lung isolation and difficult airway

[caligas]

What are folks doing for these? I have changed to a double lumen over a tube changer a few times, also used the bronchial blocker with mixed results. I've found that using a large scope to mainstem a standard tube is easy and fairly effective.

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[nimbus]

Univent by LMA is super slick. Much easier to use than our old bronchial blocker.

 

[periopdoc]

I've found that using a large scope to mainstem a standard tube is easy and fairly effective.

This.

I don't understand the need to get fancy and complicated. Make an attempt at passing the double lumen tube and then go to this as plan B.

Obviously if the right lung is to be the ventilated one, this may be more problematic.

- pod

 

[caligas]

Did a case recently and ventilated right lung only by mainstem. Sats stayed around 90. Probably was blocking the RUL but patient tolerated.

 

[cincincyreds]

I had an ankylosing sponylitis patient for a thoracotomy. I put in a single lumen tube with a glide scope. Then over a cook tube exchanger I placed a double lumen tube.

It was a long case and I didn't want to deal with the blocker moving out of place.

 

[countingdays]

C-mac straight to DLT or if it starts with broch then single lumen, cook cath, DLT. A couple of times if it really looks bad i induce, place an LMA, get deep, then look with c-mac. It's nice to have someone very well oxygenated with the lma and to know that my first back up plan will work, and to not get exhausted with a difficult mask.

 

[Precedex]

Fiberoptic DLT, had to do this last week !

 

[bentrider]

Glidescope sells stylet for double lumen tube but I have not used it yet. Several times I have used glidescope to place single lumen and then exchanged with glidescope visualization to double lumen.

 

[RxBoy]

What are folks doing for these? I have changed to a double lumen over a tube changer a few times, also used the bronchial blocker with mixed results. I've found that using a large scope to mainstem a standard tube is easy and fairly effective.

This works well if you plan on main stemming the left. Just need to be careful and inject no more than 2 cc of air). However, main stemming the right is far more tricky. The RUL bronchus takes off within 2cm of the right main. A standard ET proximal end extends too far and many times the balloon itself occludes the RUL. Even if you try to position murphys eye over the RUL, the balloon wont sit within the right main and will be half exposed in the trachea.They do make single lumen bronchial tubes but I've never used one nor do we have them on stock.

Bronchial Tube

Standard ET tube

We generally do SL to DL over cook catheter exchange. I only use the soft tipped one now (green with purple tip). I once used a stiffer one and caused a trachael laceration. Luckily the patient did well. Stiff catheters should be removed off the market.

Last tip I learned, when exchanging over catheter, use a glidescope to try and visualize the DL tube entering the glottis. Its so much easier, and rarely gets caught on arytenoids. Even if you can't visualize with GS due to abnormal airway anatomy, it still helps move tissue and facilitate passage. Plus you get the added bonus of knowing whether the airway was truly difficult once you obtain optimal GS image.

 

[periopdoc]

Last tip I learned, when exchanging over catheter, use a glidescope to try and visualize the DL tube entering the glottis. Its so much easier, and rarely gets caught on arytenoids. Even if you can't visualize with GS due to abnormal airway anatomy, it still helps move tissue and facilitate passage. Plus you get the added bonus of knowing whether the airway was truly difficult once you obtain optimal GS image.

I like to do this with a second anesthesiologist driving the glidescope while I manipulate the tube exchanger and ETT. Works really nicely for fiber optic intubations as well.

...the balloon wont sit within the right main and will be half exposed in the trachea..

As long as it does not occlude the left main stem, is this a problem?

- pod

 

[deleted126335]

Known or anticpated- Awake fiberoptic with DLT. I am 4 for 5. (deliberately heavy doses of lido for topicalization).

Not known or suspected-depends how much I have mucked things up.

Didn't know about the Glidescope stylet. Ordering one today.

 

[RxBoy]

Didn't know about the Glidescope stylet. Ordering one today.

Waste of money. Our DL tubes already have a nice stiff metallic stylet. All you need to do is grab a regular glidescope stylet, press it against the outside of the DL tube and just trace the arch as you curve the DL end yourself. Problem solved.

 

[urge]

Fiberoptic/glidescope & Bronchial blocker

 

[fakin' the funk]

Did a case recently and ventilated right lung only by mainstem. Sats stayed around 90. Probably was blocking the RUL but patient tolerated.

Um...as plan A?

I mean, if you can put in a single lumen tube, you can put in a Uniblocker.

 

[caligas]

Um...as plan A?

I mean, if you can put in a single lumen tube, you can put in a Uniblocker.

Emergent case. Pt also had pneumonia, horrible purlent secretions, very difficult to visualize things with brochoscopy for me or the thoracic surgeon. Tried the bronchial blocker but just could not get decent visualization. Mainstem worked fine.