Identifying Imminent Displacement of a Double-Lumen Tube Caused by Surgical Traction at the Pulmonary Hilum

Use of an Emergency Manual During an Intraoperative Pulmonary Arterial Rupture, Hypoxemia, and Bradycardia

The use of an emergency manual can improve team performance on critical steps during crisis events. Measures of improved performance have so far been captured through survey and simulation data; however, real-life case studies showing successful use of the manuals are fewer in number. The case of a patient with an unexpected rupture of the pulmonary artery, hypoxemia, and bradycardia during a video-assisted thoracic surgery lobectomy is described here. Relevant sections of Stanford University Operating Room Emergency Manuals were activated immediately and used during the rescue. The team of surgeons, anesthesiologists, and nurses managed the crisis in an orderly, smooth, and efficient manner, and the patient recovered without any complication. The use of the emergency manual reinforced by regular simulation-based training benefited the team and ultimately, the patient’s safety.

Comparison of displacement of polyvinyl chloride and silicone leftsided double-lumen tubes during lateral positioning

Background

Compared to an equivalent sized polyvinyl chloride (PVC) double-lumen tube (DLT), a silicone DLT has a shorter endobronchial segment. The aim of this study was to compare the incidence of clinically significant displacement of left-sided PVC and silicone DLTs after a positional change to a lateral position from a supine position and determine its effect on the need for DLT repositioning for successful lung separation in patients undergoing thoracic surgery.

Methods

One hundred eight adult patients requiring one-lung ventilation were randomly divided into group P (PVC DLT, n = 54) and group S (Silicone DLT, n = 54). The position of the DLT was observed before and after lateral positioning to assess the effect of the position change. The incidence of clinically significant displacement (>10 mm) of DLT was compared between the groups.

Results

DLTs were clinically significantly displaced in group P (17/48, 35.4%) and group S (18/52, 34.6%) after lateral positioning (p = 0.933). A proximal displacement (31.3% [group P] and 25.0% [group S]) was more common than distal displacement (4.2% [group P] and 9.6% [group S]), with no significant intergroup difference (p = 0.494). After lateral positioning, critical malposition of DLT with bronchial herniation to the right main bronchus was 8.3% (group P) and 7.9% (group S, p = 0.906).

Conclusion

Left-sided PVC and silicone DLTs produced comparable incidences of clinically significant displacement and, consequently, required similar rates of repositioning for successful lung separation after lateral positioning.

The role of an ambient pressure oxygen source during one-lung ventilation for thoracoscopic surgery

Video-assisted thoracoscopic surgery is facilitated by prompt collapse of the non-ventilated (‘operated’) lung, and interrupted and impeded if there is a need for oxygen (O2) delivery by continuous positive airways pressure in order to manage hypoxaemia. It has been proposed that connecting an ambient pressure O2 source to the airway of the non-ventilated lung at the time one-lung ventilation is initiated and before the chest is opened will, by avoiding entrainment of ambient nitrogen, serve to facilitate lung collapse. It has also been proposed that leaving the O2 source connected will enable, not only ongoing apnoeic oxygenation before the chest is opened, but also the thoracoscopic procedure to commence with the operated lung fully pre-oxygenated (with an inspired oxygen fraction of 1), and apnoeic oxygenation to continue throughout the operative procedure in those patients who exhibit a degree of small airways patency at ambient pressure. In reality, several factors can influence the speed of collapse of the operated lung, and very many factors can influence the incidence of hypoxaemia during one-lung ventilation. It therefore appears unlikely that the necessary evidence to support these proposals will be forthcoming from randomised clinical studies on large numbers of patients. Rather, the necessary evidence may only be provided by specifically designed within-patient clinical measurement studies. Nevertheless, it is argued that, in the meantime, there is already sufficient rationale for an ambient pressure O2 source to be connected to the airway of the non-ventilated lung, and for it to remain connected for the duration of one-lung ventilation.