Update on Lung Separation Techniques: Double-Lumen Tubes and Bronchial Blockers

Transcription

1 Update on Lung Separation Techniques: Double-Lumen Tubes and Bronchial Blockers Javier H. Campos, M.D. Professor Vice Chair for Clinical Affairs Director of Cardiothoracic Anesthesia Executive Medical Director of Operating Rooms Department of Anesthesia UHIC Lung Isolation Double Lumen Tube L-DLT R-DLT Arndt Bronchial Blocker Cohen Fuji EZ Blocker Surgical exposure Prevention of contamination Differential lung ventilation Difficult airways (oral or nasal intubation) Unique situations (tracheostomy pts) Selective lobar blockade Campos JH: Thorac Surg Clin 2005; 15:

2 Lung Isolation Devices Used by Non-thoracic Anesthesiologists N End Points Outcome prospective/randomized n=66-22 L-DLT - 22 Univent - 22 Arndt Blocker Non-thoracic anesthesiologists Success/failure Time placement Confirmation by thoracic anesthesiologist 38% unrecognized malpositions failed placements with FOB Campos JH: Anesthesiology 2006; 104: Tracheobronchial anatomy Flexible fiberoptic bronchoscopy Outline Anatomical differences of the airway Lung isolation devices Left and right-sided DLTs Bronchial blockers (Arndt, Cohen, Fuji EZ blocker) Lung isolation in the morbidly obese patient Summary and recommendations 2

3 Male Tracheobronchial Tree with MDCT Healthy 25 yr old Campos JH: Curr Opin Anaesthesiol 2009; 22: 4-10 Male Tracheobronchial Tree with MDCT 60 yr old Smoker Campos JH: Curr Opin Anaesthesiol 2009; 22:

4 Practice Patterns in Choice of L-DLT Size Does it make any difference what size DLT to use? n = 300 adults thoracic surgical patients Use of 35 FR vs 37, 39 L-DLT (regardless of gender) End Points % n intraoperative hypoxemia (<88%) /300 lung isolation failure /300 DLT reposition /300 Amar D, et al: Anesth Analg 2008; 106:379-3 Practice Patterns in Choice of L-DLT Size Patient Characteristics 35 FR (n = 143) 37 FR (n = 99) 39 FR (n = 58) Weight (Kg) 72 ± ± ± 19 Height (cm) 166 ± ± ± 7 Male 51 (35%) 49 (49%) 55 (95%) Female 92 (64%) 50 (51%) 3 (5%) Not a randomized study Patients that received 35 DLT majority females Only left-sided DLT was used in this study Amar D, et al: Anesth Analg 2008; 106:

5 Left Bronchocath Double-Lumen Tubes Guidelines Measured Tracheal Recommended Width (mm) DLT size (F) Campos JH: Anesthesiology 2002; 97: Double-Lumen Tubes and Intubation with Video-laryngoscope Author n= End Points Outcomes Hsu HT, etal: Anaesthesia 2012; 76; Lin W, et al: Anaesthesia 2012; 67: Prospective RS n=30 MAC blade n=30 GlideScope DLT s 35 or 37Fr Prospective RS n=85 MAC blade n=85 CEL-100 (video-laryngoscope) DLT s 35 or 37Fr Success rate intubation Time for intubation Sore throat hoarseness Success rate intubation Glottic view n, pts with correct DLT positioning (left bronchus) No difference first attempt intubation Intubation times MAC group 62 sec. GlideScope 45 sec. Sore throat and hoarseness MAC group 60%; 40% GlideScope 20%; 13% Intubation Mac CEL-100 n=65 (79%) n=77 (93%) Glotic view (grade I) Mac CEL-100 n=40 (61%) n=75 (90%) *CEL-100 group (had 3 DLT s tracheal cuff tears) 5

6 Glide Rite Stylet n=49 DLT s (normal airways) Attempts during intubation 1, 37 pts (74%) 2, 11 pts (22%) 3, 1 pt (2%) Bussières JS, et al: Can J Anaesth 2012; 59:

7 DLT Group n=25 Arndt Blocker Group n=25 P-value <0.05 BMI kg/m ± ± Neck Circumference cm 46 ± 4 47 ± Intubation Failure (first attempt) Time for Position (min) 3.4 ± ± Time to Lung Collapse (min) 18.0 ± ± Effectiveness of Lung Collapse Complete 16 Fair 7 Poor NSS Campos JH, et al: Br J Anaesth 2012; 109: Video and optic laryngoscopy assisted tracheal intubation Thong SY: Anaesth and Int Care 2009; 37: Two airway exchange catheters 11 F Cook Critical Care Suzuki A, et al: BJA 2007; 99:

8 12 cm 15 cm 29 cm Patient height 170 cm Campos JH: SAJAA 2008; 14:22-26 Sivalingam P, et al: J Cardiothorac Vasc Anesth 1999;13:312-5 (28F) Sucato DJ, et al: J Spinal Disord Tech 2002;15:133-8 (28F) Weng W, et al: J Clin Anesth 2002;14: (37F) 8

9 Campos JH: SAJAA 2008; 14:22-26 Role of Fiberoptic Bronchoscopy and DLT s Author n End Points Outcome Klein U Anesthesiology 1998; 88: L-R DLT s (prospective) Auscultation/clamping (2 nd anesthesiologist) FOB 35% malposition FOB all malpositions corrected Campos JH Anesthesiology 2006: 104: n=66 pts (22 DLT s, 44 BB s) (prospective) Success/failure Confirmation by thoracic anesthesiologist 38% unrecognized malpositions FOB all corrected (by thoracic anesth.) Bellis M Eur J Cardiothorac Surg 2011; 40: n=104 pts L-DLT s (prospective) Auscultation/clamping (endoscopist) FOB 37% unrecognized malpositions FOB all corrected Campos JH Euro J Anaesthesiol 2011; 28: n=60 pts, DLT s n=27 non-thoracic anesth (prospective) Anesthesia Simulator or Computer DVD training 23% unrecognized malpositions Failed placements with FOB 9

10 B A D C C B A D Campos JH: Curr Opin Anaesthesiol 2009; 22:

11 Right-Sided Double-Lumen Tubes B A 5 mm 15 mm 5 mm 10 mm Sheridan Mallinckrodt Campos JH. Principles and Practice of Anesthesia for Thoracic Surgery Chapter 16; 2011: Right-Sided Double-Lumen Endotracheal Tubes Campos JH Anesth Analg 2000; 90: Author N Objective Outcome Ehrenfeld JM J Cardiothorac Vasc Anesth 2010; 24: L-DLT n=20 R-DLT n=20 (left-sided surgery) Prospective Study L-DLT n=98 R-DLT n=98 Retrospective Study No right upper lobe obstruction when seen with a chest x-ray Performance Contralateral side surgery (not recommended) RUL Collapse in patients with R-DLT n=0 L R SpO 2 < 90, 25 vs. 22 ETCO 2 > 45, 28 vs. 10* PIP > 35 cm H 2 O 46 vs. 21* 11

12 A C B Campos JH: Curr Opin Anaesthesiol 2009; 22:4-10 New DLT Devices A B C L-DLT Silbroncho (Japan) R-DLT for Tracheostomy (Poland) L-DLT w/ Embedded Light (Israel) 12

13 Alternative Method to Achieve Lung Separation by Using Bronchial Blockers Useful in patients with airway abnormalities Campos JH, et al: J Cardiothorac Vasc Anesth 2003;17: Cohen E: Anesth Analg 2005; 101: Useful in the already intubated patient Arndt GA, et al: Acta Anaesthesiol Scan 1999;43:356-8 Selective lobar blockade in patients with previous lobectomy or pneumonectomy Campos JH: Anesth Analg 1997; 85:583-6 Amar D: Anesthesiology 2001; 95: Campos JH: Curr Opin in Anaesthesiol 2009; 21:4-10 Awake oral tracheal intubation Secure the airway (1 st ) Lung isolation (bronchial blocker 2 nd ) 13

14 Lung Isolation Techniques in Difficult Airways Campos JH: Curr Opin Anaesthesiol 2010; 23:12 17 A Fuji-blocker B Low pressure High volume cuff 4-8 cc of air Center hollow channel CPAP C Narayanaswamy N, et al: Anesth Analg 2009; 108: mm 14

15 DLT n=48; EZ Blocker n=50 Incidence of initial malposition DLT 42/49 EZB 37/50 > Tracheal hematoma redness DLT Group Mourisse J, et al: Anesthesiology 2013; 118: Cohen Blocker Arndt Blocker Fuji Blocker EZ Blocker Size 9F 5F, 7F, and 9F 9F 7F Balloon shape Guidance mechanism Smallest recommended *SLT for coaxial use Spherical Wheel device to deflect the tip Spherical or elliptical Nylon wire loop that is coupled with the fiberoptic bronchoscope Spherical Spherical x 2 None, preshaped tip None 9F (8.0 SLT) 9F (8.0 SLT) 9F (8.0 SLT) 7.5F (8.5 SLT) Murphy eye Present Present in 9F Not Present No Center Channel 1.6 mm internal diameter 1.4 mm internal diameter 2.0 mm internal diameter 1.4 mm internal diameter Campos JH: Curr Opin Anaesthesiol 2007; 202:

16 9 Fr FOB 4.2 mm ETT 8.0 I.D. mm Supine Campos JH: SAJAA 2008; 14: A B Campos JH: Curr Opin Anaesthesiol 2009; 22:

17 The Use of Air in the Inspired Gas Mixture During Two-Lung Ventilation Delays Lung Collapse During One-Lung Ventilation Performance Bronchial Blockers vs Double-Lumen Tubes Lung Collapse Score Arndt Cohen Fuji L-DLT n=26 pts/ group Narayanaswamy N, et al: Anesth Analg 2009; 108:

18 Performance Bronchial Blockers vs Double-Lumen Tubes Number of Repositions n=26 pts/ group Arndt Cohen Fuji L-DLT Narayanaswamy N, et al: Anesth Analg 2009; 108: Airway Injuries: DLT vs SLT and Blockers Author n End Points Outcome Ruetzler K, et al: Br J Anaesth 2011; 106: prospective RS 20 pts DLT 20 pts SLT + EZ postop hoarseness sore throat DLT hoarseness 7/20 SLT+EZ blocker hoarseness 8/19 No difference among groups Park SH, et al: Anesth Analg 2008; 107: prospective RS 160 pts / 3 groups females, 35F males, 37F sore throat and hoarseness 1h and 24hrs after placebo or dexamethasone 0.1 or 0.2 mg kg Assessment after 24 hrs D 1 47%, D 2 27% Placebo 57% (hoarseness) 18

19 Summary Every patient that requires lung isolation should receive the benefit of a R or L-DLT Fiberoptic bronchoscopy must be used during placement of lung isolation devices during supine and lateral decubitus position or whenever a malposition occurs. Bronchial blockers recommended for difficult airways or selective cases Successful placement requires recognition of tracheobronchial anatomy javier-campos@uiowa.edu 19