Difficult Airway and Lung Isolation

[dA pilot]

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What would your approach for a difficult airway and lung isolation? Patient previously had an anesthetic with easy mask ventilation, direct laryngoscopy abandoned due to grade IV view, tube passed with glidescope which showed a glimpse of the posterior arytenoids. Patient will be coming back with subsequent neck fusion and needs lung isolation now. My initial plan would be awake single ett placement and then bronchial blocker through it, however my experience is that bronchial blockers do not provide as nice of surgical field. Would anyone consider doing fiberoptic with a double lumen? or tube changer after placement of single lumen to convert to double lumen?

 

[Fastrach]

What would your approach for a difficult airway and lung isolation? Patient previously had an anesthetic with easy mask ventilation, direct laryngoscopy abandoned due to grade IV view, tube passed with glidescope which showed a glimpse of the posterior arytenoids. Patient will be coming back with subsequent neck fusion and needs lung isolation now. My initial plan would be awake single ett placement and then bronchial blocker through it, however my experience is that bronchial blockers do not provide as nice of surgical field. Would anyone consider doing fiberoptic with a double lumen? or tube changer after placement of single lumen to convert to double lumen?

I think it's reasonable to try to get good isolation first with a blocker rather than a DLT in this pt primarily for this reason: if you put in a DLT (via whatever means you like), undergo a long case, and then extubate the guy, you may find the DLT caused excessive airway edema due to its size. He might need to be reintubated afterward in that scenario, and given his difficult history you may find yourself in even deeper trouble at that point. So I think using a standard ETT with a blocker is reasonable up front, especially if you're placing it under any means other than a straight DL.

 

[Noyac]

if you put in a DLT (via whatever means you like), undergo a long case, and then extubate the guy, you may find the DLT caused excessive airway edema due to its size. He might need to be reintubated afterward in that scenario, and given his difficult history you may find yourself in even deeper trouble at that point.

How many times have you seen this?

I have never seen it.

Blockers work fine and offer plenty of lung isolation. If the surgeon isn't happy, tough ****.

 

[militarymd]

I prefer awake fibers for DLT's....I like the ability to have access to the isolated lung via the DLT for pulmonary toilet access during the case.

 

[cchoukal]

I prefer awake fibers for DLT's....I like the ability to have access to the isolated lung via the DLT for pulmonary toilet access during the case.

ditto.

 

[Planktonmd]

What would your approach for a difficult airway and lung isolation? Patient previously had an anesthetic with easy mask ventilation, direct laryngoscopy abandoned due to grade IV view, tube passed with glidescope which showed a glimpse of the posterior arytenoids. Patient will be coming back with subsequent neck fusion and needs lung isolation now. My initial plan would be awake single ett placement and then bronchial blocker through it, however my experience is that bronchial blockers do not provide as nice of surgical field. Would anyone consider doing fiberoptic with a double lumen? or tube changer after placement of single lumen to convert to double lumen?

I usually would do Awake FOB and place a single lumen tube, then put the patient to sleep and use a changer to place the DL tube.
Always remember to put a laryngoscope in the mouth when you introduce the DL tube over the changer, it makes life much easier.

 

[Idiopathic]

unanticipated difficult airway yesterday. While I was placing art line, new CA-1 attempted DL with 8.0 ETT for bronch, couldnt see anything, attending looked, could barely see epiglottis. I got LMA and slipped it in, ventilated "okay". Attending asked what I wanted to do.

Pedi fiberscope with 6.0 ETT as deep as it would go. Cook catheter through that to 25-ish centimeters, changed out to 8.0 ETT and bronched. Changed out ETT to 39 DL over same Cook catheter without incident. Fiberscopic view appropriate afterwards.

If I was doing the same patient Id probably feel comfortable doing the exact same thing, but if I had someone I didnt know with the same report of difficulty, Id probably keep him awake and use a blocker.

 

[Idiopathic]

Always remember to put a laryngoscope in the mouth when you introduce the DL tube over the changer, it makes life much easier.

Also convinces you that you could intubate this person easily, where others failed...dont be fooled 😉

 

[dfk]

unanticipated difficult airway yesterday. While I was placing art line, new CA-1 attempted DL with 8.0 ETT for bronch, couldnt see anything, attending looked, could barely see epiglottis. I got LMA and slipped it in, ventilated "okay". Attending asked what I wanted to do.

Pedi fiberscope with 6.0 ETT as deep as it would go. Cook catheter through that to 25-ish centimeters, changed out to 8.0 ETT and bronched. Changed out ETT to 39 DL over same Cook catheter without incident. Fiberscopic view appropriate afterwards.

If I was doing the same patient Id probably feel comfortable doing the exact same thing, but if I had someone I didnt know with the same report of difficulty, Id probably keep him awake and use a blocker.

hey idiopathic,
nice case.
just curious, any post-op airway edema with all the mucking around?

also, consider this a lame question, but say you used a fast-trac LMA, is it possible to keep that in and bronch thru that?

 

[jetproppilot]

unanticipated difficult airway yesterday. While I was placing art line, new CA-1 attempted DL with 8.0 ETT for bronch, couldnt see anything, attending looked, could barely see epiglottis. I got LMA and slipped it in, ventilated "okay". Attending asked what I wanted to do.

Pedi fiberscope with 6.0 ETT as deep as it would go. Cook catheter through that to 25-ish centimeters, changed out to 8.0 ETT and bronched. Changed out ETT to 39 DL over same Cook catheter without incident. Fiberscopic view appropriate afterwards.

If I was doing the same patient Id probably feel comfortable doing the exact same thing, but if I had someone I didnt know with the same report of difficulty, Id probably keep him awake and use a blocker.

WOW.

Thats some frikkin' nice work, Dude.👍

 

[Noyac]

I prefer awake fibers for DLT's....I like the ability to have access to the isolated lung via the DLT for pulmonary toilet access during the case.

Really, Why?

I have never done an awake DBL placement.

how does having them awake help you?

 

[proman]

Has anyone else used the FOB/Aintree through LMA technique? It would have saved Idiopathic the 6.0 ET and exchange catheter step. I posted about this on the other difficult airway thread and no one commented. It's a great technique. Here's a poster on if from CCF:

http://www.cookmedical.com/cc/content/mmedia/C-LMA304.pdf

 

[Mman]

-- awake FOI for the DLT? As mentioned above, why??? I can't imagine ever wanting to do that. DLTs can be hard to get past the cords sometimes and I can't imagine an awake patient would enjoy the sensation of having me try to get it to deftly slip past. Let alone the idea of having a coughing and moving patient possibly making it more difficult.


-- I tend to just use a blocker if the airway is that difficult. You get pretty darn good isolation if it is seated correctly.

-- as for FOI through an LMA, it can be a nice technique. Then again, why not just use an intubating LMA and blindly stick the tube in. Last time I tried to stick the fiberoptic down the intubating LMA after goosing it twice blindly through the LMA I couldn't see crap. The patient had loads of excess soft tissue that were flopping in the way. I couldn't use the fiberoptic through the LMA for the same reason I couldn't intubate blindly through the LMA so it didn't really help.

 

[Arch Guillotti]

Unfortunately I never placed a bronchial blocker in residency hopefully this will not hurt me when I get a real job. I was able to manuever the DLT almost every time. A couple of times the DLT absolutely wouldn't pass so I put in a regular ETT then passed a Cook, took out the SLT and passed a DLT over the Cook. The first time I did it I was pretty nervous, a DLT is a monster of a piece of plastic to be blindly shoving down a gullett.

Had I not read it on this forum I don't think I would have ever thought of an AFOI with a DLT, that sounds crazy to me.

 

[Planktonmd]

Unfortunately I never placed a bronchial blocker in residency hopefully this will not hurt me when I get a real job. I was able to manuever the DLT almost every time. A couple of times the DLT absolutely wouldn't pass so I put in a regular ETT then passed a Cook, took out the SLT and passed a DLT over the Cook. The first time I did it I was pretty nervous, a DLT is a monster of a piece of plastic to be blindly shoving down a gullett.

Had I not read it on this forum I don't think I would have ever thought of an AFOI with a DLT, that sounds crazy to me.

It has been more than 5 years since the last time I had to place a bronchial blocker, and we do a fair amount of thoracic cases.

 

[MTGas2B]

Why a tube? We have convinced our thoracic surgeons to bronch through and LMA. Makes life much easier, if the bronch is all they're doing.


As a side note, we do all of our double lumens asleep.

unanticipated difficult airway yesterday. While I was placing art line, new CA-1 attempted DL with 8.0 ETT for bronch, couldnt see anything, attending looked, could barely see epiglottis. I got LMA and slipped it in, ventilated "okay". Attending asked what I wanted to do.

Pedi fiberscope with 6.0 ETT as deep as it would go. Cook catheter through that to 25-ish centimeters, changed out to 8.0 ETT and bronched. Changed out ETT to 39 DL over same Cook catheter without incident. Fiberscopic view appropriate afterwards.

If I was doing the same patient Id probably feel comfortable doing the exact same thing, but if I had someone I didnt know with the same report of difficulty, Id probably keep him awake and use a blocker.