LUNG ISOLATION TECHNIQUES DOUBLE LUMEN TUBES, BRONCHIAL BLOCKERS

Chair Dr Meena Vijayaraghavan Dr.Muraleedharan Dr.Divya Madhu

By Dr Vimal JR in Anaesthesia MCH,TVM

OLV means:

separation of the two lungs each lung functions independently by preparation of the airway

OLV provides:

protection of healthy lung from infected/bleeding one diversion of ventilation away from damaged airway or lung improved exposure of surgical field

OLV causes:

more manipulation of airway, more damage significant physiologic change & easy development of hpoxaemia

Indications for OLV

ABSOLUTE
1. Isolation of one lung from the other to avoid spillage or contamination. 2. Control of the distribution of ventilation (fistula, cyst, T.B disruption). 3. Unilateral bronchopulmonary lavage.

RELATIVE
1. Surgical exposure. 2. Postcardiopulmonary bypass status, after removal of totally occluding chronic unilateral pulmonary emboli.

OLV is achieved

by either;

-Double lumen ETT (DLT)

-Bronchial blocker

-Endobronchial tube

Anatomy of the Tracheobronchial Tree

Features of DLT

RUL, right upper lobe;

LUL, left upper lobe

Carlens DLT

Different types of DLT

Carlens White Bryce Smith Robertshaw

lumen hook side

+ Lt

+ Rt

Lt & Rt

Lt & Rt

Basic pattern of a Right-Sided DLT

Rt

Lt

Lt

passage of the left-sided DLT

guide for Length and Size of DLT

Length of tube , For 170 cm height, tube depth of 29 cm For every 10 cm height change , 1 cm depth change

Patient characteristics
Tracheal width (mm):
18 16 15 14

Tube size (Fr gauge)

41 39 37 35 35-37 37-39 39-41 35 32 28 (lt only) 26 (lt only)

Patient height
4 6-55 55-510 511-64

Patient age (year)

13-14 12 10 8

Check Position of Lt -DLT

Checklist for Lt side Checklist for tracheal placement a. inflate tracheal cuff b. ventilate rapidly by hand c. check that both lungs are being ventilated d. If not, withdraw 2-3 cm & repeat Lt cuff > 2ml b. ventilate and check bilateral a. inflate breath sounds c. clamp Rt tube d. check unilateral (Lt) breath sounds

Checklist for Rt a. clamp Lt tube b. check unilater sounds

Major Malpositions of a Lt- DLT

Lt Breath Sounds Heard

Both cuffs inflated Clamp Rt lumen Both cuffs inflated Clamp Lt lumen Deflate Lt cuff Clamp Lt lumen

Left

Left

Both

Right

Right

None / Very minimal left

None / Very minimal Both

None / Very minimal Right

Both

To ensure correct position of DLT clinically :

breath sounds are - normal (not diminished) & - follow the expected unilateral pattern with unilateral clamping the chest rises and falls in accordance with the breath sounds the ventilated lung feels reasonably compliant no leaks are present respiratory gas moisture appears and disappears with each tidal ventilation

N.B even if the DLT is thought to be properly positioned by clinical signs, subsequent FOB may reveal an incidence of malposition ( 38 -78 %)

FOB picture of Lt - DLT

FOB picture of Rt DLT

Relationship of FOB Size to Adult DLT

FOB Size (mm)

(OD) 5.6 4.9

Adult DLT Size

(French) All sizes 41 39 37 35 All sizes

Fit of FOB inside DLT

Does not fit Easy passage Moderately easy passage Tight fit, need lubricant, hard push Does not fit Easy passage

3.64.2

Other Methods to Check DLT Position

Chest radiograph ;
may be more useful than conventional auscultation and clamping in some patients, but it is always less precise than FOB. The DLT must have radiopaque markers at the end of Rt and Lt lumina.

Comparison of capnography;
waveform and ETCO2 from each lumen may reveal a marked discrepancy (different degree of ventilation).

Surgeon ;
may be able to palpate, redirect or assist in changing DLT position from within the chest (by deflecting the DLT away from the wrong lung, etc..).

Adequacy for Sealing (air Bubble test )

Complications of DLT

impediment to arterial oxygenation for OLV

tracheobronchial tree disruption, due to -excessive volume and pressure in bronchial balloon -inappropriate tube size -malposition traumatic laryngitis (hook) inadvertent suturing of the DLT

to avoid Tracheobronchial tree Disruption ;

1. Be cautious in patients with bronchial wall abnormalities.

2. Pick an appropriately sized tube.

3. Be sure that tube is not malpositioned ; Use FOB. 4. Avoid overinflation of endobronchial cuff. 5. Deflate endobronchial cuff during turning. 6. Inflate endobronchial cuff slowly. 7. Inflate endobronchial cuff with inspired gases. 8. Do not allow tube to move during turning.

Relative Contraindications to Use of DLT

full stomach (risk of aspiration); lesion (stricture, tumor) along pathway of DLT (may be traumatized); small patients; anticipated difficult intubation; extremely critically ill patients who have a single-lumen tube already in place and who will not tolerate being taken off mechanical ventilation and PEEP even for a short time; patients having some combination of these problems.

Under these circumstances, it is still possible to separate the lungs by : -using a single-lumen tube + FOB placement of a bronchial blocker ; or -FOB placement of a single-lumen tube in a main stem bronchus.

Bronchial Blockers
(With Single-Lumen Endotracheal Tubes)

Lung separation can be effectively achieved with the use of a single-lumen endotracheal tube and a FOB placed bronchial blocker.
Often necessary in children as DLTs are too large to be used in them. The smallest DLT available is a left-sided 26 Fr tube, which may be used in patients 8 -12 years old and weighing 25 -35 kg. Balloon-tipped luminal catheters have the advantage of allowing suctioning and injection of oxygen down the central lumen.

Indications for Use of Bronchial Blockers

1st , limitations to DLT (severely distorted airway, small patients ,
anticipated difficult intubation)

2nd , to avoid a risky change of DLT to single-lumen tube

whenever postoperative ventilation is anticipated in cases of thoracic spine surgery in which a thoracotomy in the supine or LDP is followed by surgery in the prone position.

3rd , situations in which both lungs may need to be

blocked (e.g., bilateral operations, indecisive surgeons).

Types of bronchial blockers

Univent bronchial blocker system

Arndt endobronchial blocker Cohen Flexitip Endobronchial Blocker

BB independent of a single-lumen tube

Univent bronchial blocker system

steps of FOB-aided method of positioning the Univent bronchial blocker in lt main stem bronchus

One- or two-lung ventilation is achieved simply by inflating or deflating, respectively, the bronchial blocker balloon

Advantages of the Univent Bronchial Blocker Tube ( Relative to DLT )

1. Easier to insert and properly position. 2. Can be properly positioned during continuous ventilation and in the lateral decubitus position. 3. No need to change the tube when turning from the supine to prone position or for postoperative mechanical ventilation.

4. Selective blockade of some lobes of each lung.

5. Possible to apply CPAP to nonventilated operative lung.

Limitations to the Use of Univent Bronchial Blocker LIMITATION

1. Slow inflation time

SOLUTION
(a) Deflate BB cuff and administer +ve pressure breath through the main single lumen; (b) carefully administer one short high pressure (2030 psi) jet ventilation

2. Slow deflation time

(a) Deflate BB cuff and compress and evacuate the lung through the main single lumen; (b) apply suction to BB lumen
Suction, stylet, and then suction Use just-seal volume of air Make sure BB cuff is subcarinal, increase inflation volume, rearrange surgical field

3. Blockage of BB lumen ( blood, pus,..) 4. High-pressure cuff 5. Leak in BB cuff

Arndt endobronchial blocker

[Wire guided Endobronchial Blocker (WEB)]

Cohen Flexitip Endobronchial Blocker

Bronchial Blockers that are Independent of a Single-Lumen Tube

Adults -Fogarty (embolectomy) catheter with a 3 ml balloon. It includes a stylet so that it is possible to place a curvature at the distal tip to facilitate entry into the larynx and either mainstem bronchus . -balloon-tipped luminal catheters (such as Foley type) may be used as bronchial blockers. Very small children (10 kg or less) - Fogarty catheter with a 0.5 ml balloon - Swan-Ganz catheter (1 ml balloon) *

these catheters have to be positioned under direct vision; a FOB method is perfectly acceptable; the FOB outside diameter must be approximately 2 mm to fit inside the endotracheal tube (3 mm internal diameter or greater). Otherwise, the bronchial blocker must be situated with a rigid bronchoscope.
Paediatric patients of intermediate size require intermediate size occlusion catheters and judgment on the mode of placement (i.e., via rigid versus FOB).

Lung separation with a single-lumen tube, FOB, and Rt lung bronchial blocker

Disadvantages of a blocker that is independent of the single-lumen tube as compared with DLT

inability to suction and/or to ventilate the lung distal to the blocker.

increased placement time. the definite need for a fiberoptic or rigid bronchoscope. if bronchial blocker backs out into the trachea, the seal between the two lungs will be lost and the trachea will be at least partially obstructed by the blocker, and ventilation will be greatly impaired.

Endobronchial Intubation with Single-Lumen Tubes

In adults, is often the easiest, quickest way for lung separation in

patients presenting with haemoptysis , either -blind, or -FOB , or -guidance by surgeon from within chest

In children it may be the simplest way to achieve OLV

-inability to do suctioning or ventilation of operative side. -difficult positioning bronchial cuff with inadequate ventilation of Rt upper lobe after Rt endobronchial intubation.

Disadvantages

In summary,
DLT is the method of choice for lung separation in most adult patients. The precise location can be determined by FOB . In situations where insertion of a DLT may be difficult and/or dangerous, separating the lungs is achieved either with a single-lumen tube alone or in combination with a bronchial blocker (e.g., the Univent tube).

Therefore,
regardless of what method of lung separation chosen, there is a real need of a small-diameter FOB (for checking the position of the DLT, placing a single-lumen tube in a mainstem bronchus, and placing a bronchial blocker) .

The Mallinckrodt Broncho-Cath CPAP System

(Photography courtesy of Mallinckrodt Medical, Inc., St. Louis, MO.)