Difficult Airway and DLT

Started by Sonny Crocket
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Sonny Crocket

Sonny Crocket

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Anyone have a preferred method for these? I like to do an awake FOI with a single lumen tube and then change the tube over an exchange catheter or boughie. It's pretty tight with the exchange catheter in the bronchial lumen but it works. Today we had difficulty advancing the tube over the catheter and ended up reintubating and using a bronchial blocker. Not a fan of the blockers.
 
Bronchial blocker for the win. Trying to exchange SLETT for DLETT at the beginning of the case (and at the end if you have to send the pt to ICU intubated for some reason) in a known difficult airway is just asking to lose an airway at some point. This happens (including to one of my colleagues in residency) and people die. Clean kill. Blockers may be a bit more finicky and lung isolation can be less than ideal (inability to suction, etc), but this beats a dead patient. My surgeons get much less picky when I explain it that way.
 
When you use a tube exchanger make sure you also put a mac laryngoscope in the mouth and lift the tongue and the soft tissue out of the way otherwise your DLT will get stuck as you reported.
This is the most common reason for failing to advance the DLT.
 
I did all those things you guys mentioned. Lube, As well as exchange while under direct laryngoscopy. She was just so anterior. I agree. Sometimes you just have to give into a bronchial blocker. Hate those things.
 
If it's right- sided surgery, you can just left mainstem a single lumen ETT. Use a slightly smaller size than usual- this fits better in the bronchus and better allows air egress from the right lung out the cords. 100% o2 first gives you some absorption atelectatis.
 
Agree w/ bronchial blocker. The Uni-blockers are really easy to place, and I've always gotten great lung isolation with them. Other option is DLT over the FOB with the Glidescope in place as well to help visualize.
 
Sonny Crocket said:
Anyone have a preferred method for these? I like to do an awake FOI with a single lumen tube and then change the tube over an exchange catheter or boughie. It's pretty tight with the exchange catheter in the bronchial lumen but it works. Today we had difficulty advancing the tube over the catheter and ended up reintubating and using a bronchial blocker. Not a fan of the blockers.
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http://forums.studentdoctor.net/threads/one-lung-isolation-and-pt-with-a-tracheostomy.603066/

take a look
 
OB1🤙 said:
If it's right- sided surgery, you can just left mainstem a single lumen ETT. Use a slightly smaller size than usual- this fits better in the bronchus and better allows air egress from the right lung out the cords. 100% o2 first gives you some absorption atelectatis.
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Do you insert this tube over a bronchoscope? Thought about doing this but then thought this could be a big problem if it dislodges
 
nimbus said:
EZ blocker

http://www.teleflex.com/en/usa/prod...ts/endobronchialBlockers/products/ez-blocker/

Great product. It's so easy!
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I have used the EZ blocker before . Good for lung isolation but not that good for a lobectomy. We did, however, get pretty good deflation of the lung eventually. Had to deflate the the cuff to that lung and allow for a period of apnea three times during the case. It was a right lung. It went deep at first and we inadvertently ventilated the right upper lobe.
 
I don't do any DLTs any more, but why cant you put the bronchoscope through the bronchial lumen and get to the cords that way. I seem to recall doing this in residency (or at least observing). And you obviously omit the bite block.
 
HollywdAnesth said:
I don't do any DLTs any more, but why cant you put the bronchoscope through the bronchial lumen and get to the cords that way. I seem to recall doing this in residency (or at least observing). And you obviously omit the bite block.
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It can be done but it's not always easy to do an awake double lumen because of how huge the tube is.
 
I have grown to like the blockers in these cases. The only issue I have is when attempting to block the right lung and the RUL takeoff is off the trachea rather than the bronchus. I use the univent blocker and a trick I learned was to bend the tip a bit somewhat like you do on a stylet for an anterior airway. The tip is flexible so it won't bend tremendously but it gives you just enough bend to be able to steer the blocker by twisting as you advance under fiber optic guidance. This way I rarely need to place the fiber optic scope thru the loop on the end of the blocker.

I would not attempt to exchange a SL for a DL in a difficult airway pt unless I was certain I could rescue the airway.
 
HollywdAnesth said:
I don't do any DLTs any more, but why cant you put the bronchoscope through the bronchial lumen and get to the cords that way. I seem to recall doing this in residency (or at least observing). And you obviously omit the bite block.
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I had a bmi> 50, fused c spine with a MP4 airway and a massive neck for a right lobectomy the other day. Tried to awake the guy with a dbl lumen because surgeon didn't want a blocker, and even though topicalization was excellent I couldn't get it past the cords. Ended up using a single lumen for the awake fob, then exchanged with a tube exchanger while observing cords with a glide after he was asleep. I don't think I'll waste my time with a dbl lumen to start next time because they are so rigid and large, I doubt in most cases it would pass easily without causing significant distress to patient...
 
risnwb said:
I had a bmi> 50, fused c spine with a MP4 airway and a massive neck for a right lobectomy the other day. Tried to awake the guy with a dbl lumen because surgeon didn't want a blocker, and even though topicalization was excellent I couldn't get it past the cords. Ended up using a single lumen for the awake fob, then exchanged with a tube exchanger while observing cords with a glide after he was asleep. I don't think I'll waste my time with a dbl lumen to start next time because they are so rigid and large, I doubt in most cases it would pass easily without causing significant distress to patient...
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Totally a case where you cordially discuss with your surgeon that a DLT is likely to impossible. Just because they want it doesn't mean they get it. I propose that your changing to a DLT was an added and unnecessary risk.
 
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