Problem Switching from ETT to Double-Lumen Tube

[Monty Python]

Preface: this hospital does not have "tube exchangers" nor brochial blockers.

This past weekend a surgeon wanted to do a VATS for post-pneumonia empyema. The pt was about 75 inches, 220 pounds, 40 years old, and looked like he had played football many years ago. Good neck extension, Mal II appearance.

A very experienced CRNA tried twice with routine laryngoscopy (Mac 3 and Mac 4 blades) and could only lift the epiglottis but couldn't see cords (saying the cords were around the pt's umbilicus). He punted to me. On direct laryngoscopy with a Mac 4 I also could see and start to lift the epiglottis but everything below was a dark hole. None of the cartilages were seen. The pt was easy to mask-ventilate.

I had great visualization with the Glidescope but trying to insert a double-lumen tube was unfortunately impossible. Couldn't get the right angle. I easily inserted a single lumen 8.0 ETT with the Glidescope so we could formulate Plan B in a controlled manner.

Again, this hospital does not have "tube exchangers" nor brochial blockers. By now the on-call anesthesiologist arrived and she and the primary CRNA decided to feed an Eshman (sp) bougie down the single-lumen ETT, withdraw the ETT, and blindly feed a double-lumen ETT over the bougie.

Ummmmm ..... things got really ugly at that point. The words, "get the emergency trach tray" were yelled at one point.

Sixty minutes later the surgery was cancelled and the patient went to the ICU missing three upper teeth smoking a 7.0 single-lumen ETT which barely went in using Glidescope on the fourth attempt.

Given the above circumstances what would others have done? Thinking back I might have tried to expose with Glidescope, insert bougie, and attempt to railroad the double-lumen tube over the bougie. Hindsight is always 20/20.

---

Members don't see this ad.

 

[militarymd]

I don't think the bougie (eshman) is long enough for double lumen tubes.

Bronchial blocker may have been a better way to go.

 

[Monty Python]

I don't think the bougie (eshman) is long enough for double lumen tubes.

as the primary CRNA and anesthesiologist discovered yesterday to their chagrin

Bronchial blocker may have been a better way to go. not in stock at this hospital

.

 

[Monty Python]

What exactly happened after the bougie went in? Is the bougie long enough for ETT exchange? If it was the length that was an issue, I've heard of people using the 60 cm wire from a central line kit.

Do you have a fiberoptic scope? excellent question. the scope was used the previous day (Saturday). the hospital doesn't believe we need ancillary support staff on the weekends, ie, the scope was still dirty and downstairs in central processing awaiting cleaning. If so, I think the best thing to do (given that the intubation was markedly difficult) would have been to mainstem the single lumen.

.

 

[usnavdoc]

With re: to your fiberoptic situation. you just learned the first rule of Marine infantry.

One is none and two is one.

Also a regular tube exchanger is too wide and wont fit through a double lumen tube. The green aintree would have worked.

The missing teeth are another issue.

 

[LongSnow]

Why noy just advance the regular tube into the apprioriate bronchus?

I did this once in a trauma case with exploratory celiotomy that turned into a thoracic case.

This was a big dude with in rollover MVC who was tough to intubate in the field, and now after major resucitation look like a swollen troll. There was no way I was going to pull the tube and replace it with a DLT, and at 2 AM my tech "could not find the bronchial blockers". Just put the bronchoscope in the tube, advanced tube into mainstem I wanted to ventilate, and the case went very nicely from then on. Surgeon very pleased with operating conditions.

 

[SleepIsGood]

Well..if you dont have the appropriate equipment....for example, I think having a fiberoptic is one of those things that one needs to think of when they have such a 'huge' patient. Although you dont have one in the room...itshould be cleaned.


I dont think it's prudent tostart a case like this without some 'advanced' airway devices available.

 

[paiute]

I use the Bullard to intubate, almost exclusively for over 10 years. In my experience the DLT (Robert Shaw variety) is too stiff to slide over stylets or bougies. Also, it is bulky and doen't fit in the oropharynx too well along side the Bullard. I have successfully used the "Fuji Systems" DLT with the Bullard. It is smaller than the Robert Shaw and, using a maneuverable stylet (the plastic stylet with the little button on the proximal end which allows flex/ext of the tip), I have put the "Fuji" tube in several times under direct vision through the Bullard. It has been some years since I last did this, but as I recall, the Fuji tube is not a true DLT: it has a built-in bronchial blocker which has an insufflation/suction channel. Seemed to work fine for the surgeons.

 

[pgg]

excellent question. the scope was used the previous day (Saturday). the hospital doesn't believe we need ancillary support staff on the weekends, ie, the scope was still dirty and downstairs in central processing awaiting cleaning.

Go Navy. (Though to be fair, at every civilian hospital I've ever been to, there's always someone muttering about how crappy "this hospital" is and how some piece of equipment is never broken at "that hospital" ... someday I guess I'll work at "that hospital" where everything is always perfect.)

Totally apart from whether or not they expected to need a fiberoptic scope, I don't think I'd start any case anywhere without a fully stocked difficult airway cart available, and that includes a scope. It's like doing a case without a crash cart or dantrolene somewhere in the OR. Worse, it's totally predictable that a scope might be useful or needed for a lung-isolation case.

Mainstemming a single-lumen tube is an option, but in doing so you're giving up the PEEP-dependent CPAP-nondependent part of the hypoxia algorithm. Probably no big deal in this case; I've only ever had oxygenation issues with SLV in pulmonary cripples.

They also might have considered whether or not they really needed lung isolation at all. Sounds like this patient's pneumonia was resolved and the surgeon was just going after gunk in the pleural space. I've done a couple of these in kids with regular ETTs, and the surgeon's pneumothorax for the VATS was enough to keep that lung mostly deflated and give them room to work.

 

[ProRealDoc]

Preface: this hospital does not have "tube exchangers" nor brochial blockers.

This past weekend a surgeon wanted to do a VATS for post-pneumonia empyema. The pt was about 75 inches, 220 pounds, 40 years old, and looked like he had played football many years ago. Good neck extension, Mal II appearance.

A very experienced CRNA tried twice with routine laryngoscopy (Mac 3 and Mac 4 blades) and could only lift the epiglottis but couldn't see cords (saying the cords were around the pt's umbilicus). He punted to me. On direct laryngoscopy with a Mac 4 I also could see and start to lift the epiglottis but everything below was a dark hole. None of the cartilages were seen. The pt was easy to mask-ventilate.

I had great visualization with the Glidescope but trying to insert a double-lumen tube was unfortunately impossible. Couldn't get the right angle. I easily inserted a single lumen 8.0 ETT with the Glidescope so we could formulate Plan B in a controlled manner.

Again, this hospital does not have "tube exchangers" nor brochial blockers. By now the on-call anesthesiologist arrived and she and the primary CRNA decided to feed an Eshman (sp) bougie down the single-lumen ETT, withdraw the ETT, and blindly feed a double-lumen ETT over the bougie.

Ummmmm ..... things got really ugly at that point. The words, "get the emergency trach tray" were yelled at one point.

Sixty minutes later the surgery was cancelled and the patient went to the ICU missing three upper teeth smoking a 7.0 single-lumen ETT which barely went in using Glidescope on the fourth attempt.

Given the above circumstances what would others have done? Thinking back I might have tried to expose with Glidescope, insert bougie, and attempt to railroad the double-lumen tube over the bougie. Hindsight is always 20/20.

Had a female pt last tuesday who came in for esophagectomy, had a grade 4 view with the glidescope, place 7.0 ET which then removed over exchange catheter and placed a 35F left DLT. No problems at all. Helped she was average weight.

Airway exchange catheters are money but I think in a dire situation, a bougie should suffice. Of course, success is operator-dependent.

 

[dhb]

As you suggested using a blade to retract soft tissue/ epiglottis can be very helpfull when blindly passing a tube over an exchanger. Of course if the bougis was too short it doesn't really help you.

 

[cchoukal]

Go Navy. (Though to be fair, at every civilian hospital I've ever been to, there's always someone muttering about how crappy "this hospital" is and how some piece of equipment is never broken at "that hospital" ... someday I guess I'll work at "that hospital" where everything is always perfect.)

Totally apart from whether or not they expected to need a fiberoptic scope, I don't think I'd start any case anywhere without a fully stocked difficult airway cart available, and that includes a scope. It's like doing a case without a crash cart or dantrolene somewhere in the OR. Worse, it's totally predictable that a scope might be useful or needed for a lung-isolation case.

Mainstemming a single-lumen tube is an option, but in doing so you're giving up the PEEP-dependent CPAP-nondependent part of the hypoxia algorithm. Probably no big deal in this case; I've only ever had oxygenation issues with SLV in pulmonary cripples.

They also might have considered whether or not they really needed lung isolation at all. Sounds like this patient's pneumonia was resolved and the surgeon was just going after gunk in the pleural space. I've done a couple of these in kids with regular ETTs, and the surgeon's pneumothorax for the VATS was enough to keep that lung mostly deflated and give them room to work.

I agree w/ the above. I would be very reluctant to start a case requiring a DLT w/o an FOB in the room. Regardless of the likelihood of needing if for a difficult airway, I would consider it necessary to evaluate the placement and function of the DLT. Of course, now here you are. If it had been me, who has never used an Eschman stylet, I probably would've sized it up along side a DLT to make sure it would be long enough, before inserting it. Realizing it's too short, i probably would've recommended waking the patient up and coming back another day. When the surgeon huffed and puffed and insisted the patient needed the empyema drained (come on, you know that's how it went down), the wire would be my next move, or, alternatively, I might've told the surgeon to suck it up and do the case w/ the lung up.

 

[proman]

I agree w/ the above. I would be very reluctant to start a case requiring a DLT w/o an FOB in the room. ... I might've told the surgeon to suck it up and do the case w/ the lung up.

My thoughts exactly. Would not place a DLT without FOB available (DLT over FOB would have been my backup plan). I can't believe you're at a hospital that does thoracic surgery without tube exchangers. And an Eschmann is too short. VATS can be done with the lung up or not done at all. As I've learned, if you've moved on to Plan B, don't give up what's working to move back to Plan A.

 

[Frank Rizzo]

Any fogarty caths around?

 

[drccw]

I would place a DLT without a FOB. Sure a FOB is nice, but the old time version is to clinically confirm placement (remember listening to breath sounds). I've seen so many residents get confused about if they were looking at the right side or the left; etc etc. Thoracic surgery can be done without a FOB; just like regional anesthesia can be done without a US (or for that matter without a PNS).

I agree with your hindsight (I wish I had that sometime). Glidescope-> eschmann-> DLT. Oh and I believe in leaving the glidescope in when passing the DLT over the eschmann

 

[dhb]

As I've learned, if you've moved on to Plan B, don't give up what's working to move back to Plan A.

This is the most important issue.
I've also learned this the hard way but you cannot revert to a lesser degree of safety once you're engaged in a difficult situation.

 

[pushthesux]

If all you need is length, then just connect 3 or so small ET tubes together (size 4-5) and use that as a tube exchanger...plus you can ventilate through them also.

 

[urge]

If all you need is length, then just connect 3 or so small ET tubes together (size 4-5) and use that as a tube exchanger...plus you can ventilate through them also.

My spider sense is alerting me about this not being a good idea.

 

[urge]

Let's just cut to the chase. The answer is telling the surgeon and the bean counters "we don't have the equipment in this podunk hospital to do the case. Next!"

 

[Bertelman]

If all you need is length, then just connect 3 or so small ET tubes together (size 4-5) and use that as a tube exchanger...plus you can ventilate through them also.

I'm with urge on this one. How would you connect them?

 

[pgg]

My spider sense is alerting me about this not being a good idea.

The fact that I'm agreeing with urge on something 🙂 is freaking me out almost as much as the tube daisychain idea. Please elaborate.

 

[Idiopathic]

i wouldnt do a VATS/DLT without a fiberoptic scope. Difficult airway only reinforces that. Also, a tube exchanger is mandatory in cases like this. Its a really bad idea to agree to do cases like this without those two things.

 

[Idiopathic]

If all you need is length, then just connect 3 or so small ET tubes together (size 4-5) and use that as a tube exchanger...plus you can ventilate through them also.

its cute how they dont have basic anesthetic equipment but we assume they will have three 4.0 ETT lying around

 

[pillowhead]

If all you need is length, then just connect 3 or so small ET tubes together (size 4-5) and use that as a tube exchanger...plus you can ventilate through them also.

we definitely had an M&M last year related to trying to connect smaller pieces of equipment together when properly sized equipment was not available.

not a good idea.

 

[Monty Python]

I can't believe you're at a hospital that does thoracic surgery without tube exchangers. .

As a government employee of (un-named agency) at (un-named) hospital, we're living what the rest of the country will get to experience once Obama-care is enacted. And no, I'm currently not deployed on the USS Comfort. I'm downrange at another service's hospital.

if you've moved on to Plan B, don't give up what's working to move back to Plan A.

My thoughts exactly, as the primary CRNA of record and on-call anesthesiologist decided to do anyway, after I had bailed out the primary CRNA with my initial Glidescope ETT placement.

Jet, THE FORCE FAILED ME. Nananananananananananana

 

[mille125]

Preface: this hospital does not have "tube exchangers" nor brochial blockers.

This past weekend a surgeon wanted to do a VATS for post-pneumonia empyema. The pt was about 75 inches, 220 pounds, 40 years old, and looked like he had played football many years ago. Good neck extension, Mal II appearance.

A very experienced CRNA tried twice with routine laryngoscopy (Mac 3 and Mac 4 blades) and could only lift the epiglottis but couldn't see cords (saying the cords were around the pt's umbilicus). He punted to me. On direct laryngoscopy with a Mac 4 I also could see and start to lift the epiglottis but everything below was a dark hole. None of the cartilages were seen. The pt was easy to mask-ventilate.

I had great visualization with the Glidescope but trying to insert a double-lumen tube was unfortunately impossible. Couldn't get the right angle. I easily inserted a single lumen 8.0 ETT with the Glidescope so we could formulate Plan B in a controlled manner.

Again, this hospital does not have "tube exchangers" nor brochial blockers. By now the on-call anesthesiologist arrived and she and the primary CRNA decided to feed an Eshman (sp) bougie down the single-lumen ETT, withdraw the ETT, and blindly feed a double-lumen ETT over the bougie.

Ummmmm ..... things got really ugly at that point. The words, "get the emergency trach tray" were yelled at one point.

Sixty minutes later the surgery was cancelled and the patient went to the ICU missing three upper teeth smoking a 7.0 single-lumen ETT which barely went in using Glidescope on the fourth attempt.

Given the above circumstances what would others have done? Thinking back I might have tried to expose with Glidescope, insert bougie, and attempt to railroad the double-lumen tube over the bougie. Hindsight is always 20/20.

Blindly withdrawing a correctly placed tube in a difficult airway? Why would anyone think that this is a good idea. The thought would have never crossed my mind. Mainstem the patient and the surgeon will need to make due. Otherwise wake him up and come back another day.


If your collegues still decide to enter down this terrible path, then at the least they should have an emergency trach kit in the room +/- ENT availability (ie standing next to you). This is not the time to search.

 

[thegasman]

this case makes me thankful I have a fiberoptic and cook exchanger when doing thoracic anesthesia. Seems to me mainstem placement of single tube or reschedule case are only options. (although mainstem placement without fob may be a challenge) Obamacare is gonna suck

 

[Idiopathic]

do you guys really think obama himself is going to come pick up all your fiberoptic equipment (and with it, your sensibility?) and that this will be the way thoracic cases are done in the future? its easy to shout "obamacare" at the drop of a hat but then it reduces us to pawns, who are "forced to make do", shrugging our shoulders at complications.

the optimist in me believes that increased efficiency doesn't necessarily have to mean tremendous sacrifice of safety and efficacy

 

[Monty Python]

do you guys really think obama himself is going to come pick up all your fiberoptic equipment (and with it, your sensibility?) and that this will be the way thoracic cases are done in the future? its easy to shout "obamacare" at the drop of a hat but then it reduces us to pawns, who are "forced to make do", shrugging our shoulders at complications.

the optimist in me believes that increased efficiency doesn't necessarily have to mean tremendous sacrifice of safety and efficacy

"Obama-care" is my euphamism for the result of combining government bureaucracy and decreased funding.

Decreased funding: we don't have the means to schedule ancillary support staff to work weekends. We don't have the funds for duplicate sets of back-up equipment.

Bureaucracy: the central processing department is off-limits to us, because we're not "certified" on their high-tech scope cleaning machine.

Ergo .... on the weekends we have no support staff, no back up equpiment, and no ability to wash our equipment ourself due to bureaucratic policies.
Welcome to government-run healthcare.

 

[jwk]

"Obama-care" is my euphamism for the result of combining government bureaucracy and decreased funding.

Decreased funding: we don't have the means to schedule ancillary support staff to work weekends. We don't have the funds for duplicate sets of back-up equipment.

Bureaucracy: the central processing department is off-limits to us, because we're not "certified" on their high-tech scope cleaning machine.

Ergo .... on the weekends we have no support staff, no back up equpiment, and no ability to wash our equipment ourself due to bureaucratic policies.
Welcome to government-run healthcare.

100% on the money - even if you don't actually have any.

 

[Idiopathic]

well the answer is you dont put in a DLT if you dont have the equipment to manage a straightforward one (i.e. FO scope), much less standard equipment for difficult airway