Difficult DL, need DLT

[coffeebythelake]

Kink in tube or massive airway booger. Some type of obstruction.

Tension pneumo will also cause incredible obstruction but is incredibly unlikely in this scenario.

Immediately after intubating? These are not things seen immediately after sticking in that tube and trying to bag. Wall of airway resistance from massive airway booger in the trachea? Aspirated solid material (e.g. coin) causing complete airway obstruction?Definitely way far down the ddx for routine case compared to bronchospasm. Lots of asthmatics out there, lots of URI sox and obvious anaphylaxis causing profound beonchospasm should be on the list.

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[Arch Guillotti]

Immediately after intubating? These are not things seen immediately after sticking in that tube and trying to bag. Wall of airway resistance from massive airway booger in the trachea? Aspirated solid material (e.g. coin) causing complete airway obstruction?Definitely way far down the ddx for routine case compared to bronchospasm. Lots of asthmatics out there, lots of URI sox and obvious anaphylaxis causing profound beonchospasm should be on the list.

I get it and I don’t disagree.

Complete abrupt inability to ventilate as described in this scenario is either severe bronchospasm or total tube occlusion (whatever the cause). The few times I have seen truly severe bronchospasm I was able to squeak a bit of air in.

 

[deleted875186]

However, too small increases youR risk of tube migration And over inflation of cuff (which makes the cuff no longer a low pressure cuff).

I use a 35 DLT in all but very large males, never any problems with cuff pressure or tube placement, only occasionally harder to pass a fiberoptic scope down the lunen. All the tubes are the same legnth, just different diameters.

mid any difficulty, I would advise trying a 35 if not already using it.

 

[mdawarre]

Whenever I hear about the warm saline, I'm reminded of the story my attendings used to tell me in residency. There was a case where a resident warmed the ETT in preparation for an intubation, may have been a nasal intubation. Not uncommon. Easy intubation, grade 1 view. After intubating, found that they were completely unable to ventilate. Checked to make sure the tube wasn't misplaced. Performed DL again, same grade 1 view with the ETT going right thru the cords. Still can't ventilate. Severe bronchospasm perhaps? Nothing they tried worked. Patient arrested, died. Long story short, the warm tube had folded upon itself past the cords. They never thought to take it out.

wonder if it's this case:

On Reducing Fixation Errors

Although it has been nearly twenty years since the publication of the Institute of Medicine's landmark publication “To Err is Human,” medical errors

www.apsf.org

 

[abolt18]

wonder if it's this case:

On Reducing Fixation Errors

Although it has been nearly twenty years since the publication of the Institute of Medicine's landmark publication “To Err is Human,” medical errors

www.apsf.org

Holy crap I bet it is!

 

[Drwine]

I use a 35 DLT in all but very large males, never any problems with cuff pressure or tube placement, only occasionally harder to pass a fiberoptic scope down the lunen. All the tubes are the same legnth, just different diameters.

mid any difficulty, I would advise trying a 35 if not already using it.

I lost count on the number of times that I have been called by colleagues to troubleshoot migration or displacement of DLT intraop when they used small tubes. I am copying Jay Brodsky's article from several years ago.

http://ether.stanford.edu/library/thoracic_anesthesia/One-Lung%20Ventilation/DLT%20Placement.pdf

 

[deleted875186]

I lost count on the number of times that I have been called by colleagues to troubleshoot migration or displacement of DLT intraop when they used small tubes. I am copying Jay Brodsky's article from several years ago.

http://ether.stanford.edu/library/thoracic_anesthesia/One-Lung%20Ventilation/DLT%20Placement.pdf

The real question is why were they misplaced. If you always check with a fiberoptic and get the bronchial cuff just past the carina, turn lateral, check again and secure the tube, i don’t think you’ll have a problem.

also, this paper quoted offers no real evidence that larger tubes are better, it just repeats the same thing the textbooks say, “resistance to airflow is less” and “smaller tubes more likely to be advanced too deep”.

the paper also says fiberoptic use is “controversial” with DLTs, which I think most would find outdated.

 

[sevoflurane]

37 on nearly all my DLT’s

 

[deleted875186]

37 on nearly all my DLT’s

I think a 37 is perfect, not too small to have issues with passing a fiberoptic, and going any larger I don’t think offers any benefit.

 

[drmwvr]

the paper also says fiberoptic use is “controversial” with DLTs, which I think most would find outdated.

to say nothing about their plateau pressures and tidal volumes...times have changed a bit...

 

[coffeebythelake]

Never heard of it. Not sure I would even have considered that diagnosis. Glad I read it hear to add to my differential. That case should have been written up.

Probably after the lawsuit concluded.

 

[Drwine]

the paper also says fiberoptic use is “controversial” with DLTs, which I think most would find outdated.

I agree with that statement. I use the FOB to place the tube initially by just getting tube just past the cords and putting FOB through bronchial lumen and watching tube go to carina and down L mainstem bronchus. If necessary I use the scope to steer the tube or as a stylet if it doesn't want to go. I find that the view is less likely to be obscured by blood and secretions prior to attempted blind insertion. I then look down the other lumen to adjust the depth and recheck it once patient positioned.

 

[drmwvr]

Interested to know what scopes folks are using...we've transitioned to the disposable flex bronch 2/2 regular and frequent FO scope repairs...using both the Glidescope Bflex and Ambu product...any biases?

 

[mdawarre]

Immediately after intubating? These are not things seen immediately after sticking in that tube and trying to bag. Wall of airway resistance from massive airway booger in the trachea? Aspirated solid material (e.g. coin) causing complete airway obstruction?Definitely way far down the ddx for routine case compared to bronchospasm. Lots of asthmatics out there, lots of URI sox and obvious anaphylaxis causing profound beonchospasm should be on the list.

Somewhere, and I'm too lazy to look, there is a searchable event involving some type of plastic wrapping around CO2 absorbent within the canister. The wrapping is supposed to be removed, but wasn't. I forget what harm the patient suffered but it was not a benign event. The lesson is, change the tube, grab an ambubag and take the machine and circuit out of the equation. We almost had a pt get b/l chest tubes when an ogt was in the trachea and placed on suction and there was a loss of etco2 and inability to ventilate. Sounds obvious but it's not when you're the attending walking in the room and don't know that happened 30 seconds before you were called in the room.

 

[mdawarre]

Interested to know what scopes folks are using...we've transitioned to the disposable flex bronch 2/2 regular and frequent FO scope repairs...using both the Glidescope Bflex and Ambu product...any biases?

we have the ambu. the suction is not great. really convenient though. a lot of our scopes are always out for repairs.

 

[caligas]

I've intubated with a bougie then placed the DLT over the bougie blind on a difficult airway. It worked so well I almost didn't believe it. I know this isn't fancy but I'm definitely doing this as my difficult airway DLT strategy.

The other day: complex lobectomy, really wanted a DLT. Grade 3 view.

Started to plan some complex dance of green tube changers and single lumen tubes and glidescopes, then I heard a voice “REMEMBER YOUR SDN TRAINING!”

grabbed bougie, slipped under the epiglottis, popped 37 DL over that...Done.

(Well, confirmed with FOS, then done.)

 

[mdawarre]

this is nice

https://journals.lww.com/anesthesia-analgesia/fulltext/2010/01000/double_lumen_tubes__which_lumen_for_the_gum.54.aspx

 

[Ronin786]

Speaking of difficulty ventilating, story from a residency colleague:

Patient dropped in ICU, vented, post-some sort of combo procedure that included oral surgery. Difficulty ventilating, high peak airway pressures, audible wheeze. Suction catheter passes. Try everything, albuterol, ketamine, inhaled volatile, epi, epi drip. Can't break the spasm. Patient codes and comes back immediately with one round of CPR. ECMO consult. Cardiac surgeon says he wants a bronch first. Bronched and they found surgiclot had found its way into the tube. Was creating a one way valve. Patient auto-peeped themselves into cardiac arrest and came back with CPR. Switch the tube and extubated shortly thereafter

 

[abolt18]

Speaking of difficulty ventilating, story from a residency colleague:

Patient dropped in ICU, vented, post-some sort of combo procedure that included oral surgery. Difficulty ventilating, high peak airway pressures, audible wheeze. Suction catheter passes. Try everything, albuterol, ketamine, inhaled volatile, epi, epi drip. Can't break the spasm. Patient codes and comes back immediately with one round of CPR. ECMO consult. Cardiac surgeon says he wants a bronch first. Bronched and they found surgiclot had found its way into the tube. Was creating a one way valve. Patient auto-peeped themselves into cardiac arrest and came back with CPR. Switch the tube and extubated shortly thereafter

There's a once-in-a-lifetime event!

 

[fakin' the funk]

I agree with that statement. I use the FOB to place the tube initially by just getting tube just past the cords and putting FOB through bronchial lumen and watching tube go to carina and down L mainstem bronchus. If necessary I use the scope to steer the tube or as a stylet if it doesn't want to go. I find that the view is less likely to be obscured by blood and secretions prior to attempted blind insertion. I then look down the other lumen to adjust the depth and recheck it once patient positioned.

This is the correct way. Those who disagree will be executed.

 

[Ezekiel2517]

Speaking of difficulty ventilating, story from a residency colleague:

Patient dropped in ICU, vented, post-some sort of combo procedure that included oral surgery. Difficulty ventilating, high peak airway pressures, audible wheeze. Suction catheter passes. Try everything, albuterol, ketamine, inhaled volatile, epi, epi drip. Can't break the spasm. Patient codes and comes back immediately with one round of CPR. ECMO consult. Cardiac surgeon says he wants a bronch first. Bronched and they found surgiclot had found its way into the tube. Was creating a one way valve. Patient auto-peeped themselves into cardiac arrest and came back with CPR. Switch the tube and extubated shortly thereafter

If the patient is already in the unit, seems like they should've went with the bronch for a quick look a lot sooner. I mean, it's literally right there and you have respiratory and a lot of hands to help out. If it doesn't respond to epi, it's pretty much a guarantee it's not spasm.

 

[Hork Bajir]

I saw “real” auto peep (leading to peri-code) for the first time during COVID, with an ETT that was plugged up with thick secretions. I was called to trouble shoot the tube in the unit, and as I was standing outside the room donning PPE the RT made one last attempt to pass a suction catheter... then sticks his head out of the room to tell me that now he can’t move any air at all. Barrel chest, narrow pulse pressure on art line trending towards flatline, very dramatic. I had about 1 minute worth of donning left at this point, so instructed the RT to extubate the patient. Immediate recovery of hemodynamics when the tube came out. Fortunately patient was maskable by the RT for the final 30 seconds it took for me to get into the room and perform DL to replace the tube.

Lessons I took away:
Auto peep is f******* real, and can be dramatic
Don’t hesitate to extubate in that situation
Mask ventilation is life saving (obviously... But in this case it was the RT’s ability to mask that made a difference)
Don’t compromise on PPE during a pandemic. Even if the patient is dying and desaturating in front of you, take the time to put on PPE properly

 

[drmwvr]

I saw “real” auto peep (leading to peri-code) for the first time during COVID, with an ETT that was plugged up with thick secretions. I was called to trouble shoot the tube in the unit, and as I was standing outside the room donning PPE the RT made one last attempt to pass a suction catheter... then sticks his head out of the room to tell me that now he can’t move any air at all. Barrel chest, narrow pulse pressure on art line trending towards flatline, very dramatic. I had about 1 minute worth of donning left at this point, so instructed the RT to extubate the patient. Immediate recovery of hemodynamics when the tube came out. Fortunately patient was maskable by the RT for the final 30 seconds it took for me to get into the room and perform DL to replace the tube.

Lessons I took away:
Auto peep is f******* real, and can be dramatic
Don’t hesitate to extubate in that situation
Mask ventilation is life saving (obviously... But in this case it was the RT’s ability to mask that made a difference)
Don’t compromise on PPE during a pandemic. Even if the patient is dying and desaturating in front of you, take the time to put on PPE properly

Can't you just look at the spirometry on the ventilator to see the auto peep occurring? Whether it's due to obstructive a/w dz or a plugged large airway it ought to be fairly apparent.

 

[deleted162650]

This is the correct way. Those who disagree will be executed.

Agree with you. The only thing I like to do differently is start with the FOB in the tracheal lumen so I can watch the bronchial lumen advance into place and set the depth without having to switch lumens.

 

[GassYous]

Agree with you. The only thing I like to do differently is start with the FOB in the tracheal lumen so I can watch the bronchial lumen advance into place and set the depth without having to switch lumens.

Very nice. I do it the other way described but I will try it this way. Do you notice that this causes more damage to the fiberoptic scopes? I heard from the techs that people leave the tip bent as they pull it out and it damages the fibers.

 

[deleted162650]

Very nice. I do it the other way described but I will try it this way. Do you notice that this causes more damage to the fiberoptic scopes? I heard from the techs that people leave the tip bent as they pull it out and it damages the fibers.

You should always pull out while your tip is straight.

 

[ethilo]

The other day: complex lobectomy, really wanted a DLT. Grade 3 view.

Started to plan some complex dance of green tube changers and single lumen tubes and glidescopes, then I heard a voice “REMEMBER YOUR SDN TRAINING!”

grabbed bougie, slipped under the epiglottis, popped 37 DL over that...Done.

(Well, confirmed with FOS, then done.)

Go forth and conquer private practice young padawan.

 

[Endee]

This happened at my place today:

Patient having left VATS, blebectomy, pleurodesis. Came in with a Pleurex chest tube in already.

Induced, grade 4 view with Mac 4. Poor dentition as well with a lot of sharp, misaligned teeth. Got Glidescope, was a little tricky but got the DLT in. Connected it to the machine and heard an air leak with both cuffs up as if we tore the tracheal cuff. Removed tube, intubated with Mac4+bougie with a single lumen.

Called the thoracic surgeon in to help/troubleshoot. He wanted to intubate with the fiberoptic loaded with the DLT over it. He did that, connected to vent.. no CO2/TV. Removed the DLT, masked the patient for a while. Put a single lumen in again with Mac4+bougie. Tried the Cook catheter to exchange the SLT for a DLT. Connected the DLT to the vent.. no CO2 no TV. Pulled it out, and intubated again with a SLT... then took 45 minutes for all of us to figure out how to use the crappy bronchial blocker that we had. We intubated this guy 4 times..

 

[fakin' the funk]

This happened at my place today:

Patient having left VATS, blebectomy, pleurodesis. Came in with a Pleurex chest tube in already.

Induced, grade 4 view with Mac 4. Poor dentition as well with a lot of sharp, misaligned teeth. Got Glidescope, was a little tricky but got the DLT in. Connected it to the machine and heard an air leak with both cuffs up as if we tore the tracheal cuff. Removed tube, intubated with Mac4+bougie with a single lumen.

Called the thoracic surgeon in to help/troubleshoot. He wanted to intubate with the fiberoptic loaded with the DLT over it. He did that, connected to vent.. no CO2/TV. Removed the DLT, masked the patient for a while. Put a single lumen in again with Mac4+bougie. Tried the Cook catheter to exchange the SLT for a DLT. Connected the DLT to the vent.. no CO2 no TV. Pulled it out, and intubated again with a SLT... then took 45 minutes for all of us to figure out how to use the crappy bronchial blocker that we had. We intubated this guy 4 times..

This story is a little nuts, but, did this pt have such a large leak that you couldn't positive pressure ventilate *at all* to both lungs? (Hence no VT, no CO2) This happens occasionally and you have to be prepared to go on OLV to the good lung as soon as you induce and intubate. Assessing degree of preinduction chest tube leak is key.

 

[mdawarre]

was the chest tube on water seal or suction?

 

[Hork Bajir]

This story is a little nuts, but, did this pt have such a large leak that you couldn't positive pressure ventilate *at all* to both lungs? (Hence no VT, no CO2) This happens occasionally and you have to be prepared to go on OLV to the good lung as soon as you induce and intubate. Assessing degree of preinduction chest tube leak is key.

Never personally seen this, but could imagine it with a large enough bronchopleural fistula (would have to be massive). If that were the case here though, dude would not have been able to vent stably with a SLT while they mucked around with blockers and so forth. Makes me think the DLT was never in the right place

 

[Arch Guillotti]

This happened at my place today:

Patient having left VATS, blebectomy, pleurodesis. Came in with a Pleurex chest tube in already.

Induced, grade 4 view with Mac 4. Poor dentition as well with a lot of sharp, misaligned teeth. Got Glidescope, was a little tricky but got the DLT in. Connected it to the machine and heard an air leak with both cuffs up as if we tore the tracheal cuff. Removed tube, intubated with Mac4+bougie with a single lumen.

Called the thoracic surgeon in to help/troubleshoot. He wanted to intubate with the fiberoptic loaded with the DLT over it. He did that, connected to vent.. no CO2/TV. Removed the DLT, masked the patient for a while. Put a single lumen in again with Mac4+bougie. Tried the Cook catheter to exchange the SLT for a DLT. Connected the DLT to the vent.. no CO2 no TV. Pulled it out, and intubated again with a SLT... then took 45 minutes for all of us to figure out how to use the crappy bronchial blocker that we had. We intubated this guy 4 times..

Uh, what?

 

[Endee]

This story is a little nuts, but, did this pt have such a large leak that you couldn't positive pressure ventilate *at all* to both lungs? (Hence no VT, no CO2) This happens occasionally and you have to be prepared to go on OLV to the good lung as soon as you induce and intubate. Assessing degree of preinduction chest tube leak is key.

Never personally seen this, but could imagine it with a large enough bronchopleural fistula (would have to be massive). If that were the case here though, dude would not have been able to vent stably with a SLT while they mucked around with blockers and so forth. Makes me think the DLT was never in the right place

The first of the three times we placed the DLT we heard the air leak coming from the mouth and the second two times there was just no ventilation or CO2. I swear the DLT went into the trachea the first time but the second two times the thoracic surgeon was doing it with the bronchoscope. Lots of secretions so it’s possible it kept going into the esophagus I suppose, or one suggestion was it was linking somewhere in the airway.

The chest tube was connected to a Pleurevac which was not connected to suction because we had our suction on a Yankauer and the OR’s suction on the bronchoscope. At one point I remember saying out loud “is the chest tube working?” but everyone was focused on the airway situation. This was probably a fixation error in hindsight.

We also never attempted to clamp the bronchial lumen and just ventilate the tracheal lumen. Every time the DLT ventilation failed, we pulled it out and either masked or reintubated with a SLT. The single lumen tube worked every time.

During the case the surgeon goes “oh! I think there was a tension pneumo” ... I guess the chest tube was not functioning properly.

This also explained why every time I manually ventilated the patient to get his SpO2 back up after an intubation attempt, he got severely hypotensive (50-60 systolic).

There was a lot of conflicting information but it seems like it was a combination of a difficult airway + difficult DLT placement + tension pneumo + non functioning chest tube.

 

[vector2]

This happened at my place today:

Patient having left VATS, blebectomy, pleurodesis. Came in with a Pleurex chest tube in already.

Induced, grade 4 view with Mac 4. Poor dentition as well with a lot of sharp, misaligned teeth. Got Glidescope, was a little tricky but got the DLT in. Connected it to the machine and heard an air leak with both cuffs up as if we tore the tracheal cuff. Removed tube, intubated with Mac4+bougie with a single lumen.

Called the thoracic surgeon in to help/troubleshoot. He wanted to intubate with the fiberoptic loaded with the DLT over it. He did that, connected to vent.. no CO2/TV. Removed the DLT, masked the patient for a while. Put a single lumen in again with Mac4+bougie. Tried the Cook catheter to exchange the SLT for a DLT. Connected the DLT to the vent.. no CO2 no TV. Pulled it out, and intubated again with a SLT... then took 45 minutes for all of us to figure out how to use the crappy bronchial blocker that we had. We intubated this guy 4 times..

Even with terrible secretions, for the first fiberoptic attempt you should’ve still been able to tell if one is in trachea or esophagus. Same goes for when you changed the SLT out for a DLT over a cook catheter. End tidal is good but the gold standard for placement (short of surgically seeing a tube in a lumen or a high res CT scan) is using the bronch, especially if we’re talking about a pt with anatomic broncho/pleural disruption, severe reactive airway disease, anaphylaxis, etc

If you’re using a small caliber bronch with the DLT and the suction is weak, it can also help taking some nasal cannula extension tubing, putting it on the O2 on your anesthesia machine, cranking it to 15L, and then connect the other end to the suction port on the bronch. You now have an air gun to blow secretions out of the way while adding additional oxygen.

 

[Endee]

Even with terrible secretions, for the first fiberoptic attempt you should’ve still been able to tell if one is in trachea or esophagus. Same goes for when you changed the SLT out for a DLT over a cook catheter. End tidal is good but the gold standard for placement (short of surgically seeing a tube in a lumen or a high res CT scan) is using the bronch, especially if we’re talking about a pt with anatomic broncho/pleural disruption, severe reactive airway disease, anaphylaxis, etc

If you’re using a small caliber bronch with the DLT and the suction is weak, it can also help taking some nasal cannula extension tubing, putting it on the O2 on your anesthesia machine, cranking it to 15L, and then connect the other end to the suction port on the bronch. You now have an air gun to blow secretions out of the way while adding additional oxygen.

Yeah, everyone (including the thoracic surgeon doing the bronch) was sure we were in the trachea each time. And there was compliance when I was ventilating. It didn’t feel like I was squeezing the bag against an obstruction and it didn’t feel like stomach. It felt like lungs, although a little bit tighter than usual. We considered bronchospasm and gave albuterol when we had a SLT in but the next DLT tube was still unsuccessful. It was bizarre. I think it definitely had something to do with the air leak in his chest.

 

[vector2]

Yeah, everyone (including the thoracic surgeon doing the bronch) was sure we were in the trachea each time. And there was compliance when I was ventilating. It didn’t feel like I was squeezing the bag against an obstruction and it didn’t feel like stomach. It felt like lungs, although a little bit tighter than usual. We considered bronchospasm and gave albuterol when we had a SLT in but the next DLT tube was still unsuccessful. It was bizarre. I think it definitely had something to do with the air leak in his chest.

The first one you have to remove because of the leak and the high suspicion the cuff is torn. I would have kept troubleshooting and not necessarily have removed 2 and 3 immediately if no leak and everyone is staring at the screen and agrees that the bronchial and tracheal lumens are patent and the scope (after passing through said patent lumens) is terminating in trachea and/or bronchus. Also consider calling for fluoro for another data point on where the tube is.

Another learning point with this case is having a propofol drip or an extra set of hands to intermittently bolus prop while all the tube in tube out business is going on, especially in a pt with high risk of spasm or losing Etco2 or adequate ventilation secondary to getting light.

 

[MirrorTodd]

Was the pt desatting with each new tube placement or if they did desat, were you able to bag them up? Or did you all not wait and removed the tube quickly to mask ventilate?

 

[Endee]

Was the pt desatting with each new tube placement or if they did desat, were you able to bag them up? Or did you all not wait and removed the tube quickly to mask ventilate?

With every DLT attempt we were bronching/troubleshooting until the SpO2 started getting down into the 80's and below at which point we would abort. We were able to get them back up above 90% every time via mask or single lumen tube. However, as time was going on, it was getting harder and harder to get the SpO2 all the way back up to the high 90's, it would plateau in the low 90's or so. And each subsequent attempt, the patient was desaturating quicker.

The first one you have to remove because of the leak and the high suspicion the cuff is torn. I would have kept troubleshooting and not necessarily have removed 2 and 3 immediately if no leak and everyone is staring at the screen and agrees that the bronchial and tracheal lumens are patent and the scope (after passing through said patent lumens) is terminating in trachea and/or bronchus. Also consider calling for fluoro for another data point on where the tube is.

Another learning point with this case is having a propofol drip or an extra set of hands to intermittently bolus prop while all the tube in tube out business is going on, especially in a pt with high risk of spasm or losing Etco2 or adequate ventilation secondary to getting light.

I was managing the anesthetic depth/paralysis/hemodynamics while the anesthesiologist and surgeon were dealing with the airway, so we were doing this. As expected, after the first round, succinylcholine was wearing off. At first we considered not paralyzing but it was just too difficult to have the patient fighting while trying to do all of this, so I paralyzed and had suggamadex ready if needed.

I think the consensus in the room was that we didn't want to muck around to the point of the patient desaturating so low that it becomes a crisis or peri-code situation. We had three successful intubations with a SLT and a successful round of mask ventilation, so everyone was pretty much agreed that we would try, stop if the saturation fell into the 80's, establish an airway, pause, and consider other options. It felt a lot more methodical that way and never felt like we were losing control of the situation. However, looking back I think we were definitely overlooking things that were either contributing factors and/or direct causes of our issues.

 

[Hork Bajir]

I would also question why you did not decide to use a bronchial blocker sooner. Most of the time they’re easy to place, provide comparable isolation to a double lumen tube (assuming you are using the blocker correctly), and of course they give you the option for selective lobar isolation if you are worried about BPF. It pays to be facile with blockers in addition to DLT

 

[Endee]

I would also question why you did not decide to use a bronchial blocker sooner. Most of the time they’re easy to place, provide comparable isolation to a double lumen tube (assuming you are using the blocker correctly), and of course they give you the option for selective lobar isolation if you are worried about BPF. It pays to be facile with blockers in addition to DLT

Thoracic surgeon really wanted a DLT and we only went with the blocker when it became apparent the DLT wasn’t going to work out. Since he was there pretty much the whole time during this we had no problem with trying a few times to get the DLT in.

 

[Hoya11]

Thoracic surgeon really wanted a DLT and we only went with the blocker when it became apparent the DLT wasn’t going to work out. Since he was there pretty much the whole time during this we had no problem with trying a few times to get the DLT in.

did you try a smaller DLT?

 

[Endee]

did you try a smaller DLT?

We did not. No particular reason. I don’t think anyone suggested it. Patient was a tall male and we were using a 39Fr.

 

[nimbus]

What did his endobronchial anatomy look like? Did he have anatomic variation? I don’t understand why the DLT didn’t work but a bronchial blocker did.

 

[Hoya11]

We did not. No particular reason. I don’t think anyone suggested it. Patient was a tall male and we were using a 39Fr.

thats a big tube.. i would have tried changing to a 37 or even a 35. downsizing tube is part of my algorithm for difficult placement once intubated.

more than once i have struggled with placement. stopped, reintubated with a size down, and it was straightforward.. ?? not sure why

 

[Endee]

What did his endobronchial anatomy look like? Did he have anatomic variation? I don’t understand why the DLT didn’t work but a bronchial blocker did.

I don’t quite remember but anatomical issues were definitely highly suspected by the team.

 

[Drwine]

In a difficult airway situation I would stand my ground why I am going to use a regular tube and bronchial blocker. Try to use them enough that you can make them work in a reliable fashion.

 

[Arch Guillotti]

In a difficult airway situation I would stand my ground why I am going to use a regular tube and bronchial blocker. Try to use them enough that you can make them work in a reliable fashion.

Or a Univent. Sometimes you just have to bail on a double lumen tube.

 

[drmwvr]

In a difficult airway situation I would stand my ground why I am going to use a regular tube and bronchial blocker. Try to use them enough that you can make them work in a reliable fashion.

...in the best of circumstances, a BB is just ok....when a dlt isn't feasible, they downright suck.....at least they make the case go faster....

 

[zizzer]

I've intubated with a bougie then placed the DLT over the bougie blind on a difficult airway. It worked so well I almost didn't believe it. I know this isn't fancy but I'm definitely doing this as my difficult airway DLT strategy.

By airway bougie, you mean the standard blue one, right? I just tried this with confidence today and to my dismay, my anesthesia tech was unable to pass a 37Fr DLT over it with lube. I just put in SLT instead and exchanged it. Later, I noticed the blue bougie I had used was 15Fr. Perhaps they're not all the same size or you all were using a bigger DLT? Upon review, sizes 37, 39, and 41Fr will accommodate a 14Fr AEC, but a 35Fr will not. It seems reasonable therefore that a 37Fr DLT may not accommodate a 15Fr bougie, but perhaps larger ones will.

 

[GassYous]

If your surgeon is fast enough you can passively oxygenate with high flow nasal cannula without a tube at all. Patients can be apneic for like 30 minutes with no problems and probably even longer. At the end you can put a single lumen in and get that co2 down before waking the patient up. Run tiva.