An audit of Robertshaw double lumen tube placement using the fibreoptic bronchoscope

Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care

Introduction

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients.

Methods

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria.

Results

Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis.

Conclusions

These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Endobronchial intubation in thoracic surgery: Which side should be preferred?

AIM

This study was undertaken to compare the clinical performance of right versus left double-lumen endotracheal tubes placed without using fiberoptic bronchoscopy in thoracic surgery operations.

METHODS

This was a retrospective review of patients who were operated on in our institution between January 2013 and February 2014. We analyzed clinical performance in terms of hypoxia, hypercapnia, and adequate deflation of the lungs with both left- and right-sided double-lumen endotracheal tubes.

RESULTS

There were 80 patients with a mean age of 53.74 ± 15.59 years. Right-sided double-lumen tubes were used in 33 patients, and left-sided double-lumen tubes were used in 47. Perioperative hypoxi (p < 0.05), hypercapnia (p < 0.01), and inadequate deflation of the lung (p < 0.001) were found more frequently with the use of right-sided double-lumen endotracheal tubes. Arterial blood gas analyses in the post-anesthesia care unit showed that high pCO2 (>45 mm Hg), low pH (<7.36), and high lactate levels (>4 mmol L(-1)) were more frequent with right-sided double-lumen endotracheal tubes (p < 0.001). The incidence of atelectasis was greater (p < 0.001) and the duration of hospital stay was longer (p = 0.02) with the use of right-sided double-lumen endotracheal tubes.

CONCLUSION

Right-sided double-lumen endotracheal tubes resulted in poorer clinical performance. Therefore, a left-sided double-lumen endotracheal tube should be preferred in thoracic surgery operations when an appropriate size of fiberoptic bronchoscope is not available.

Audit of double-lumen endobronchial intubation

BACKGROUND

Many technical variations are possible in the placing and management of a double-lumen tube (DLT). We surveyed our practice to relate these variations to the course of the anaesthetic.

METHODS

We used a questionnaire to obtain details of technique in 506 consecutive double lumen intubations. The details were related to the incidence of secretions, tube displacement, and decreases of oxygen saturation (<88%) during one lung anaesthesia (OLA).

RESULTS

Robertshaw tubes were used for 482 of the 506 intubations. During OLA there were 48 instances of desaturation (<88%), 19 cases of upper lobe obstruction, 15 of carinal obstruction, 16 of isolation failure, eight of excessive secretions (none of whom had received an antisialogogue; P<0.01) and 12 miscellaneous events. The experience of the anaesthetist or use of a fibre-optic bronchoscope did not affect these events. Air was of no advantage as a maintenance gas. Atropine 400-600 micro g appeared to prevent desaturation on OLA (P<0.05) but glycopyrrolate 200 micro g did not.

CONCLUSION

Most factors had little effect on the progress of the anaesthetic, but an antimuscarinic usefully reduced secretions, and atropine (but not glycopyrrolate) was associated with less desaturation during OLA.

Fiberoptic bronchoscopy need not be a routine part of double-lumen tube placement

PURPOSE OF REVIEW

The debate continues as to whether a fiberoptic bronchoscope must be used to position a double-lumen tube. This review supports the argument that although bronchoscopy is extremely helpful, it is not always needed for the routine placement of left double-lumen tubes.

RECENT FINDINGS

Several recent clinical reports have demonstrated that an experienced anesthesiologist can safely and consistently position double-lumen tubes without bronchoscopic assistance. In order to do so several important factors must be considered. These include the appropriate choice of tube (left or right), size of tube, and endpoint for the depth of insertion.

SUMMARY

Although bronchoscopy is useful, no double-lumen tube positioning method is fail-safe. The choice of which approach to use, 'blind' versus fiberoptic bronchoscope-assisted, is influenced by many factors. Operator experience with any method increases the likelihood of success. A fiberoptic bronchoscope is not always needed for left double-lumen tube placement.