One-Lung Isolation and Pt with a Tracheostomy

[drlee]

How would you isolate one lung in a patient with a tracheostomy? I recall doing this case as a resident and involved the use of a bronchial blocker. Don't remember the exact details. I think we just threaded the bronchial blocker through a port (a Uniblocker??) which hooked up to the pt's tracheostomy attachment which was connected to the breathing circuit the entire time. What is the difference between a Univent and a Uniblocker??

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[Noyac]

Pull the trach and insert a reinforced ET tube and sew it in place. Now insert a bronchial blocker into the side you want to drop.

I recently have become a big fan of the blockers after many years of using Dbl-lumen tubes almost exclusively.

 

[IceDoc]

Univent: an ETT with a built in bronchial blocker. Not really useful for pt with trach unless you pull out trach and intubate from above.

The Bronchial Blocker comes with a port that can be attached to the trach (or a regular ETT). If you want to leave the trach in, then I think this the only way to get isolation. If you can take the trach out, then insert an ETT (as described by Noy), or just intubate orally with whatever you want (Univent, ETT with subsequent bronchial blocker, DLT).

Or tell the surgeon he must do the case without isolation because the patient has no absolute indication for one lung ventilation. That'll go over well.

 

[Jeff05]

choice of DLT vs blocker would depend on the clinical scenario.

current thoracic literature suggests that DLTs are really the last word in absolute lung separation - should haves for bleeding, severe infection, protein.

blockers should be really reserved for isolation - just collapse and not really a tightly sealed division between the L and R sides.

 

[i want out]

How would you isolate one lung in a patient with a tracheostomy? I recall doing this case as a resident and involved the use of a bronchial blocker. Don't remember the exact details. I think we just threaded the bronchial blocker through a port (a Uniblocker??) which hooked up to the pt's tracheostomy attachment which was connected to the breathing circuit the entire time. What is the difference between a Univent and a Uniblocker??

I had a case like this a month or so ago, and the stoma was only big enough to get about a 6 or 6.5 tube down. Pt had laryngeal CA as reason for longstanding trach, and known hx of difficulty passing tube from above.

I was stewing about getting a blocker down the lumen of a 6.0 tube and still having enough lumen to ventilate.

My faculty suggested just mainstemming the guy since we needed the right lung to be ventilated, and the left lung down.

We tried it this way, lung isolation was not ideal to say the least. They initially wanted to do a VATS, but converted to Open because the lung was still to inflated. (that part could be surgeon dependent, as our CT surgeon has a reputation for rarely completing a VATS without opening.)

If I had it to do over again, I probably would have put the tube in the right like we did, then used the FO to thread the blocker from above after the tube was in, then pull the tube back out of the mainstem under direct visualization. (this is just a thought, as I haven't tried it this way)

i want out(of IRR)

 

[urge]

I would do as Noy suggested. Also you can intubate from above with a dlt like you normally do. Assuming there is no stenosis, that is. Cover the trach hole with some vaseline gauze/tegaderm.

 

[BLADEMDA]

Acta Anaesthesiol Scand. 2001 Feb;45(2):250-4. Links

Bronchial blocker compared to double-lumen tube for one-lung ventilation during thoracoscopy.

Bauer C, Winter C, Hentz JG, Ducrocq X, Steib A, Dupeyron JP.
Anesthesiology Department, H pital Civil, Strasbourg University Hospital, France. [email protected]
BACKGROUND: Video-assisted thoracoscopic surgery (VATS) requires one-lung ventilation with a properly collapsed lung. This study compared the Broncho-Cath double-lumen endotracheal tube with the Wiruthan bronchial blocker to determine the advantages of one device over the other during anaesthesia with one-lung ventilation for thoracoscopy. METHODS: Thirty-five patients undergoing VATS were randomly assigned to one of two groups. Sixteen patients received a left-sided double-lumen tube (DLT) and nineteen a Wiruthan bronchial blocker (BB). The BB group was subdivided in two: BB in the right mainstem bronchus (BBR) for right-sided VATS (9 patients), BB in the left mainstem bronchus (BBL) for left-sided VATS (10 patients). The position of the devices was checked using a fibreoptic bronchoscope. The following variables were measured: 1) number of unsuccessful placement attempts; 2) number of malpositions of the devices; 3) time required to place the device in the correct position; 4) number of secondary dislodgements of the devices after turning the patient into the lateral decubitus position. The quality of lung deflation was evaluated by the surgeons who were blinded to the type of tube being used. RESULTS: The number of unsuccessful placement attempts was one in the DLT group (1/16), three in the BBL group (3/10) and none in the BBR group (0/9). The number of malpositions was significantly greater in the BBL group (10/10) compared to the DLT group (2/16) and to the BBR group (1/9) (P<0.001). The time (mean+/-SD) required to place a BBL was 4.21 min+/-1.28, significantly longer than the time required to place a DLT (2.26 min+/-0.55, P<0.0006) or a BBR (2.41 min+/-0.53, P<0.008). The difference in placement time between DLT and BBR was not significant. The number of secondary dislodgements was one in the DLT group, one in the BBR group and none in the BBL group (NS). The quality of lung deflation was judged excellent or fair in all patients in the DLT and the BBL groups and poor in 44% of the patients in the BBR group. CONCLUSION: It took significantly longer to place a left BB than a DLT (P<0.0006) or a right BB (P<0.008). The number of initial malpositionings of the left BB was significantly greater than in the other groups (P<0.001). The quality of lung deflation was better in the BBL and in the DLT groups than in the BBR group. We conclude that for routine use during left-sided VATS, the use of a DLT is preferable to a left BB because of its greater ease of placement. For right-sided VATS, DLT and right BB showed the same facility of placement but the DLT provided a better quality of lung deflation.

 

[BLADEMDA]

1: Anesth Analg. 2003 Nov;97(5):1266-74. Links

Erratum in: Anesth Analg. 2004 Jan;98(1):131. An update on bronchial blockers during lung separation techniques in adults.

Campos JH.
Department of Anesthesia, University of Iowa Health Care, Iowa City, Iowa 52242-1079, USA. [email protected]
Techniques for one-lung ventilation (OLV) can be accomplished in two ways: The first involves the use of a double-lumen endotracheal tube (DLT). The second involves blockade of a mainstem bronchus (bronchial blockers). Bronchial blockade technology is on the rise, and in some specific clinical situations (e.g., management of the difficult airway during OLV or selective lobar blockade) it can offer more as an alternative to achieve OLV in adults. Special emphasis on newer information for the use of Fogarty embolectomy catheter as a bronchial blocker, the torque control blocker Univent, and the wire-guided endobronchial blocker (Arndt blocker) is included. Also this review describes placement, positioning, complications, ventilation modalities, and airflow resistances of all three bronchial blockers. Finally, the bronchial blockers can be used in many cases that require OLV, taking into consideration that bronchial blockers require longer time for placement, assisted suction to expedite lung collapse, and the use of fiberoptic bronchoscopy. The current use of bronchial blockers, supported by scientific evidence, dictates that bronchial blockers should be available in any service that performs lung separation techniques.

 

[BLADEMDA]

Curr Opin Anaesthesiol. 2007 Feb;20(1):27-31. Links

Which device should be considered the best for lung isolation: double-lumen endotracheal tube versus bronchial blockers.

Campos JH.
University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa 52242, USA. [email protected]
PURPOSE OF REVIEW: This review is a clinical comparison between double-lumen endotracheal tubes and bronchial blockers to determine which device is considered the best for lung isolation. RECENT FINDINGS: Double-lumen endotracheal tubes and bronchial blockers have been found to be clinically equivalent in terms of performance in providing lung collapse for patients with normal airways. In the last five years, however, numerous reports have indicated a preference for the use of bronchial blockers in patients with airway abnormalities. For nonthoracic anesthesiologists who have limited experience in thoracic anesthesia cases, none of the devices (double-lumen tubes or bronchial blockers) have been shown to provide any advantage while in use due to a high incidence of unrecognized malpositions. Overall, each device provides advantages depending upon the case, such as absolute lung separation with a double-lumen endotracheal tube or the use of a bronchial blocker in a difficult airway for a patient requiring lung isolation. SUMMARY: Double-lumen endotracheal tubes and bronchial blockers should be part of the armamentarium of every anesthesiologist involved in lung isolation techniques and every device should be tailored to specific case needs.

 

[dfk]

1: Anesth Analg. 2003 Nov;97(5):1266-74. Links

Erratum in: Anesth Analg. 2004 Jan;98(1):131. An update on bronchial blockers during lung separation techniques in adults.

Campos JH.
Department of Anesthesia, University of Iowa Health Care, Iowa City, Iowa 52242-1079, USA. [email protected]
Techniques for one-lung ventilation (OLV) can be accomplished in two ways: The first involves the use of a double-lumen endotracheal tube (DLT). The second involves blockade of a mainstem bronchus (bronchial blockers). Bronchial blockade technology is on the rise, and in some specific clinical situations (e.g., management of the difficult airway during OLV or selective lobar blockade) it can offer more as an alternative to achieve OLV in adults. Special emphasis on newer information for the use of Fogarty embolectomy catheter as a bronchial blocker, the torque control blocker Univent, and the wire-guided endobronchial blocker (Arndt blocker) is included. Also this review describes placement, positioning, complications, ventilation modalities, and airflow resistances of all three bronchial blockers. Finally, the bronchial blockers can be used in many cases that require OLV, taking into consideration that bronchial blockers require longer time for placement, assisted suction to expedite lung collapse, and the use of fiberoptic bronchoscopy. The current use of bronchial blockers, supported by scientific evidence, dictates that bronchial blockers should be available in any service that performs lung separation techniques.

have you or anyone used a BB? are they really that difficult to get into place?

 

[Noyac]

have you or anyone used a BB? are they really that difficult to get into place?

Did you read my post?

 

[dfk]

Did you read my post?

yea. did you read the conclusion to the article blade posted?

 

[Noyac]

yea. did you read the conclusion to the article blade posted?

Yes. But that's not your question.

And the answer to your question is in my post. I use them and I am beginning to like them a lot. They are not that difficult to use if you are good with the FOB.

My technique: I bend the tip of the BB (about 15-30 degrees) b/4 inserting it into the adapter connected tot he ETT. The I pass the BB down the ETT while following it down with the FOB. I do not put the FOB thru the loop in the BB. When I am at the carina I twist the BB so the bend directs the BB towards the bronchus I want it to enter. Then I advance the BB under direct visualization with the FOB. Inflate till the blue cuff just begins to reach the carina or even slightly extend out of the bronchus. This is real important in the right side or you won't be able to get the RUL down.

The last one I did the RUL takeoff was at the carina and I showed the surgeon so he wouldn't complain about the RUL not dropping. A DBL would have been better but nobody in their right mind would have extubated this pt in order to place a DBL tube. I got no complaints from the surgeon.

 

[BLADEMDA]

yea. did you read the conclusion to the article blade posted?

IMHO, the Univent tube isn't much more difficult to use than a left DLT.
It make take 5-10 more minutes. When doing R upper lobe thoracoscopic lung resections the blocker seemed to be less effective than a DLT. Perhaps, it has to do with the right upper lube take off and the fact that the balloon would migrate upwards easier than a DLT. So, you end up pushing the blocker farther down the right main stem or the blocker would "migrate out" to the carina. In either case you may end up with poor right upper lobe isolation.

A "true" bronchial blocker is more difficult to place. I have spent 30-45 minutes getting the blocker positioned compared to 5-10 minutes for a DLT (using fiberoptic guidance).

But, as the articles state you need at least a blocker plus DLT in your practice. I prefer to have all three available but reserve the "true" bronchial blocker for plan C.

Plan A: DLT (Left in my practice 99% of the time)
Plan B: Univent
Plan C: Bronchial Blocker and plan on buying lunch for the CT Surgeon

For others like Noy, my plan C may be his Plan A. Just get good and fast at what you do but everybody needs a plan B!

 

[Simple]

I have placed the bronchial blocker between the cords and run it adjacent to the trach. This allowed me to use a fiberscope through the trach lumen to position it. Worked really well and inflating the cuff on the trach holds the blocker in place.

 

[Airlife91]

Resurrecting an old thread. New wrinkle on the same question - need lung isolation for a double lung transplant. Patient has tracheostomy that is 6 days old. Thoughts?

 

[Twiggidy]

Resurrecting an old thread. New wrinkle on the same question - need lung isolation for a double lung transplant. Patient has tracheostomy that is 6 days old. Thoughts?

Cover OB that day.....

 

[AdmiralChz]

Resurrecting an old thread. New wrinkle on the same question - need lung isolation for a double lung transplant. Patient has tracheostomy that is 6 days old. Thoughts?

Presumably you’ll need to selectively ventilate one lung and then the other, this is a reasonable opportunity to use the “EZ Blocker” if you have it:

Rusch® EZ-Blocker™ Endobronchial Blocker

It sits at the carina and has two balloons that sit in either mainstem. Sometimes both balloons like to migrate down one mainstem which can be a bit tricky.

If you don’t have it you can put a blocker in from above as mentioned, you’ll just have to reposition it which can introduce some problems for a fresh anastamosis if you aren’t careful.

I wonder aloud if you could just intubate from above anyway as you usually would and just call it a day.... I’m not sure.

 

[WholeLottaGame7]

See @urge 's comment above. Why not intubate from above w/ DLT and cover trach site w/ vaseline gauze/tegaderm?

 

[Twiggidy]

All jokes aside from my previous post and piggybacking what others are saying.....the trach is your fail safe. You can plug him to the vent or put him to sleep however you please and work from above with DL, Glide, FOB, anything.....just keep him plugged until you get something beyond the cords and then remove the trach and place a DLT. If working from above is becoming a problem the trach will osygenate and ventilate for you until you get a formal DLT in

 

[urge]

See @urge 's comment above. Why not intubate from above w/ DLT and cover trach site w/ vaseline gauze/tegaderm?

For a lung transplant intubate with DLT from the top and have surgeon suture the trache closed.

 

[deleted162650]

Not sure if it's already been mentioned, but you can also run a BB outside the tube. The ETT cuff will still seal well and help hold the BB in place.

 

[Airlife91]

Not sure if it's already been mentioned, but you can also run a BB outside the tube. The ETT cuff will still seal well and help hold the BB in place.

Thanks for the responses. Went ahead and did what most suggested - intubated from above w/ DLT, removed trach when DLT thru cords. At end of case, withdrew DLT and put an ETT thru the trach.

 

[anes121508]

Presumably you’ll need to selectively ventilate one lung and then the other, this is a reasonable opportunity to use the “EZ Blocker” if you have it:

Rusch® EZ-Blocker™ Endobronchial Blocker

It sits at the carina and has two balloons that sit in either mainstem. Sometimes both balloons like to migrate down one mainstem which can be a bit tricky.

If you don’t have it you can put a blocker in from above as mentioned, you’ll just have to reposition it which can introduce some problems for a fresh anastamosis if you aren’t careful.

I wonder aloud if you could just intubate from above anyway as you usually would and just call it a day.... I’m not sure.

I had a case the other day: needed lung isolation in patient with prior laryngectomy with a mature trach. The stoma was low in relation to the carina. After the ett was placed just barely into the trachea, the ez blocker was unable to spread out (due to the tip of the ett being so close to the carina already). Didn't have a regular blocker. Pulled the ett back out the stoma while the ez was still in place. Then ez blocker opened up. Advanced the ez blocker into place. Then advanced the ett back in. Thought I'd share because this hadn't happened to me yet.

 

[lunaire]

Another alternative is the Fogarty cath. Keep the trach in, then insert the cath from above, outside the trach, with fiberoptic guidance. Higher chance of success if patient has a downsized trach already in place.

 

[urge]

Another alternative is the Fogarty cath. Keep the trach in, then insert the cath from above, outside the trach, with fiberoptic guidance. Higher chance of success if patient has a downsized trach already in place.

Yes, in theory if it were the 1960’s, but a program that does lung transplants has no business doing lung separation with Fogarty catheters (low volume high pressure cuff).

Why do people still bring them up is beyond comprehension.