, 2.55 to 10.75).ConclusionWhen utilized in minimally invasive thoracic surgery, the quality of lung collapse with DLT was identical to that with BB. However, patients treated with the latter demonstrated a significantly lower incidence of postoperative sore throat.

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.

Radiographic Demonstration of Hypoxic Pulmonary Vasoconstriction during One-lung Ventilation.

Hypoxic pulmonary vasoconstriction occurs when the microvasculature perfusing hypoxic alveoli vasoconstricts, diverting blood to oxygenated alveoli to match ventilation with perfusion.1 Hypoxic pulmonary vasoconstriction can occur within seconds and reach a maximum intensity within minutes of hypoxia developing. It appears to be triggered by a mitochondrial redox signal secondary to changes in molecular oxygen that activates voltage-gated potassium and calcium channels which results in vasoconstriction.2 One-lung ventilation can acutely cause global alveolar hypoxia and hypoxic pulmonary vasoconstriction in the nonventilated lung. It is estimated that blood flow to a nonventilated lung can be reduced by as much as 50% if the lung is without atelectasis.3The pulmonary angiograms were performed in a patient with a history of hemoptysis in whom a computed tomography angiogram demonstrated a pulmonary pseudoaneurysm with a presumed bronchial fistula in the right lung. The patient was scheduled for embolization with interventional radiology under general anesthesia. Because of concern for potential bleeding, lung isolation with a left-sided double lumen tube was positioned with the right lung open to ambient pressure. Isoflurane 1.1% was used for maintenance anesthesia. After approximately 15 min of one-lung ventilation, a pulmonary angiogram was performed that dramatically revealed selective peripheral microvascular perfusion to the left lung, but almost no microvascular perfusion to the right lung (fig. 1A and Supplemental Digital Content 1, http://links.lww.com/ALN/C912). This limited visualization of the right pseudoaneurysm. Repeat angiogram after 5 min of two-lung ventilation restored symmetric microvascular perfusion (fig. 1B and Supplemental Digital Content 2, http://links.lww.com/ALN/C913). The patient subsequently underwent selective catheterization and coil embolization of the pulmonary artery pseudoaneurysm.The authors declare no competing interests.Pulmonary Angiogram during One-Lung Ventilation, http://links.lww.com/ALN/C912Pulmonary Angiogram during Two-Lung Ventilation, http://links.lww.com/ALN/C913

An algorithm for difficult double lumen tube placement and troubleshooting a malpositioned double lumen tube harnessing A, B, Cs of lung isolation.

An algorithm for difficult double lumen tube placement and troubleshooting a malpositioned double lumen tube harnessing A, B, Cs of lung isolation.

Comparison of double lumen tube insertion using the McGrath MAC versus direct laryngoscopy in adult patients with a limited glottis view: A prospective interventional study.

Passage of double-lumen tubes (DLT) can be challenging in patients with limited glottis view. This study aims to determine the usefulness of McGrath® MAC videolaryngoscope (VL) in cases with limited glottis view on direct laryngoscopy with Macintosh blade. After study approval and registration of trial, consent was sought from all adult patients planned for elective DLT insertion for lung isolation during the course of general anesthesia. Patients not consenting, less than 18 years, with anticipated difficult mask ventilation or need for rapid sequence induction were excluded. Following routine anesthetic induction, laryngoscopy was attempted by an experienced anesthesiologist using Macintosh scope. If the view obtained was Cormack and Lehane (CL) view IIB and above or the attempt at intubation using DLT failed despite a CL I/IIA view, the patient was included in the trial. The laryngoscope was removed and after ensuring adequate oxygenation and depth of anesthesia, intubation was attempted using McGrath® MAC VL. The percentage of glottis opening (POGO) score was noted for both the scopes. DLT insertion was attempted in 76 patients in the study period. Eight patients were included in the trial on account of limited glottis view/failure with Macintosh scope. Insertion of DLT with McGrath MAC was tried only in six patients, in two patients, the VL was not available for use. The mean (standard deviation) POGO score with Macintosh scope was 9 (±20), which significantly improved with the use of VL to 71 (±24), P = 0.01. McGrath MAC is helpful in inserting DLT in patients with limited glottis view with Macintosh scope.

The association between double-lumen tube versus bronchial blocker and postoperative pulmonary complications in patients after lung cancer surgery.

BackgroundBoth double-lumen tube (DLT) and bronchial blocker (BB) are used for lung isolation in patients undergoing lung cancer surgery. However, the effects of different devices for lung isolation remain inconclusive. Present study was designed to investigate the association between the choice of the two devices and postoperative pulmonary complications (PPCs) in patients with lung cancer.MethodsIn this retrospective cohort study, patients who underwent lung cancer surgery between January 1, 2020 and October 31, 2020 were screened. Patients were divided into two groups according to different devices for lung isolation: DLT group and BB group. Primary outcome was the incidence of a composite of PPCs during postoperative in-hospital stay.ResultsA total of 1721 were enrolled for analysis, of them, 868 received DLT and 853 BB. A composite of PPCs was less common in patients with BB (25.1%, [214/853]) than those received DLT (37.9% [329/868] OR 0.582 95% CI 0.461-0.735 P < 0.001). Respiratory infection was less common in BB group (14.4%, [123/853]) than DLT group (30.3%, [263/868], P<0.001). The incidence of non-PPCs complications was not statistically significant between the 2 groups.ConclusionsFor patients undergoing surgery for lung cancer, the use of BB for lung isolation was associated with a reduced risk of PPCs when compared with DLT.

650. ROBOTIC ESOPHAGEAL LEIOMYOMA ENUCLEATION

Abstract Leiomyomas are rare benign esophageal neoplasms. Surgery is indicated in symptomatic patients or if malignancy is suspected. A 20-year-old female presented with dysphagia to solids. Contrast enhanced computed tomography showed a 33-mm by 30-mm by 51 mm well circumscribed lobulated mass arising from the right anterolateral wall of the upper thoracic esophagus, causing luminal narrowing and abutting the azygos vein. An esophageal ultrasound performed for confirmation showed the lesion arising from the muscularis propria. Patient was scheduled for a robotic leiomyoma excision. Patient was placed in left lateral position, lung isolation was obtained with a double lumen tube. Four standard ports were placed in the sixth intercostal space. Robotic instruments used were the monopolar scissors, Maryland bipolar forceps, fenestrated bipolar forceps for dissection and needle holder for suturing. The leiomyoma was identified, mediastinal pleura and muscle layer were incised longitudinally. The leiomyoma was dissected all around in the submuscular plane taking care not to injure the underlying mucosa. However, while delivering the deep lobulated portion, there was an inadvertent injury to the mucosa. The mucosal tear was repaired with interrupted sutures utilising 4-0 Polydiaxanone sutures and the muscle layer was closed with V-Lock sutures. A check endoscopy was performed on table along with air insufflation with saline in the pleural cavity to check for an air leak. A nasogastric tube was placed, specimen was retrieved in a bag through the assistant port. Surgery was completed in 155 minutes with 50 ml blood loss. Post-operative course was uneventful, and the patient was discharged on full diet on the fourth post-operative day. Histopathology showed a SMA and desmin-positive spindle cell neoplasm without conspicuous mitotic activity. Precise dissection in a confined space is possible due to wrist-like movements, three-dimensional view and magnification offered by the robot. Repair of the injured mucosa and myotomy closure to prevent future diverticulum formation is easily accomplished with robotic suturing. Intraoperative endoscopy is useful in evaluating the integrity of the mucosa and muscle repair. Hence a robotic approach may be superior to a thoracoscopic/open leiomyoma enucleation and can be utilised even in moderate size masses.

Development and Validation of a Hybrid Bronchoscopy Trainer Using Three-Dimensional Printing.

Simulation is an essential component of medical education. Commercially available intubation simulators often lack anatomical fidelity of the lower airway and are therefore not suitable for teaching bronchoscopy or lung isolation. By using a desktop 3-dimensional (3D) printer, we aimed to create and validate a hybrid simulator from an existing mannequin with a 3D-printed lower airway that has anatomical fidelity and is financially affordable compared with commercially available models. Using an anonymized computed tomography scan of an adult male patient, we developed a 3D model of the airway from below the larynx to the 3rd generation bronchi, which was then printed on a desktop 3D printer. The printed airway was attached to an existing mannequin below the larynx via a universal adaptor. Ten anesthesiology attendings performed a blinded comparison of the hybrid mannequin with a commercially available mannequin for tactile and visual fidelity when performing intubation, bronchoscopy, and lung isolation. They were also asked to assess the models for educational suitability. The 3D printed model was judged more suitable for teaching double-lumen tube insertion to novice physicians compared with the commercial model, with median (interquartile range) scores of 5 (4-5) versus 3 (2-4), P = 0.017. Similar results were found for bronchial blocker insertion and bronchoscopy. The visual fidelity of the bronchial anatomy was scored as 5 (4-5) and 2 (1-3) for the 3D-printed and the commercial models, respectively ( P = 0.007). By creating a hybrid model combining an existing commercially available mannequin with a 3D-printed trachea and bronchial tree, we have created an affordable training simulator suitable for teaching lung isolation and bronchoscopy. Enhancing existing mannequins with 3D-printed parts may be of particular interest to institutions that do not have the funds to buy models with anatomical fidelity but do have access to a 3D printer.

Addition of lumbar intrathecal morphine along with standard thoracic epidural anesthesia for abdomino thoracic esophagectomy

Introduction: Thoracic epidural anaesthesia (TEA) has been the standard of care for postoperative pain management for patients undergoing abdomino-thoracic esophagectomy. The study aims to observe whether addition of lumbar intrathecal morphine along with TEA reduces the post operative pain scores, post operative opioid consumption and total epidural drug requirement. Materials and methods:50 patients divided into two groups, one group was given standard TEA at level T5-T7, other group was receiving intrathecal morphine along with TEA. General anaesthesia will be provided as per standard protocol and one lung isolation will be achieved using Robertsons double lumen tube of proper size. Pain scores will be monitored using Numerical rating Scale. Total requirement of epidural drug in both the groups , requirement of rescue analgesia, complications in both the groups will be observed. Results and observations: In our study we found that VAS score were better in the combined intrathecal morphine plus thoracic intrathecal morphine plus thoracic epidural approach group and there were less need of rescue analgesia and good recovery compared to conventional thoracic epidural approach. Haemodynamic parameters and complications were almost comparable in both the groups except for heart rate.

One Lung Extraluminal Bronchial Blocker

Introduction: This video shows the various methods employed for one lung ventilation (OLV) for thoracoscopic surgery in infants and toddlers. Currently, there are no best practice guidelines on the best method to achieve OLV in this challenging patient population. The different methods include main stem intubation, double lumen tubes, and extraluminal bronchial blockers.1 Extraluminal bronchial blocker for OLV has unique advantages for infants and smaller children that balances the needs of both the surgical and anesthesia providers. We demonstrate a standard method for extraluminal bronchial blocker placement in an infant and a novel modification of the technique that facilitates more accurate blocker placement into the target bronchus.2 The rationale for a multicenter study of OLV techniques in infants is presented as next steps are discussed. Materials and Methods: A novel modification for the technique of extraluminal bronchial blocker for OLV using an uncuffed tube facilitates deployment of the bronchial blocker. To start, the endotracheal tube (ET) here is placed through video laryngoscopy. A flexible fiberoptic endoscope is then used to ensure correct placement into the left main stem. The bronchial blocker is then deployed directly into the left mainstem through the main stemmed endotracheal tube. While holding the blocker in place, The ET tube is then removed from the trachea over the external portion of the blocker shaft. Next, under direct or video laryngoscopy, a new ET tube is positioned in the trachea and anterior to the now extraluminal/endotracheal bronchial blocker. Flexible bronchoscopy through the ET tube is then used to observe the bronchial blocker in the left bronchus and the balloon is inflated once placement is confirmed. Results: Effective placement of extraluminal bronchial blockers into the left mainstem can be achieved with this novel modification to placement. Conclusions: The primary literature on this subject is limited and there are no best practice guidelines at this time. Small single-center studies have shown that extraluminal bronchial blockers are associated with less hypoxemia and hypercarbia.3 The novel modification to the placement of extraluminal bronchial blockers described in this video may help with ease of placement and encourage wider adoption of this technique. There is a need for multicenter study to adequately determine the most effective method for OLV that maximizes the safety profile for patients, ensures ease of placement for the anesthesia providers, and maintains quality lung isolation for the surgeon. No competing financial interests exist. Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. Runtime of video: 5 mins

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.

Case report on peri-operative surgical and anaesthetic management of ruptured humongous lung abscess.

IntroductionEarly thoracic empyema is usually treated through video-assisted thoracoscopic (VATS) decortication. Patient selection is important for decortication if an effective surgical outcome is required. Lung isolation techniques are required to provide anesthesia for these patients to facilitate the surgeon while operating on the affected lung. The ultimate target is to protect the non-diseased contra-lateral lung from contamination.Presentation of caseWe are presenting a unique case of 20-year-old female, resident of Karachi, who was brought to the emergency room (ER) with signs of sepsis, hypotension, and multi-organ failure. She was brought to the operating room to undergo video-assisted thoracoscopy (VATS) for lung abscess decortication when her medical therapy had failed. On table decision of right upper lobe resection was made and ventilation strategy had to be modified accordingly.DiscussionThe main anaesthetic aim was to protect the healthy parts of the lung from the abscess. Regular suctioning of secretions during surgery via the double lumen tube (DLT) lumen on the diseased side is recommended. While performing VATS, the lung abscess got ruptured and immediate measures to isolate the lung was taken to assist with surgical resection of the affected lobe. Lobectomy can only be done once the lung was completely isolated and maintaining perfusion and ventilation of the relatively healthy lung help in managing hypoxia.ConclusionPeri-operative management of ruptured lung abscesses required thorough pre-op evaluation, intraoperative lung isolation and ventilation, and postoperative analgesia with combined team effort both surgical and anaesthetic, are vital fundamentals to consider in guaranteeing the best outcome.

Bronchial blocker through Proseal LMA - A useful approach for paediatric lung isolation.

Bronchial blocker through Proseal LMA - A useful approach for paediatric lung isolation.

Lung isolation strategies for repeat video-assisted thoracoscopic surgery (VATS) after major lung resections: a case series

Lung isolation strategies for repeat video-assisted thoracoscopic surgery (VATS) after major lung resections: a case series

Intubation with vivasight double-lumen tube versus conventional double-lumen tube in adult patients undergoing lung resection: A retrospective analysis.

ABSTRACTObjectives:The present study was designed to compare outcomes in patients undergoing thoracic surgery using the VivaSight double-lumen tube (VDLT) or the conventional double-lumen tube (cDLT).Design:A retrospective analysis of 100 patients scheduled for lung resection recruited over 21 consecutive months (January 2018–September 2019).Setting:Single-center university teaching hospital investigation.Participants:A randomized sample of 100 patients who underwent lung resection during this period were selected for the purpose to compare 50 patients in the VDLT group and 50 in the cDLT group.Interventions:After institutional review board approval, patients were chosen according to inclusion and exclusion criteria and we created a general database. The 100 patients have been chosen through a random process with the Microsoft Excel program (Microsoft 2018, Version 16.16.16).Measurements and Main Results:The primary endpoint of the study was to analyze the need to use fiberoptic bronchoscopy to confirm the correct positioning of VDLT or the cDLT used for lung isolation. Secondary endpoints were respiratory parameters, admission to the intensive care unit, length of hospitalization, postoperative complications, readmission, and 30-day mortality rate. The use of fiberoptic bronchoscopy was lower in the VDLT group, and the size of the tube was smaller. The intraoperative respiratory and hemodynamics parameters were optimal. There were no other preoperative, intraoperative, or postoperative differences between both groups.Conclusions:The VDLT reduces the need for fiberoptic bronchoscopy, and it seems that a smaller size is needed. Finally, VDLT is cost-effective using disposable fiberscopes.

One lung ventilation in left sided cystic hygroma: Anaesthesia challenges

Cystic hygroma [CH], also called as cavernous lymphangioma is a histologically benign congenital tumor of lymphatic origin. Its presence in the cervical region,most common site [25%] poses multiple challenges to the anaesthetist which includes tumor extension in oral and thoracic cavity, restricted neck movements, airway management, haemorrhage, post-operative respiatory obstruction and coexisting anomalies [down syndrome, turner syndrome, and congenital cardiac defects]. The recommended treatment is surgical excision which can be achieved with no mortality and little morbidity. The advantages of video assisted thoracoscopic surgery (VATS) in children have led to its increased usage over the years. VATS, however requires an efficient technique for one lung ventilation. Today there is an increasing interest in developing the technique for lung isolation to meet the anatomic and physiologic variations in infants and children. Significant differences exist between airways of the neonate and the adult. Anaesthetic management of the airway is challenging in neonates and young infants with large neck mass like huge cystic hygroma because these patients are at risk for sudden complete airway occlusion resulting in hypoventilation and hypoxemia. We report a successful anaesthesia management in an infant undergoing video assisted thoracoscopic excision of cystic hygroma in left side of neck which was extending to anterior mediastinum under general anaesthesia.

Case report: anaesthetic and surgical management of a diaphragmatic rupture with tension pneumothorax and iatrogenic bowel perforation in an undiagnosed Bochdalek hernia patient

BackgroundCongenital diaphragmatic defects are rare, with most cases presenting in childhood. Diagnosis in adulthood is usually incidental or when symptoms develop. We present a case of a strangulated Bochdalek hernia complicated by possible tension pneumothorax and iatrogenic bowel injury in a healthy young male.Case presentationA 23-year-old Chinese man initially presented with complaints of mild back pain and was discharged with symptomatic treatment. He presented again 3 days later, with dyspnea and left upper back pain and was haemodynamically unstable and hypoxic. A chest x-ray was reported as a moderately large left-sided pneumothorax with herniation of bowel into the left hemithorax. Needle decompression resulted in feculent fluid being aspirated with no resolution of symptoms. The patient required an immediate transfer to the operating theatre for surgical intervention of his left diaphragmatic rupture, complicated by visceral herniation and left tension pneumothorax, with accidental puncture of the herniated bowel. He underwent an emergent laparotomy with requirements for rapid lung isolation and continued aggressive resuscitation.ConclusionsPatients with congenital diaphragmatic hernias may present in adulthood, either incidentally or emergently. In the well adult patient with good reserves, these initial symptoms may be mild, and may be symptomatically treated with no further workup. However, patients may deteriorate rapidly once their compensatory mechanisms are exhausted.This is the first reported case of a patient with diaphragmatic rupture and bowel herniation, complicated by iatrogenic tension pneumothorax. This rare case illustrates the speed at which a diaphragmatic rupture may progress, possible pitfalls and offers insights on how a misdiagnosis may be avoided.

Recent Advances in Videolaryngoscopy for One-Lung Ventilation in Thoracic Anesthesia: A Narrative Review.

Since their advent, videolaryngoscopes have played an important role in various types of airway management. Lung isolation techniques are often required for thoracic surgery to achieve one-lung ventilation with a double-lumen tube (DLT) or bronchial blocker (BB). In the case of difficult airways, one-lung ventilation is extremely challenging. The purpose of this review is to identify the roles of videolaryngoscopes in thoracic airway management, including normal and difficult airways. Extensive literature related to videolaryngoscopy and one-lung ventilation was analyzed. We summarized videolaryngoscope-guided DLT intubation techniques and discussed the roles of videolaryngoscopy in DLT intubation in normal airways by comparison with direct laryngoscopy. The different types of videolaryngoscopes for DLT intubation are also compared. In addition, we highlighted several strategies to achieve one-lung ventilation in difficult airways using videolaryngoscopes. A non-channeled or channeled videolaryngoscope is suitable for DLT intubation. It can improve glottis exposure and increase the success rate at the first attempt, but it has no advantage in saving intubation time and increases the incidence of DLT mispositioning. Thus, it is not considered as the first choice for patients with anticipated normal airways. Current evidence did not indicate the superiority of any videolaryngoscope to another for DLT intubation. The choice of videolaryngoscope is based on individual experience, preference, and availability. For patients with difficult airways, videolaryngoscope-guided DLT intubation is a primary and effective method. In case of failure, videolaryngoscope-guided single-lumen tube (SLT) intubation can often be achieved or combined with the aid of fibreoptic bronchoscopy. Placement of a DLT over an airway exchange catheter, inserting a BB via an SLT, or capnothorax can be selected for lung isolation.

Comparison of Airtraq DL™ and Macintosh laryngoscope for double-lumen tube placement in simulated difficult airway: A randomised study.

ABSTRACTBackground and Aims:The Airtraq DL ™ is a prototype channeled video laryngoscope, designed specifically for endobronchial intubation with a double-lumen tube (DLT). Evidence on its superiority over Macintosh laryngoscope for DLT placement in the difficult airway is limited. This study compared the efficacy of both these laryngoscopes in the simulated difficult airway.Methods:A prospective randomised controlled study was conducted on 52 patients undergoing elective thoracic surgery with lung isolation using a left-sided DLT. The patients were randomised into Airtraq DL ™ group (group A) and Macintosh group (group M). The primary objective was to compare the time required for intubation, and the secondary objectives were to evaluate time to best glottic view, Cormack–Lehane (CL) grading, intubation difficulty score (IDS), manoeuvres, attempts at intubation, haemodynamic response and complications. Operating anaesthesiologists were also asked to grade the ease of laryngoscopy and intubation for both devices on a 4-point Likert scale.Results:The mean time to intubation was found to be lesser in group A than in group M (18 ± 6.91 s vs 25.48 ± 9.47 s, P = 0.003). Group A showed better CL grading (P ≤ 0.001), lesser requirement of manoeuvres (P = 0.02) and lower IDS (P = 0.003). Also, group A had significantly better Likert scale results as compared to group M.Conclusion:The Airtraq DL ™ is superior to Macintosh laryngoscope as it requires lesser time for intubation and provides favourable intubating conditions (better CL grading, lesser manoeuvres, lower IDS and improved Likert scales) for double-lumen placement in the simulated difficult airway.

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.