Double-lumen Tube Placement Research Articles

Technique of Thoracoscopic Basilar Segmentectomy

STRATEGY FOR THORACOSCOPIC BASILAR SEGMENTECTOMY Although individual basilar segments may be resected, most basilar resections include all 4 segments (ie, segments 7-10). Computed tomography is used preoperatively to determine lesion size, segment location, the presence of adenopathy, and the presence of metabolically active nodal disease (via positron emission tomography), as well as to ascertain that the lesion is not too close to the superior segment to exclude the option of basilar segmentectomy. Anesthesia is administered in the usual fashion, with single-lung ventilation achieved by double-lumen endotracheal tube or bronchial blocker placement. After bronchoscopy and mediastinosopy (when indicated), single-lung anesthesia is established. The patient is positioned in the lateral decubitus position with slight flexion of the table at the level of the hip. This slight flexion provides splaying of the ribs, improving thoracoscopic access and exposure. The chest is then marked for the placement of thoracoscopic incisions, prepped, and draped.

Curved knife "Khukuri" injury in the back and anaesthesia induction in lateral position for thoracotomy

Penetrating injury in the back with knife (Khukri) demands induction of anaesthesia and intubation in lateral position. In thoracic injury a double lumen tube placement is required to facilitate one lung ventilation during thoracotomy. In emerging situation, we could successfully execute induction of patient in right lateral position using right sided DLT for left thoracotomy. Its correct placement was confirmed by fiberoptic bronchoscopy. In conclusion right-DLT intubation can be performed without difficulty by conventional direct laryngoscopy using Macintosh blade in lateral position.

Intraoperative bronchoscopy prevents hypoxaemia during one-lung ventilation for second-stage oesophagectomy: a prospective cohort study

Intraoperative bronchoscopy prevents hypoxaemia during one-lung ventilation for second-stage oesophagectomy: a prospective cohort study

Double lumen tube placement with Airtraq in unanticipated difficult airway cases

Double lumen tube placement with Airtraq in unanticipated difficult airway cases

The addition of a brief ultrasound examination to clinical assessment increases the ability to confirm placement of double-lumen endotracheal tubes

Study Objective To evaluate the role of a brief ultrasound examination (US) in detecting the correct position of the left double-lumen endotracheal tube (LDLT). Design Prospective, randomized clinical study. Setting Operating room of a university hospital. Patients 50 elective adult thoracic surgery patients who required a LDLT during anesthesia. Intervention and Measurements Patients were randomized to two groups: Group A, who underwent clinical assessment of the LDLT position, and Group B, who were examined clinically and by ultrasound. All 50 patients underwent the same conventional procedure of LDLT placement. In all patients, clinical assessment of LDLT positioning was made by observing chest wall expansion and checking lung compliance by manual ventilation and by auscultation of both lungs. In Group B, a very brief ultrasound (15-30 sec) examination was added. Ultrasound examination included visualization of the pleural movements (“lung sliding”) and motion of the diaphragm from both sides before and after selective clamping of the bronchial and tracheal limbs. In both groups, a second anesthesiologist performed bronchoscopy to estimate actual LDLT position. Main Results Sensitivity and negative predictive values in detecting proper LDLT positioning for both methods were 100%. For the clinical assessment alone (Group A), specificity was 22%, accuracy was 72%, and positive predictive value, 70%; for the clinical and ultrasound assessment (Group B), specificity was 50%, accuracy was 88%, and positive predictive value, 86%. Conclusion A brief ultrasound examination added to clinical assessment ensured more precise placement of LDLT than did clinical assessment alone.

Double lumen size selection: A model based on audit of successful and failed double lumen tube placement

Double lumen size selection: A model based on audit of successful and failed double lumen tube placement

Ketamine eliminates propofol pain but does not affect hemodynamics during induction with double-lumen tubes

Propofol injection during induction of anesthesia induces pain. Ketamine has been shown to reduce the injection pain. However, ketamine has unfavorable adverse effects, including increased secretion production and hemodynamic responses, which might induce pulmonary or hemodynamic adverse events, especially in patients undergoing lung surgery who require a double-lumen tube (DLT). The aim of this study was to determine whether ketamine can safely reduce propofol injection pain during induction of anesthesia for lung surgery. Forty-five patients scheduled for elective lung surgery requiring DLT were randomly allocated into three groups. Patients received saline (control), ketamine 0.5 mg kg(-1) (0.5 ketamine), or ketamine 1.0 mg kg(-1) (1.0 ketamine), followed by 5 ml propofol 30 s later. An anesthesiologist blinded to the study group assessed pain score during induction, hemodynamics during DLT placement, and secretion production during anesthetic management. Pretreatment of 0.5 mg kg(-1) ketamine reduced the incidence and intensity of propofol injection pain, whereas 1.0 mg kg(-1) ketamine completely eliminated the pain. There were no significant differences regarding oxygenation during one-lung ventilation (OLV) and hemodynamics during induction among the three groups, although ketamine increased secretion production. One milligram per kilogram of ketamine completely eliminated pain associated with propofol injection without affecting hemodynamics during induction of anesthesia and oxygenation during OLV.

Double-Lumen Tube Placement Using a Retractable Carinal Hook: A Preliminary Report

Proper placement of a double-lumen tube (DLT) is vital for its optimal functioning. We modified the standard blind method of left-sided DLT placement using a retractable carinal hook. The aim of this study was to determine whether this modified method could improve the success rate of correct initial tube positioning compared with the conventional method. Forty patients scheduled for general anesthesia requiring left-sided DLTs in a prospective, randomized, controlled trial were studied. The incidence of malpositions and time required for proper placement of a DLT using either the conventional method (conventional group, n = 20) or a modified method using a retractable carinal hook (hook group, n = 20) were recorded. The hook is a modified gum elastic bougie. Correct positioning was confirmed by fiberoptic bronchoscopy (FOB). After initial DLTs placement, clinical finding alone detected malpositions in 3 of 20 (15%) and 1 of 20 (5%) patients in the conventional and hook groups, respectively. Subsequent FOB revealed a significantly lower incidence of tube malposition in the hook group 2 of 20 (10%), compared with the conventional group 9 of 20 (45%) (P = 0.03). The time for clinical placement of DLTs was comparable in the two groups (P = 0.63), and the time for FOB confirmation and adjustment was significantly shorter in the hook group (88.9 +/- 35.7 s) compared with the conventional group (152.3 +/- 40.3 s) (P < 0.0001). The use of a retractable carinal hook increased the success rate and shortens the time for correct DLT positioning. Further, larger studies are required to confirm its safety and reliability.

Case 3—2009 Robotically Assisted Cardiac Surgery

THE FIRST ROBOTICALLY ASSISTED totally endoscopic coronary artery bypass graft (TECAB) surgery was described by Loulmet et al1 in 1999. Since then, there continues to be a growing interest in this technique for performing minimally invasive cardiac surgery.2-11 Although the technique has been deemed safe and effective, these cases present unique challenges to the anesthesiologist and surgeon.12 These challenges include double-lumen tube (DLT) placement and prolonged one-lung ventilation (OLV), dealing with thoracic insufflation and its hemodynamic consequences, limited physical access to the patient, and technical difficulties with the robot itself.

DOUBLE LUMEN INTUBATION

Introduction: Auscultation is well established and most commonly used method for checking of correct placement ofDouble Lumen Tube(DLT). Now with widespread availability of fibre optic bronchoscope, confirmation of DLT placement by fibre opticbronchoscope is recommended by many and considered mandatory by some anaesthetist. Objective: To discuss method of insertion andreliability of auscultatory method to confirm correct placement of double lumen tubes. S t u d y d e s i g n : Observational. Place a n d d u r a t i o n:Combined Military Hospital Rawalpindi from 16th Nov 2003 to 13th July 2007. Material &amp; M e t h o d s . We have performed about one thousandone hundred and fifty double lumen intubation without use of fibreoptic bronchoscope. Results: 85% of patients did not need any tubeadjustment during surgical procedure. Only 15% cases required tube adjustment intra-operatively. None of procedures were abandoneddue to double lumen tubes problems. C o n c l u s i o n : We conclude that auscultation is not that unreliable though not perfect method of DLTplacement. Use of fibreoptic bronchoscope is recommended but not mandatory for DLT placement. Anatomical malpositioning detected byfibre optic bronchoscope which according to some studies is 70 to 80% does not necessarily translate into physiological malfunctioning.

Electrical impedance tomography to confirm correct placement of double-lumen tube: a feasibility study

BackgroundDouble-lumen tubes (DLTs) are frequently used to establish one-lung ventilation (OLV). Their correct placement is crucial. We hypothesized that electrical impedance tomography (EIT) reliably displays distribution of ventilation between left and right lung and may thus be used to verify correct DLT placement online. MethodsRegional ventilation was studied by EIT in 40 patients requiring insertion of left-sided DLTs for OLV during thoracic surgery. EIT was recorded during two-lung ventilation before induction of anaesthesia and after DLT placement, and during OLV in the supine and subsequently in the lateral position. EIT measurements were made before and after verification of correct DLT placement by fibreoptic bronchoscopy (FOB). ResultsEIT accurately displayed distribution of ventilation between left and right lung online. All cases (n=5) of initially misplaced DLTs in the contralateral right main bronchus were detected by EIT. However, EIT did not allow prediction of FOB-detected endobronchial cuff misplacement requiring DLT repositioning. Furthermore, after DLT repositioning, distribution of ventilation, as assessed by EIT, did not change significantly (all P>0.5). ConclusionsThis study demonstrates that EIT enables accurate display of left and right lung ventilation and, thus, non-invasive online recognition of misplacement of left-sided DLTs in the contralateral main bronchus. However, as distribution of ventilation did not correlate with endobronchial cuff placement, EIT cannot replace FOB in the routine control of DLT position.

Right- and Left-Sided Mallinckrodt Double-Lumen Tubes Have Identical Clinical Performance

Left-sided double-lumen tubes are perceived to be safer than right-sided tubes, because they may be less prone to malposition. If this is true, then the incidence and severity of hypoxemia, hypercapnea, and high airway pressures should be higher for right-sided tubes during thoracic surgery than for left-sided tubes. We retrospectively reviewed thoracic surgical anesthetics between April 15, 2003, and December 31, 2004, using an automated anesthesia information management system. The system automatically records pulse oximetry, end-tidal carbon dioxide, and peak inspiratory pressure data every 30 s. Side of surgery and double-lumen tube placement are also documented. We compared the frequency of right- and left-sided Mallinckrodt tube use by thoracic anesthesiologists. Next, we examined the incidence, duration, and severity of hypoxemia (Spo(2) <90%), hypercapnea (Etco(2) >45 mm Hg) and high airway pressures (peak inspiratory pressure >35 cm H(2)O) for lung and chest wall surgery patients. Group counts and means were compared by standard statistical methods. Right- (n = 241) and left- (n = 450) sided tubes were almost exclusively used on the side contralateral to surgery. There were no differences in the incidence or duration of hypoxemia, hypercarbia, or high airway pressures. There was a small but significant increase in Etco(2) for patients having left lung ventilation. The supposition that left-sided double-lumen tubes are safer than right-sided tubes when intraoperative hypoxemia, hypercapnea, and high airway pressures are used as criteria for safety is not supported by our data comparing the two types of tubes from one manufacturer.

Tension Pneumothorax During One-Lung Ventilation

In Response: Our intent in submitting this case report was to highlight the pathophysiology and early clinical signs of a tension pneumothorax in the setting of an open contralateral thorax. Dr. Lohser1 reiterates established literature that defines the challenges confronted with lung isolation with a right-sided double-lumen tube (DLT). Experienced clinicians can safely institute functional lung isolation without the assistance of fiberoptic bronchoscopy with a left-sided DLT.2 The greater margin of safety with a left-sided DLT is due to the distal take-off of the left upper lobe orifice.3 We agree that successful placement of a right-sided DLT requires fiberoptic bronchoscopy and visualization of a patent right upper lobe orifice.4 DLT malposition is commonly responsible for increasing airway pressures during one lung ventilation. However, bronchospasm, secretions, dynamic hyperinflation, and pneumothorax must also be considered as potential causes. Fixating attention on just tube malposition may distract from the diagnosis and delay timely treatment of these other serious causes. The “classic” presentation of a tension pneumothorax during an open thoracotomy is herniation of the mediastinum into the operative field. This phenomenon was not observed in our patient. From the surgeon's vantage this case appeared as a failure of lung isolation since “normal” appearing lung obscured the operative field. Displacement of the mediastinum would only be appreciated if the operative lung was collapsed and the open hemithorax inspected before the pneumothorax expanded. In our case with its unique presentation, the risk of significant complications from decompressing the contralateral pleural space with a needle directed through the operative field (e.g., normal lung) would have been unacceptable. Gordon N. Finlayson, MD, FRCP Jay B. Brodsky, MD Department of Anesthesia Stanford University School of Medicine Stanford, California [email protected]

Ultrasound examination added to clinical assessment ensure safer placement of double-lumen tube and better lung isolation

Ultrasound examination added to clinical assessment ensure safer placement of double-lumen tube and better lung isolation

Double lumen tube placement with the Pentax-Airway Scope®

Double lumen tube placement with the Pentax-Airway Scope®

Placement of a double-lumen intubation tube with the assistance of fibreoptic bronchoscope in a patient with tracheoesophageal fistula after an operation of esophageal stent

Placement of a double-lumen intubation tube with the assistance of fibreoptic bronchoscope in a patient with tracheoesophageal fistula after an operation of esophageal stent

Tracheal Laceration After the Use of an Airway Exchange Catheter for Double-Lumen Tube Placement

Tracheal Laceration After the Use of an Airway Exchange Catheter for Double-Lumen Tube Placement

Results of the Study Comparing Devices Used for Lung Isolation Are Rather Concerning

Results of the Study Comparing Devices Used for Lung Isolation Are Rather Concerning

Effects of inhaled nitric oxide on oxygenation and haemodynamic performance during one-lung ventilation in pigs

AbstractObjective: To study the effects of 20 ppm inhaled nitric oxide (iNO) on haemodynamics and systemic oxygenation during one-lung ventilation (OLV) in vivo. Design: Prospective animal study with a cross-over design. Setting: Animal laboratory of a university hospital. Subjects: Eight female pigs. Outcome measures: The pigs were anaesthetized, tracheally intubated, and mechanically ventilated. Following placement of femoral arterial and pulmonary artery catheters, a left-sided double-lumen tube (DLT) was placed via tracheotomy After DLT placement, in each animal OLV was performed during intravenous anaesthesia in a cross-over design with and without iNO (20ppm) in 100% oxygen. After haemodynamic stabilization, haemodynamic measurements and blood gas analyses were made, in addition we measured differential lung perfusion with colored microspheres in three animals. Results and Conclusions: iNO did not improve oxygenation nor did iNO reduce pulmonary arterial pressure in our animal model. Mixed venous Pv...

Shearing of a Frova Intubating Introducer by a Bronchocath double lumen tube

Intubation with a double lumen tube (DLT) may be more difficult than an equivalent intubation with a single lumen tracheal tube. The larger size of the tube can make an otherwise good view of the glottis obscured. The gum elastic bougie is well established as an aid to intubation but it is generally too short to be of use with DLTs. Newer versions of the bougie have been developed which are longer, disposable and may have a central lumen to allow oxygenation in difficult circumstances. These can be used to assist both tracheal and endobronchial intubation. We report a case demonstrating a problem using one such bougie, the Frova Intubating Introducer (Cook (UK) Ltd, Letchworth, UK) used to aid the insertion of a DLT. A 59-year-old female was listed for right thoracotomy and right upper lobectomy for bronchial carcinoma. On airway examination she was Mallampati grade 3. Following induction of anaesthesia, laryngoscopy revealed a grade 2 Cormack and Lehane view of the glottis. An initial attempt to pass a 37 FG left-sided Bronchocath (Mallinckrodt, Athlone, Ireland) was hindered by prominent dentition and the decision was made to use the bougie (Frova Intubating Introducer) to avoid dental trauma and aid intubation. The bougie was preloaded on the DLT via the bronchial lumen and the ensemble passed through the cords into the trachea without difficulty. Removal of the bougie did not require any more force than would be expected. Clinical assessment of the DLT showed that the bronchial lumen was in fact in the right main bronchus and an attempt was made to reposition the DLT using a fibreoptic bronchoscope. On bronchoscopy via the bronchial lumen two thin blue fragments of plastic were seen within the right main bronchus (Fig. 1). It became apparent that these were thin shavings from the bougie. The site of shaving was a ledge within the Bronchocath tube. Initial attempts to remove these with suction and then biopsy forceps via the bronchoscope were unsuccessful. The DLT was removed and the patient re-intubated with a single lumen tube and later a second DLT but attempts to remove the fragments by both anaesthetists and surgeons were again unsuccessful. Surgery proceeded and following the right upper lobectomy, the foreign bodies were removed by the surgical team, via the right bronchial stump, using a fibreoptic bronchoscope with biopsy forceps. The chest was closed and the patient woken and extubated at the end of the case. Fragments of Frova Intubating Introducer produced by shaving of the plastic. Several techniques for placement of DLTs have been described [1-4]. These frequently involve the use of some type of stylet or bougie, with or without fibreoptic verification. Although this case may be the first in the literature with regard to the Frova Intubation Introducer, similar problems have been described with other intubating aids [5]. The fact that this had happened at all was noticed only once the fibreoptic scope was used. Clearly, a fibreoptic scope is not used to assess all intubations, and it is feasible that this may have happened before without being noticed. Such particles may then lodge in the smaller bronchi, which may then cause small airway collapse and make the lung more prone to infection. Longer intubation aids such as the Cook Exchange catheter may be useful in certain circumstances but they do not possess the same degree of ‘memory’ as the older gum elastic and newer bougie versions. The production of a disposable yet hard wearing bougie, which is compatible with DLT use, is required. This case was reported to Cook (Australia and UK) who have stated that these intubating aids will now carry a warning of this potential hazard.