An update on bronchial blockers during lung separation techniques in adults

A novel approach to calculate the required volume of air for bronchial blockers in young children

INTRODUCTION

Bronchial blocker balloons inflated with small volumes of air increase balloon pressure, involving a risk of airway injury especially in young children. However, there are no established guidelines regarding the appropriate volumes of air required to provide safe bronchial occlusion.

METHODS

This study aimed to introduce a novel method for calculating the amount of air required for safe bronchial blocker balloon occlusion for one lung anesthesia in young children. We included 79 pediatric patients who underwent video-assisted thoracoscopic surgery at our hospital. Preoperatively, the balloon pressure and corresponding diameter of 5F bronchial blockers inflated with different volumes of air were measured. Intraoperatively, bronchial diameters measured by computerized tomographic scans were matched to the ex vivo measured balloon diameters. The quality of lung isolation, incidence of balloon repositioning, and airway injury were documented. Postoperatively, airway injury was evaluated through fiberoptic bronchoscopy.

RESULTS

Balloon pressure and balloon diameter showed linear and nonlinear correlations with volume, respectively. The median lengths of the right and left mainstem bronchi were median (interquartile range) range: 5.3 mm (4.5-6.3) 2.7-8.15 and 21.8 (19.6-23.4) 14-29, respectively. Occluding the left mainstem bronchus required <1 mL of air, with a balloon pressure of 27 cm H2O. The isolation quality was high with no case of mucosal injury or displacement. Occluding the right mainstem bronchus required a median air volume of 1.3 mL, with a median balloon pressure of 44 cm H2O. One patient had poor lung isolation due to a tracheal bronchus and another developed mild and transient airway injury.

CONCLUSION

The bronchial blocker cuff should be regarded as a high-pressure balloon. We introduced a new concept for safe bronchial blocker balloon occlusion for one-lung ventilation in small children.

Anesthetic Management of Large Bronchogenic Cyst With Severe Tracheal Compression in Adults: A Case Report

Bronchogenic cysts (BCs) are a congenital anomaly, forming fluid-filled sacs in the bronchial tree during fetal development, and are relatively rare in adults. Patients with large BCs in the mediastinum presenting with severe tracheal compression pose a significant challenge to anesthesiologists. The confined and narrow space of the mediastinum exacerbates the compression effect on surrounding structures, leading to potential respiratory or cardiovascular collapse during anesthesia and postoperatively. Herein, we report the stepwise anesthetic management of a patient with a BC in the paratracheal region of superior mediastinum, causing near-complete tracheal compression, scheduled for right posterolateral thoracotomy and tumor excision. The patient presented with dyspnea, chest pain, cough, and severe tracheal compression necessitating meticulous airway management. Utilizing awake fiberoptic intubation with a single-lumen endotracheal tube and one-lung ventilation facilitated by an EZ bronchial blocker, we successfully secured the airway, provided ideal surgical conditions through lung deflation, and ensured perioperative safety. This case underscores the crucial role of comprehending the underlying pathophysiology, anticipating complications, and meticulously planning, preparing, and executing strategies for airway management and perioperative care in patients with mediastinal masses leading to significant tracheal compression.

Novel Non-surgical Strategy of Severe Chest Trauma With Venovenous Extracorporeal Membrane Oxygenation, Angioembolization, and Bronchial Blocker: A Case Report

Severe chest trauma often requires immediate intervention, typically involving open chest surgery. However, advancements in medical technology offer alternative approaches, such as endovascular therapy and venovenous extracorporeal membrane oxygenation (VV-ECMO). In a recent case, a middle-aged male cyclist was admitted after colliding with a vehicle, presenting in shock with multiple injuries, including cerebral contusion and rib fractures. Despite initial treatments such as chest tubes and blood transfusions, his condition remained unstable, with worsening respiratory failure and hemorrhagic shock. A multidisciplinary team devised a comprehensive treatment plan, utilizing VV-ECMO for oxygenation support, a bronchial blocker to localize the hematoma, and interventional radiology for hemothorax hemostasis. These interventions successfully stabilized the patient without resorting to open chest surgery. Endovascular therapy, alongside bronchial blockers, facilitated adequate hemostasis and hematoma localization, avoiding invasive procedures. VV-ECMO plays a crucial role in maintaining oxygenation during respiratory failure. Strategic anticoagulation with nafamostat mesylate prevented clotting in the ECMO circuit. This case highlights the effectiveness of minimally invasive strategies in managing severe chest trauma, preserving lung function, and improving outcomes. In refractory cases, VV-ECMO acts as a bridge to stabilize respiratory status before definitive treatment, while bronchial blockers localize hematomas, reducing the need for surgery. Interventional radiology offers a less invasive option for achieving hemostasis. Collaboration among medical specialties and innovative technologies is critical to successfully navigating complex chest trauma cases.

Recent Advances in Videolaryngoscopy for One-Lung Ventilation in Thoracic Anesthesia: A Narrative Review

Since their advent, videolaryngoscopes have played an important role in various types of airway management. Lung isolation techniques are often required for thoracic surgery to achieve one-lung ventilation with a double-lumen tube (DLT) or bronchial blocker (BB). In the case of difficult airways, one-lung ventilation is extremely challenging. The purpose of this review is to identify the roles of videolaryngoscopes in thoracic airway management, including normal and difficult airways. Extensive literature related to videolaryngoscopy and one-lung ventilation was analyzed. We summarized videolaryngoscope-guided DLT intubation techniques and discussed the roles of videolaryngoscopy in DLT intubation in normal airways by comparison with direct laryngoscopy. The different types of videolaryngoscopes for DLT intubation are also compared. In addition, we highlighted several strategies to achieve one-lung ventilation in difficult airways using videolaryngoscopes. A non-channeled or channeled videolaryngoscope is suitable for DLT intubation. It can improve glottis exposure and increase the success rate at the first attempt, but it has no advantage in saving intubation time and increases the incidence of DLT mispositioning. Thus, it is not considered as the first choice for patients with anticipated normal airways. Current evidence did not indicate the superiority of any videolaryngoscope to another for DLT intubation. The choice of videolaryngoscope is based on individual experience, preference, and availability. For patients with difficult airways, videolaryngoscope-guided DLT intubation is a primary and effective method. In case of failure, videolaryngoscope-guided single-lumen tube (SLT) intubation can often be achieved or combined with the aid of fibreoptic bronchoscopy. Placement of a DLT over an airway exchange catheter, inserting a BB via an SLT, or capnothorax can be selected for lung isolation.

Evaluation and Treatment of Massive Hemoptysis

Massive hemoptysis is appropriately defined as life-threatening hemoptysis that causes airway obstruction, respiratory failure, and/or hypotension. Patients with this condition die from asphyxiation, not hemorrhagic shock. Any patient who presents with life-threatening hemoptysis requires immediate treatment to secure the airway and stabilize hemodynamics. Early activation and coordinated response from a multidisciplinary team is critical. Once the airway is secure and appropriate resuscitation is initiated, priorities are to localize the source of the bleeding and gain hemorrhage control. Nonsurgical control of hemorrhage is superior to surgery in the acute situation.

A Case Report of Iatrogenic Bronchial Rupture following Endobronchial Blocker Placement

Physiologists Eduard Pfluger and Claude Bernard first introduced one lung ventilation (OLV) in 1871. Today, it is now a frequently used technique in open or minimally invasive cardiothoracic surgeries. One key benefit of the use of OLV is improved surgical exposure. Historically, lung isolation catheters used under fluoroscopic guidance or a Fogarty catheter were used to achieve OLV. In present times, endobronchial blockers (EBBs) in conjunction with single lumen endotracheal tubes and double lumen endotracheal tubes (DLTs) are used to achieve intraoperative OLV. Some complications of EBBs include mucosal injury, bleeding, bronchial rupture, pneumothorax, malpositioning-induced respiratory arrest, severe hypoxemia, and dislodgement. The incidence of iatrogenic tracheal rupture with single lumen endotracheal intubation is reported to be approximately 0.005%, and with double lumen ETT, the incidence may be between 0.05 and 0.19%. Mortality associated with tracheal rupture with DLTs is approximately 8.8%. Data on airway injury with endobronchial blockers is limited, and reported cases of bronchial perforations with use of EBBs are rare suggesting that EBBs may be the safer option for OLV. In this case report, we will be discussing a case of iatrogenic endobronchial rupture following endobronchial blocker placement.

Lung separation in adult thoracic anesthesia

Thoracic anesthesia is mainly the world of OLV during anesthesia. The indications for OLV, classified as absolute or relative are more representative of the new concepts in OLV: It includes either the separation or the isolation of the lungs. Modern DLTs are most widely employed worldwide to perform OLV including the concept of one lung separation. Endobronchial blockers are a valid alternative to DLTs, and they are mandatory in the education of lung separation and in case of predicted difficult airways as they are the safest approach (with an awake intubation with an SLT through a FOB). Every general anesthesiologist should know how to insert a left-sided DLT, but he/she should also have in his technical luggage and toolbox, basic knowledge and minimal expertise with BBs, this option being considered a suitable alternative, particularly in emergency situation where the patient is already intubated and/or in case of difficult airways. One should keep in mind that extubation or re-intubation after DLT might be difficult too, and additional intubation tools are necessary for the safety conditions.

Bronchus-blocked ultrasound-guided percutaneous transthoracic needle biopsy (BUS-PTNB) for intubated patients with severe lung diseases

BACKGROUND

Examinations based on lung tissue specimen can play a significant role in the diagnosis for critically ill and intubated patients with lung infiltration. However, severe complications including tension pneumothorax and intrabronchial hemorrhage limit the application of needle biopsy.

METHODS

A refined needle biopsy technique, named bronchus-blocked ultrasound-guided percutaneous transthoracic needle biopsy (BUS-PTNB), was performed on four intubated patients between August 2020 and April 2021. BUS-PTNB was done at bedside, following an EPUBNOW (evaluation, preparation, ultrasound location, bronchus blocking, needle biopsy, observation, and withdrawal of blocker) workflow. Parameters including procedure feasibility, sample acquisition, perioperative conditions, and complications were observed. Tissue specimens were sent to pathological examinations and microbial tests.

RESULTS

Adequate specimens were successfully obtained from four patients. Diagnosis and treatment were correspondingly refined based on pathological and microbial tests. Intrabronchial hemorrhage occurred in patient 1 but was stopped by endobronchial blocker. Mild pneumothorax happened in patient 4 due to little air leakage, and closed thoracic drainage was placed. During the procedure, peripheral capillary hemoglobin oxygen saturation (SPO2), blood pressure, and heart rate of patient 4 fluctuated but recovered quickly. Vital signs were stable for patient 1-3.

CONCLUSIONS

BUS-PTNB provides a promising, practical and feasible method in acquiring tissue specimen for critically ill patients under intratracheal intubation. It may facilitate the pathological diagnosis or other tissue-based tests for intubated patients and improve clinical outcomes.

The use of bronchial blockers in patients with aberrant tracheobronchial anatomy: a case report

Abnormal tracheal bronchus originates from the sidewall of the trachea, and most frequently occurs on the right side, involves subsegmental bronchi and the segmental. The anatomical structure of the airway is of great significance for general anesthesia and lung isolation. Abnormal tracheal bronchus makes lung isolation more complicated. This study presents four rare cases of aberrant tracheobronchial anatomy in the right main bronchus. We review the literature and discuss our solution and propose possible solutions for lung isolation in patients with tracheobronchial abnormalities. Of these, three patients were scheduled for radical resection of lung cancer, and one patient was scheduled for radical resection of middle esophageal cancer. After anesthesia induction, we intubated the right-side double-lumen tube (DLT) using a fiberoptic bronchoscope to guide the intubation. During DLT repositioning, we discovered the tracheobronchial abnormality of the patients. We could not place the DLT appropriately, however we made an effort to achieve lung isolation. We used a bronchus blocker [(BB) Univent tube] to achieve lung isolation for case 1, and the patient had good ventilation and no dyspnea and carbon dioxide retention during the operation. We completed lung isolation for the other three patients with abnormal airways by adjusting the position and replacing the DLT.

The efficacy and adverse effects of the Uniblocker and left-side double-lumen tube for one-lung ventilation under the guidance of chest CT

One-lung ventilation (OLV) is essential in numerous clinical procedures, in which the left-sided double-lumen tube (LDLT) is the most commonly used device. The application of bronchial blockers, including the Uniblocker or Arndt blocker, has increased in OLV. The present study aimed to compare the efficacy and adverse effects of the Uniblocker and LDLT for OLV under the guidance of chest CT. A total of 60 adult patients undergoing elective left-side thoracic surgery requiring OLV were included in the study. The patients were randomly assigned to the Uniblocker group (U group, n=30) or the LDLT group (D group, n=30). The time for initial tube placement, the number of optimal positions of the tube upon blind insertion, the number of attempts to adjust the tube to the optimal position, incidence of airway device displacement, injury to the bronchi and carina, the duration until lung collapse and the occurrence of sore throat and hoarseness over 24 h following surgery were recorded. The time for successful placement of the LDLT was 83.9±19.4 sec and that for the Uniblocker was 84.3±17.1 sec (P>0.05). The degree of lung collapse 1 min following opening of the pleura was greater in the D group than that in the U group (P<0.01) and the time required for the lung to completely collapse was shorter in the D group (3.3±0.5 min) than that in the U group (8.4±1.2 min; P<0.01). On the contrary, the incidence of injury to the bronchi and carina was lower in the U group (2/30 cases) than in the D group (10/30 cases; P=0.02); the incidence of sore throat was also lower in the U group (2/30 cases) compared with that in the D group (9/30 cases). The mean arterial pressure of patients immediately following intubation was lower in the U group (122.0±13.4 mmHg) than that in the D group (129.2±12.1 mmHg; P<0.05). The results of the present study indicated that the extraluminal use of the Uniblocker under guidance of chest CT is an efficient method with few adverse effects in left-side thoracic surgery. The study was registered at ClinicalTrials.gov on 16th December 2017 (no. NCT03392922).

A Prospective, Ex Vivo Trial of Endobronchial Blockade Management Utilizing 3 Commonly Available Bronchial Blockers

BACKGROUND

Lung isolation with bronchial blockers is a well-described and accepted procedure, often described for use during the management of massive hemoptysis. Recommendations for balloon inflation are sparse, with some advocating for saline whereas other suggest air, including the manufacturers. We sought to evaluate the optimal method for balloon inflation in an ex vivo trial.

METHODS

We performed a prospective trial utilizing 3 commercially available bronchial blockers commonly described for use in lung isolation and massive hemoptysis management. We utilized the Arndt Endobronchial Blocker (Cook Medical), the Cohen Tip Deflecting Endobronchial Blocker (Cook Medical), and the Fogarty Venous Thrombectomy Catheter (Edwards LifeSciences). Balloon size and deflation assessment were tested within 3 different scenarios comparing air versus saline.Welch t test was performed to compare means between groups, and a generalized estimating equation model was utilized to compare balloon diameter over time to account for correlation among repeated measures from the same balloon.

RESULTS

All 3 endobronchial blocker systems were observed in triplicate. During free-standing balloon inflation, all 3 endobronchial systems displayed a greater degree of balloon deflation over time with air as opposed to saline (P < .001). Within a stent-based model, inflation with air of all 3 endobronchial systems, according to manufacturer recommendations, demonstrated significantly decreased time until fluid transgression occurred when compared to a saline model (P < .001). Within a stent-based model, inflation with air, according to clinical judgment, demonstrated significantly decreased time until fluid transgression in the Arndt (P = .016) and the Fogarty (P < .001) system, but not the Cohen (P = .173) system, when compared with saline.

CONCLUSIONS

The utilization of saline for balloon inflation during bronchial blockade allows for more consistent balloon inflation. The use of saline during balloon inflation appears to delay passive, spontaneous balloon deflation time when compared to air during a model of endobronchial blockade. The approach of saline inflation should be tested in humans to demonstrate the overall applicability and validity of the current findings.

Management of Pulmonary Hemorrhage Complicating Pulmonary Thromboendarterectomy

Airway management during pulmonary thromboendarterectomy (PTE) can prove challenging, especially in the face of unexpected intraoperative pulmonary hemorrhage. Utilization of proper airway equipment on induction is crucial for the successful management of intraoperative pulmonary hemorrhage. Our case series describes the preoperative risk factors that can lead to intraoperative pulmonary hemorrhage, the preinduction airway equipment considerations for PTE, and the intraoperative management of pulmonary hemorrhage. We summarize the lessons learned at our institution from four cases of post perfusion pulmonary hemorrhage.

Use of bronchial blocker in emergent thoracotomy in presence of upper airway hemorrhage, and cervical spine fracture: a difficult decision

Female, 85 y.o., weighting 60 kg, multiple trauma patient. After an initial laparotomy, an emergent thoracotomy was performed using a bronchial blocker for lung isolation (initial active suction was applied). During surgery, bronchial cuff was deflated, causing a self-limited tracheal blood flooding. A second lung isolation was attempted but it was not as effective as initially. Probably, a lung collapse with the same bronchial blocker was impaired in the second attempt because of the obstruction of bronchial blocker lumen by intraoperative endobronchial hemorrhage. Bronchial blocker active suction may contribute to obtain or accelerate lung collapse, particularly in patients that do not tolerate ventilator disconnection technique or lung surgical compression. The use of bronchial blockers technology was a valuable alternative to double lumen tubes in this case of emergent thoracotomy in the context of a patient having thoracic, abdominal trauma, severe laceration of tongue and apophysis odontoid fracture associated to massive hemorrhage, despite several pitfalls that could compromise its use. The authors intend to discuss the advantages and disadvantages of bronchial blockers comparing to double-lumen tubes for lung isolation, and the risks of our approach, in this complex multitrauma case.

The EZ-blocker for one-lung ventilation in patients undergoing thoracic surgery: clinical applications and experience in 100 cases in a routine clinical setting

Background

In certain clinical situations the insertion of a double-lumen tube (DLT) for one-lung ventilation (OLV) is not feasible or unfavorable. In these cases, the EZ-Blocker (EZB) may serve as an alternative. The aim of our analysis was to report on the clinical applications and our experience with the EZB for one-lung ventilation in 100 patients undergoing thoracic surgery.

Methods

All anesthetic records from patients older than 18 years of age undergoing general anesthesia in the department of thoracic surgery with intraoperative use of an EZB for OLV at the University Hospital of Erlangen in four consecutive years were analyzed retrospectively.

Results

Most frequently, EZB was used in difficult airway (27%) and for surgical procedures with high risk for left recurrent laryngeal nerve injury (21%), followed by application in intubated (12%) or tracheostomized (11%) patients. 11% of the patients had an increased risk of gastric regurgitation. Almost all EZBs were placed free of complications (99%). Clinically sufficient lung collapse was achieved in all patients. No serious airway injuries or immediate complications were documented.

Conclusions

The EZB is an efficient, easy-to-use and safe airway device and enables OLV in several clinical situations, when conventional DLTs are not feasible or less favorable. Three major applications were depicted from the data: expected difficult airway, surgical procedures with necessity of intraoperative recurrent laryngeal nerve monitoring and already intubated or tracheostomized patients.

[Use of bronchial blocker in emergent thoracotomy in presence of upper airway hemorrhage, and cervical spine fracture: a difficult decision]

Female, 85 y.o., weighting 60kg, multiple trauma patient. After an initial laparotomy, an emergent thoracotomy was performed using a bronchial blocker for lung isolation (initial active suction was applied). During surgery, bronchial cuff was deflated, causing a self-limited tracheal blood flooding. A second lung isolation was attempted but it was not as effective as initially. Probably, a lung collapse with the same bronchial blocker was impaired in the second attempt because of the obstruction of bronchial blocker lumen by intraoperative endobronchial hemorrhage. Bronchial blocker active suction may contribute to obtain or accelerate lung collapse, particularly in patients that do not tolerate ventilator disconnection technique or lung surgical compression. The use of bronchial blockers technology was a valuable alternative to double lumen tubes in this case of emergent thoracotomy in the context of a patient having thoracic, abdominal trauma, severe laceration of tongue and apophysis odontoid fracture associated to massive hemorrhage, despite several pitfalls that could compromise its use. The authors intend to discuss the advantages and disadvantages of bronchial blockers comparing to double-lumen tubes for lung isolation, and the risks of our approach, in this complex multitrauma case.

Two-minute disconnection technique with a double-lumen tube to speed the collapse of the non-ventilated lung for one-lung ventilation in thoracoscopic surgery

Background

Thoracic surgery requires the effective collapse of the non-ventilated lung. In the majority of cases, we accomplished, accelerated lung collapse using a double-lumen tube (DLT). We hypothesized that using the two-minute disconnection technique with a DLT would improve lung collapse during subsequent one-lung ventilation.

Methods

Fifty patients undergoing thoracoscopic surgery with physical classification I or II according to the American Society of Anesthesiologists were randomly divided into two groups for respiratory management of one-lung ventilation (OLV). In group N, OLV was initiated after the DLT was disconnected for 2 min; the initiation time began when the surgeon made the skin incision. In group C, OLV was initiated when the surgeon commenced the skin incision and scored the quality of lung collapse (using a four-point ordinal scale). The surgeon’s satisfaction or comfort with the surgical conditions was assessed using a visual analogue scale. rSO₂ level, mean arterial pressure, pulse oxygen saturation, arterial blood gas analysis, intraoperative hypoxaemia, intraoperative use of CPAP during OLV, and awakening time were determined in patients at the following time points: while inhaling air (T₀), after anaesthesia induction andinhaling 100% oxygen in the supine position under double lung ventilation for five mins (T₁), at two mins after skin incision (T₂), at ten mins after skin incision (T₃), and after the lung recruitment manoeuvres and inhaling 50% oxygen for five mins (T₄).

Results

The two-minute disconnection technique was associated with a significantly shorter time to total lung collapse compared to that of the conventional OLV ventilation method (15 mins vs 22 mins, respectively; P < 0.001), and the overall surgeon’s satisfaction was higher (9 vs 7, respectively; P < 0.001). At T₂, the PaCO₂, left rSO₂ and right rSO₂ were higher in group N than in group C. There were no statistically significant differences between the incidence of intraoperative hypoxaemia and intraoperative use of CPAP during OLV (10% vs 5%, respectively; P = 1.000), duration of awakening (18 mins vs 19 mins, respectively; P = 0.616).

Conclusions

A two-minute disconnection technique using a double-lumen tube was used to speed the collapse of the non-ventilated lung during one-lung ventilation for thoracoscopic surgery. The surgeon was satisfied with the surgical conditions.

Trial registration

Chinese Clinical Trial Registry number, ChiCTR-IPR-17010352. Registered on Jan, 7, 2017.

A comparison of extraluminal and intraluminal use of the Uniblocker in left thoracic surgery: A CONSORT-compliant article

BACKGROUND

The aim of this study was to assess the feasibility and safety issues concerning extraluminal use of the Uniblocker for one-lung ventilation (OLV) in the left thoracic surgery.

METHODS

Forty patients undergoing elective left thoracic surgery were included in this study, and all patients were randomly allocated to extraluminal use of Uniblocker group (E group, n = 20) or intraluminal use of Uniblocker group (I group, n = 20). Time for intubation, time for verification of the correct position of Uniblocker, incidence of Uniblocker displacement, index of pulmonary collapse, mean arterial pressure, heart rate, peak airway pressure, oxygen saturation in two-lung ventilation, and 30 minutes after OLV, bronchial damage after OLV, sore throat, and hoarseness postoperative were recorded.

RESULTS

The time for positioning Uniblocker was 112.6 ± 31.2 seconds in intraluminal use group, whereas the time for positioning Uniblocker was significantly shorter in extraluminal use group (63.4 ± 15.8 seconds). The incidence of main bronchial injury, the time of intubation, the incidence of Uniblocker malposition after initial placement, the time of OLV, the degree of pulmonary collapse, mean arterial pressure, heart rate, peak airway pressure, oxygen saturation in two-lung ventilation, and 30 minutes after OLV, the incidence of sore throat and hoarseness postoperative have no statistical significance (P > .05).

CONCLUSION

Extraluminal use of the Uniblocker was proved to be a more rapid and more accurate method than conventional intraluminal use of the Uniblocker for OLV in left thoracic surgery.

[Anesthesia in thoracic surgery]

Thoracic surgery represents a special challenge for anesthesia and requires a high level of human and material resources. Accurate knowledge of the pathophysiology is essential for selection of the anesthetic procedure, the separation of the lungs, monitoring and treatment of hemodynamics as well as for postoperative follow-up care. The increasing number of thoracic interventions and patients who are often suffering from complex diseases require close interdisciplinary cooperation between surgeons, anesthesiologists and intensive care specialists. In addition to the anesthetic techniques particular attention must be paid to the prevention of perioperative complications that can have a relevant effect on patient outcome. In particular hypoxemia during one-lung ventilation influences postoperative morbidity and mortality. Protective pulmonary ventilation strategies play an important role in prevention of postoperative acute lung injury.

Rigid Bronchoscopic Placement of Fogarty Catheter as a Bronchial Blocker for One Lung Isolation and Ventilation in Infants and Children Undergoing Thoracic Surgery: A Single Institution Experience of 27 Cases

One-lung ventilation (OLV) is a challenging task in infants and children as few techniques are possible because of narrow anatomy. The aim of this study is to evaluate and experience lung isolation with Fogarty catheters as a bronchial blocker placed by rigid bronchoscope for OLV in infants and children with lung pathologies requiring surgical management in an industrial hospital. This study is a prospective study carried out in J.L.N. Hospital and Research Centre, Bhilai (CG), from January 2011 to December 2014. The study was designed to place Fogarty catheter for achieving OLV using rigid bronchoscope in children. The patient and anaesthesia characteristics, placement and positioning of Fogarty catheters, intraoperative course, complications and recovery of the patient were studied. The data were then compared with the relevant and available literature. Over the study period of 4 years, 27 cases were included, out of which 22 (81.48 %) cases had suppurative lung disease, three cases (11.11 %) had hydatid cyst of the lung, whereas one case (3.7 %) each of congenital lobar emphysema and congenital cystic adenomatoid malformation of the lung, respectively. In all cases general anaesthesia was provided using single lumen endotracheal tube and one lung ventilation achieved by parallel placement of Fogarty catheter as a bronchial blocker with rigid bronchoscope. The surgical management included thoracotomy with decortication in 21 cases, thoracotomy with excision of hydatid cyst in 3 cases, video-assisted thoracoscopic surgery, thoracotomy with left upper lobectomy and thoracotomy with left lower lobectomy in one case each, respectively. There were no major intraoperative and postoperative complications. There was no mortality in our study. We conclude that rigid bronchoscope can be safely and effectively used to place Fogarty catheter in main bronchus in infants and children for achieving OLV.

Combined use of a double-lumen tube and Fogarty catheter to prevent the endobronchial spread of infection: a case report

Huntington's disease is a neurodegenerative disorder with an autosomal dominant inheritance pattern. Patients with Huntington's disease show an increased risk of aspiration pneumonia when the pharyngeal muscle is invaded. We report a case of advanced-stage Huntington's disease in which the patient received right middle lobectomy for a lung abscess caused by repeated aspiration. The best lung isolation technique has not yet been established in these patients. We successfully performed selective lobar isolation of the right lower and middle lobes using a double lumen tube and a Fogarty embolectomy catheter.

A comparison of the disconnection technique with continuous bronchial suction for lung deflation when using the Arndt endobronchial blocker during video-assisted thoracoscopy: A randomised trial

BACKGROUND

The use of the Arndt endobronchial blocker has not gained widespread acceptance during video-assisted thoracoscopic surgery (VATS) because of its high cost and longer time to operative lung collapse especially in patients with chronic obstructive pulmonary disease (COPD). The use of a ventilator disconnection technique has been shown to produce a comparable degree of lung collapse when used with either a double-lumen tube or an Arndt endobronchial blocker.

OBJECTIVE

We hypothesised that the use of bronchial suction through the suction port of the endobronchial blocker would be associated with a comparable time to achieve optimum lung collapse as the disconnection technique.

DESIGN

A randomised, double-blind study.

SETTING

Single university hospital.

PARTICIPANTS

Fifty-eight patients with spontaneous pneumothorax scheduled for elective VATS using the Arndt endobronchial blocker for one-lung ventilation (OLV).

INTERVENTIONS

Patients were randomly assigned to one of two groups (n = 29 per group) to deflate the operative lung with either disconnection of the endotracheal tube from the ventilator for 60 s prior to inflation of the endobronchial blocker or connection of a suction pressure of -30 cmH2O to the suction port of the endobronchial blocker through the barrel of a 1 ml syringe.

MAIN OUTCOME MEASURES

The primary outcome was the time to total lung collapse. Secondary outcomes included surgeon rating of lung collapse, overall surgeon satisfaction, need for further fibreoptic bronchial suction manoeuvres and intraoperative hypoxaemia.

RESULTS

The bronchial suction technique was associated with a significantly shorter time to total lung collapse than the disconnection method [93 (95% confidence interval, 95% CI 81.3 to 103.7) vs. 197 (95% CI 157.4 to 237) s respectively; P < 0.001]. Both the disconnection and bronchial suction groups had a comparable surgical rating of excellent lung collapse 40 min after the start of OLV (65.5 vs. 79.3%, respectively; P = 0.24), overall surgeon satisfaction [median (interquartile range, IQR) 9 (8 to 10) vs. 9 (8 to 10) respectively; P = 0.90] and intraoperative hypoxaemia (3.5 vs. 0%, respectively; P = 0.32). No patient in the bronchial suction group needed further manoeuvres to collapse the surgical lung. Moreover, the presence of COPD showed a significant positive correlation with the time to total lung collapse (Spearman r = 0.564; P < 0.001).

CONCLUSION

The use of continuous bronchial suction through the lumen of the Arndt blocker offers an effective method to accelerate lung collapse.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02030795.

Lung isolation, one-lung ventilation and hypoxaemia during lung isolation

Lung isolation is being used more frequently in both adult and paediatric age groups due to increasing incidence of thoracoscopy and video-assisted thoracoscopic surgery in these patients. Various indications for lung isolation and one-lung ventilation include surgical and non-surgical reasons. Isolation can be achieved by double-lumen endotracheal tubes or bronchial blocker. Different issues arise in prone and semi-prone position. The management of hypoxia with lung isolation is a stepwise drill of adding inhaled oxygen, adding positive end-expiratory pressure to ventilated lung and continuous positive airway pressure to non-ventilated side.

Endotracheal Tube Management and Obstructed Airway

Thoracic surgery encompasses a wide array of surgical techniques, most of which require lung isolation for surgical exposure in the pleural cavity; this, in turn, demands an extensive knowledge of respiratory mechanics and modalities of airway control. Likewise, effective treatment of an acute central airway obstruction calls for a systematic approach using clear communication between teams and a comprehensive knowledge of available therapeutic modalities by the surgeon.

Intraoperative management of failed single lung ventilation using a Fogarty balloon catheter through the open bronchus during off-pump left lung transplantation

The use of balloon catheters as an interventional procedure is well established in various fields of medicine. Failure of single lung ventilation (SLV) can add difficulty to open bronchus procedures, and could result in a life-threatening situation very quickly. Trying to achieve single lung ventilation by alternate methods is fraught with dangers, and use of urgent cardiopulmonary bypass is less desirable because of increased primary graft dysfunction and mortality. We describe a novel approach of using a Fogarty balloon catheter through the open bronchus to achieve SLV during off-pump left lung transplantation when conventional SLV failed.

Airway strategies for lung isolation in a patient with high-velocity nail gun injuries to the right cardiac ventricle and floor of the mouth: a case report

Introduction

We report a case of deliberate self-harm in which three three-inch nails were fired from a nail gun resulting in mandibular fixation and two penetrating injuries to the right cardiac ventricle. This combination of high-velocity penetrating injury has not been previously described.

Case presentation

A 69-year-old Caucasian man with a medical history of chronic depression was brought to hospital after a failed suicide attempt. The attempt consisted of self-asphyxiation with car exhaust fumes and shooting himself thrice with a three-inch nail gun. He sustained a penetrating nail injury to the floor of his mouth, effectively pinning his mouth closed, and penetrating injuries to the right ventricular free wall and at the junction of the right atrioventricular septum. The patient required emergency surgery with requirements for thoracotomy and sternotomy, lung isolation and cardiopulmonary bypass.

Conclusions

This is the first reported case of a combination high-velocity penetrating nail gun injury to the face and the right cardiac ventricle. This rare case offers airway strategies to accommodate the surgical requirement for lung separation for penetrating chest trauma in a patient with iatrogenically limited mouth opening.

Design and implementation of an educational program in advanced airway management for anesthesiology residents

Education and training in advanced airway management as part of an anesthesiology residency program is necessary to help residents attain the status of expert in difficult airway management. The Accreditation Council for Graduate Medical Education (ACGME) emphasizes that residents in anesthesiology must obtain significant experience with a broad spectrum of airway management techniques. However, there is no specific number required as a minimum clinical experience that should be obtained in order to ensure competency. We have developed a curriculum for a new Advanced Airway Techniques rotation. This rotation is supplemented with a hands-on Difficult Airway Workshop. We describe here this comprehensive advanced airway management educational program at our institution. Future studies will focus on determining if education in advanced airway management results in a decrease in airway related morbidity and mortality and overall better patients' outcome during difficult airway management.

Bronchial selective ventilation in a wide tracheocutaneous fistula

We present the treatment and management of a wide tracheocutaneous fistula after tracheotomy correlated with excessive cuff pressure in a 36-year-old woman with cerebral palsy since infancy in which persistent type II respiratory failure required continuous ventilatory support. We discuss the surgical treatment adopted for the management of this particularly wide lesion. At the end of surgery, mechanical ventilation through a tracheal cannula was hindered by the reduced length of the residual trachea below the tracheotomy. The need to guarantee mechanical ventilation to the patient led to the implementation of a cuff securing system in the two main bronchi. We describe the approach that may be attempted under extreme conditions, when traditional ventilation methods cannot be applied for anatomical reasons.

Application of lobe-selective bronchial blockade against airway bleeding

A 48-year-old man underwent resection of a right upper lobe necrotic tumor and part of his chest wall. Lobe-selective bronchial blockade of bleeding from the right upper lobe was achieved by combining a left-side double-lumen endotracheal tube with a bronchial blocker placed at the right intermediate bronchus. The bleeding right upper lobe was isolated, and the other lobes were protected from blood contamination during the lobectomy procedure.