Difficult DL, need DLT

[Iso4ane]

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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.

I would like to see that ABG.

 

[GassYous]

I would like to see that ABG.

heh
I haven't done it for thoracic but know of apneic oxygenation being done successfully.
I've done it for vocal cord surgery. ENTs were a little hesitant but it worked beautifully. They had a wide open field to work in.

I believe the literature describes people with paco2s in the 200s without any long term sequelae. Probably goes higher than that too.

 

[Iso4ane]

I believe the literature describes people with paco2s in the 200s without any long term sequelae. Probably goes higher than that too.

I believe the literature calls than a MAC of CO2.

 

[Hork Bajir]

I’ve always wondered whether apneic oxygenation for vocal cord surgery (which often involves lasers) carries a higher risk of airway fire. I know there’s no ETT to act as a fuel source, but surely there are other things in the airway which can burn (when you’re blasting the surgical field with high flows of 100% FiO2)

Im also dubious that apneic oxygenation would work on one lung, but would be curious to be proven wrong

 

[coffeebythelake]

heh
I haven't done it for thoracic but know of apneic oxygenation being done successfully.
I've done it for vocal cord surgery. ENTs were a little hesitant but it worked beautifully. They had a wide open field to work in.

I believe the literature describes people with paco2s in the 200s without any long term sequelae. Probably goes higher than that too.

Pt selection key. A PaCO2 of 200 (or even 100) would easily throw some people with RV dysfunction, elevated Pa pressures, or existing metabolic disorders into all sorts of trouble.

 

[deleted875186]

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.

Wait, I thought this was a joke

 

[ethilo]

I just tried this, it just BARELY fits into a 35F DLT, requires lots of lube and lots of force AKA it's impractical. Definitely manageable with larger sizes though. Remember lots of lube!!!

 

[pgg]

The Cook catheters are better for DLTs. They make a green version with a soft/flexible purple end that presumably is less traumatic to bronchi. It also has a lumen and comes with an adapter to connect to a circuit, so oxygen can be delivered through it. I think it comes in 10 Fr and 14 Fr sizes.

For lube, the greasy eye ointment works really well. Doesn't dry out if you prep the thing ahead of time, very slick. I always use it on fiberoptic scopes and airway exchange catheter.

 

[deleted875186]

The Cook catheters are better for DLTs. They make a green version with a soft/flexible purple end that presumably is less traumatic to bronchi. It also has a lumen and comes with an adapter to connect to a circuit, so oxygen can be delivered through it. I think it comes in 10 Fr and 14 Fr sizes.

For lube, the greasy eye ointment works really well. Doesn't dry out if you prep the thing ahead of time, very slick. I always use it on fiberoptic scopes and airway exchange catheter.

Do you use these like a bougie?

ive used them for tube exchange, but they seem too flimsy to be helpful to be used as a bougie.

 

[Southpaw]

The Cook catheters are better for DLTs. They make a green version with a soft/flexible purple end that presumably is less traumatic to bronchi. It also has a lumen and comes with an adapter to connect to a circuit, so oxygen can be delivered through it. I think it comes in 10 Fr and 14 Fr sizes.

For lube, the greasy eye ointment works really well. Doesn't dry out if you prep the thing ahead of time, very slick. I always use it on fiberoptic scopes and airway exchange catheter.

I was trained on these and always found them to work very well. Also we used a drop of two of lubricant that came in the fiberoptic carts and was used for the scope. Didn’t need much, just a drop or two as it was super slick. Surgilube dries out way too fast to be useful for planning ahead.

 

[pgg]

Do you use these like a bougie?

ive used them for tube exchange, but they seem too flimsy to be helpful to be used as a bougie.

I've used them as bougies though admittedly more for the small-mouth kind of difficult DL than the anterior-airway kind of difficult DL. Maybe a McGill would be helpful for the anterior airways.

 

[drmwvr]

Way better than lube and it doesn't get on the FOB lens. Get it from your endo dept....and don't get it on the floor....

 

[zizzer]

View attachment 326204View attachment 326210
I just tried this, it just BARELY fits into a 35F DLT, requires lots of lube and lots of force AKA it's impractical. Definitely manageable with larger sizes though. Remember lots of lube!!!

My anesthesia tech didn't try hard enough apparently. Good to know! Thanks for checking that.

 

[mdawarre]

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.

which lumen was he trying to instrument, the tracheal or bronchial?

 

[zizzer]

which lumen was he trying to instrument, the tracheal or bronchial?

The bronchial lumen

 

[mdawarre]

The bronchial lumen

Just stick the bougie in the tracheal lumen and get the tube in the trachea. You can direct it into the bronchus later with FO. I tried to find the inner diameters of DLT lumens for you but it's not so easy, reportedly because the lumens are not a perfect circle like they are in SLT.

Edit: The bougie is not a tube changer. It is a device to facilitate intubation. But if you don't have any cook catheters and in are in a pinch...