slinger, peter, md, frcpc advances in lung isolation for ... · 2/3/2015 1 advances in lung...
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2/3/2015
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Advances in Lung Isolation forThoracic Anesthesia
✦ Anatomy, Bronchoscopy, Chest Imaging
✦ Improved Double-Lumen Tubes
✦ New Bronchial Blockers
✦ Difficult Airways
Peter SlingerMD, FRCPC
University ofToronto
(NoDisclosures)
55 y.o. Female Post-op. Right Pneumonectomy
Post-op. Day 1 Post-op. Day 7
Methods of Lung Isolation:
Single Lumen Tubes
Double-lumen Tubes
Bronchial Blockers
Single Lumen Endobronchial Tubes
Techniques of Lung Isolation:
Single Lumen Tubes
Double-lumen Tubes
Bronchial Blockers
Slinger, Peter, MD, FRCPC Advances in Lung Isolation for Thoracic Anesthesia
2/3/2015
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UNIVENT TUBE The “Arndt” Bronchial Blocker
Bronchial Blockers – CohenFuji “Uni-Blocker”
COHEN FUJI ARNDT
New Bronchial Blockers Arndt
Slinger, Peter, MD, FRCPC Advances in Lung Isolation for Thoracic Anesthesia
2/3/2015
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Cohen Fuji
Bronchial Blockers vs. Left DLTsLeft-Thoracotomy/VATS
LungCollapse
Score
.
Complete Collapse
Nil
Narayanaswamy M, et al. Anesth Analg 2009, 108: 1097-1101
Bronchial Blocker “Tricks”
✦ De-Nitrogenate the lung before collapse (FiO2 1.0)✦ Prolonged expiration before blocker inflation✦ Suction blocker lumen✦ Pressure-control ventilation✦ Warn Surgeon
Bronchial Blockers vs. Left DLTsLeft-Thoracotomy/VATS
Number Of
Repositions
.(n= 26/ group)
Narayanaswamy M, et al. Anesth Analg 2009, 108: 1097-1101
Elliptical SphericalArndt Blockers
Slinger, Peter, MD, FRCPC Advances in Lung Isolation for Thoracic Anesthesia
2/3/2015
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EZ Blocker (Teleflex/Rusch)
Mungroop HE, et al. Br J Anaesth 2010, 104: 119-20
EZ Blocker for R Thoracotomy/VATS
38% Incidence of major malpositions of Double-lumen Tubes and Blockers
Campos JH, et al.Anesthesiology 2006;104: 261-6
“The most critical factorin successful placementwas the Anesthesiologist’sknowledge of endoscopicbronchial anatomy”
The structure seen in the Yellow circle is?
A. Right Bronchus intermedius
B. Left upper lobe bronchus
C. Left mainstem bronchus
D. Right middle lobe bronchus
E. Right upper lobe bronchus
Slinger, Peter, MD, FRCPC Advances in Lung Isolation for Thoracic Anesthesia
2/3/2015
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Bronchoscopy Quiz Scores
%Correct
The ABC’s of Lung Isolation:
Anatomy
Bronchoscope
Chest X-ray, CT Scan
Left Upper Lobe Sleeve Resection
What Airway Device?
Slinger, Peter, MD, FRCPC Advances in Lung Isolation for Thoracic Anesthesia
2/3/2015
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Left Upper Lobe Sleeve Resection
Right and Left-Sided Mallinckrodt Double-Lumen Tubes Have Identical Clinical Performance
Ehrenfeld J, et al. Anesth Analg 2008,106: 1847-52
The ABC’s of Lung Isolation:
Anatomy
Bronchoscope
Chest X-ray, CT Scan
Slinger, Peter, MD, FRCPC Advances in Lung Isolation for Thoracic Anesthesia
2/3/2015
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CT Measurement of Right Mainstem Bronchus
55 y.o. Female Post-op. Right Pneumonectomy
Post-op. Day 1 Post-op. Day 7
Anesthesia for Broncho-Pleural Fistula
Goals: Protect Healthy Lung Avoid Tension Pneumothorax Ensure Adequate Ventilation
Lung Isolation Before Pos. Press.Ventilation or Re-Positioning Patient
Anesthesia for Broncho-Pleural Fistula
Airway Management:Single-, Double-lumen, BB Intubation:Awake, Spont. Vent., Rapid
Sequence
Slinger, Peter, MD, FRCPC Advances in Lung Isolation for Thoracic Anesthesia
2/3/2015
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Single-lumen EBT Double-lumen EBT 62 y.o. Male, Left Lower Lobe Lung CancerPrevious Failed Intubation
Awake Fiberoptic Double-Lumen Intubation
Russell T, et al.Anaesthesia 2013,
68: 1253-8
Video-Laryngoscope + Tube Exchanger
Glidescope
Video-Laryngoscope + Tube Exchanger
Slinger, Peter, MD, FRCPC Advances in Lung Isolation for Thoracic Anesthesia
2/3/2015
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Rush FujiMallinckrodt
69 y.o. Female, R Upper Lobe Ca.
Severe Rheumatoid arthritis
Neck pain on Extension
X-ray instability C3-C4 in flexion
GE Reflux
Neck flexion
60 y.o. Female, 2 hr. Post-op. Mitral Valve Replacement
Intubated, ventilated in ICU
Sudden onset massive hemoptysis
Diagnosis ?
PA Catheter Induced Pulmonary Hemorrhage
1. Initially position with bleeding lung dependent
2. ETT , oxygenate, suction
3. Lung isolation: DLT, Bronchial Blocker or single-lumen endobronchial tube?
4. Withdraw PA cath 2-3cm, do not inflate
5. Position with isolated bleeding lung non-dependent + PEEP
60 y.o. Female, 2 hr. Post-op. Mitral Valve Replacement
The OR Your MomNobody, the
patient is stableRadiology
Patient stabilized, now who you gonna call?
60 y.o. Female , 2 h Post-op.Mitral Valve Replacement
Slinger, Peter, MD, FRCPC Advances in Lung Isolation for Thoracic Anesthesia
2/3/2015
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Tube Selection for Lung Isolation:
Bronchial Blocker orSingle-Lumen EBTube• Adaptability•Difficult airways• No need to change tube• Suctioning
Double-Lumen Tube• Excellent Isolation• Independent Lung Access• Fixed Anatomical Design• Adults
Advances in Lung Isolation forThoracic Anesthesia
✦ Anatomy, Bronchoscopy, Chest Imaging
✦ Improved Double-Lumen Tubes
✦ New Bronchial Blockers
✦ Difficult Airways
1. Auscultate
• Fiberoptic Bronchoscopy
• Look Again
• Know WhatYou areLooking At
Slinger, Peter, MD, FRCPC Advances in Lung Isolation for Thoracic Anesthesia