Javier H. Campos

Devices for lung isolation used by anesthesiologists with limited thoracic experience: Comparison of double-lumen endotracheal tube, Univent® torque control blocker, and Arndt Wire-guided Endobronchial Blocker®

Background:Lung isolation is accomplished with a double-lumen tube or a bronchial blocker. Previous studies comparing lung isolation methods were performed by experienced anesthesiologists in thoracic anesthesia. Therefore, the results of these studies may not be relevant to the anesthesiologist with limited experience. This study compared the success rates of lung isolation devices among anesthesiologists with limited experience in thoracic anesthesia. Methods:A prospective, randomized trial was designed to determine the success and time required for proper placement of the left-sided double-lumen tube (n = 22), the Univent® tube (Vitaid Ltd., Lewiston, NY; n = 22), and the Arndt Blocker® (Cook Critical Care, Bloomington, IN; n = 22). Anesthesiologists with less than two lung isolation cases per month were included (faculty n = 17 and senior residents n = 11). Variables recorded included (1) successful placement (as determined by an independent observer), (2) time of placement, and (3) the number of times the fiberoptic bronchoscope was used. Results:Participants failed to place or position their assigned device in 25 of 66 patients (failure was 39% among faculty and 36% among senior residents). The failure rate did not differ among the three devices (P = 0.65). The median (25th–75th percentile) times to complete the placement procedures were as follows: (1) double-lumen tube: 6.1 min (4.6–9.5 min), (2) Univent tube: 6.7 min (4.9–8.8 min), and (3) Arndt Blocker: 8.6 min (5.8–17.5 min) (P = 0.45 comparing all devices). After device malposition was identified, it took 1 min or less for the investigating anesthesiologist to achieve optimal position. Conclusions:Anesthesiologists with limited experience in thoracic anesthesia frequently fail to successfully place lung isolation devices. Rapid successful device placement by an experienced anesthesiologist excluded any contribution of uniquely difficult anatomy. The nature of the malpositions suggests that the most critical factor in successful placement was the anesthesiologist’s knowledge of endoscopic bronchial anatomy.

Which device should be considered the best for lung isolation: double-lumen endotracheal tube versus bronchial blockers.

Purpose of review This review is a clinical comparison between double-lumen endotracheal tubes and bronchial blockers to determine which device is considered the best for lung isolation. Recent findings Double-lumen endotracheal tubes and bronchial blockers have been found to be clinically equivalent in terms of performance in providing lung collapse for patients with normal airways. In the last five years, however, numerous reports have indicated a preference for the use of bronchial blockers in patients with airway abnormalities. For nonthoracic anesthesiologists who have limited experience in thoracic anesthesia cases, none of the devices (double-lumen tubes or bronchial blockers) have been shown to provide any advantage while in use due to a high incidence of unrecognized malpositions. Overall, each device provides advantages depending upon the case, such as absolute lung separation with a double-lumen endotracheal tube or the use of a bronchial blocker in a difficult airway for a patient requiring lung isolation. Summary Double-lumen endotracheal tubes and bronchial blockers should be part of the armamentarium of every anesthesiologist involved in lung isolation techniques and every device should be tailored to specific case needs.

A comparison of a left-sided Broncho-Cath® with the torque control blocker univent and the wire-guided blocker

Lung isolation can be accomplished in two ways: the first, a double-lumen endotracheal tube (DLT) and the second, a bronchial blocker (Univent® or Arndt® blocker). Previous studies have found that the DLT and the Univent® are comparable when providing lung isolation. A new bronchial blocker, the wire-guided endobronchial blocker (Arndt® blocker), has been introduced. However, there is no study to report its effectiveness with lung isolation during elective thoracic surgical cases. Therefore, we designed a prospective, randomized trial to compare the effectiveness of lung isolation among the 3 endotracheal tubes: the left-sided DLT Broncho-Cath® Group A (n = 16 patients), the torque control blocker Univent® Group B (n = 16 patients), and the wire-guided Arndt® blocker Group C (n = 32 patients). The following variables were recorded: 1) time to initially position the assigned tube, 2) frequency of malpositions, 3) frequency of use of fiberoptic bronchoscope, 4) overall surgical exposure, and 5) tube acquisition cost. The Arndt® blocker took longer to place (3:34 min/s) compared with the other 2 groups: the DLT group (2:08 min/s) or the Univent® group (2:38 min/s) (P < 0.0004). There was no statistical difference in tube malpositions among the three groups: two for the DLT group, four for the Univent® group, and nine in the Arndt® group. Excluding the time for tube placement, the Arndt® group also took longer for the lung to collapse (26:02 min/s), compared with the DLT group (17:54 min/s) or Univent® group (19:28 min/s) (P < 0.0060). Furthermore, unlike the other two groups, the majority of the Arndt® patients required suction to achieve lung collapse. Once lung isolation was achieved, overall surgical exposure was rated excellent for the three groups. Acquisition cost for the DLT group was

The first series of completely robotic esophagectomies with three-field lymphadenectomy: initial experience.

1663.20 (21 tubes opened),

Current Techniques for Perioperative Lung Isolation in Adults

2329.00 for the Univent® group (17 tubes opened), and

Lung isolation techniques for patients with difficult airway

3567.00 for the Arndt® group (33 wire-guided blockers opened). This study demonstrates that the Arndt® blocker takes longer to position and longer to deflate the isolated lung. For elective thoracic surgical cases, once the lung was isolated, the management seemed to be similar for all three tube groups.

Effects on oxygenation during selective lobar versus total lung collapse with or without continuous positive airway pressure

BackgroundThis study investigated the use of robotics to perform extended esophageal resection in a series of patients.MethodsA total of 14 patients with a median age of 64 years underwent esophagectomy using the da Vinci robot. At presentation, there were 12 cases of cancer, staged at T2N1 (n = 2), T3N0 (n = 2), T3N1 (n = 6), T4N1 (n = 1), and M1a (n = 1); 2 cases of high-grade dysplasia; 8 cases of adenocarcinoma; and 4 cases of squamous cell cancer; as well as 2 middle third, 9 lower third, and one gastroesophageal junction tumor. Nine patients had undergone preoperative chemoradiotherapy, and six had undergone prior abdominal surgery. The patients were categorized into three chronological groups according to the procedure performed. Group 1 consisted of the first three patients in the series, whose surgery was thoracic only (robotically assisted esophagectomy). Group 2, the next three patients, had robotically assisted thoracic esophagectomy plus thoracic duct ligation using a laparoscopic gastric conduit. Group 3, the last eight patients, underwent completely robotic esophagectomy.ResultsFor Group 3, the total operating room time was 11.1 ± 0.8 h (range, 11.3–13.2 h), with a console time of 5.0 ± 0.5 h (range, 4.8–5.8 h). The estimated blood loss was 400 ± 300 ml (range, 200–950 ml). One patient in group 1 had a thoracic duct leak. In groups 2 and 3, thoracic duct ligation resulted in no further leaks. Other postoperative complications included severe pneumonia (1 case), atrial fibrillation (5 cases), cervical anastomotic leak (2 cases), wound infection (1 case), and bilateral vocal cord paresis requiring tracheostomy (1 case). In seven of the cases, no intensive care unit time was required. There was one death from pneumonia 72 days after the procedure. The rate of disease-free survival was 87%.ConclusionThe robotic approach facilitates an extended three-field esophagolymphadenectomy even after induction therapy and abdominal surgery. Larger scale trials are needed to define the role of this technique.

The incidence of right upper-lobe collapse when comparing a right-sided double-lumen tube versus a modified left double-lumen tube for left-sided thoracic surgery.

LUNG isolation techniques are used in thoracic, esophageal, vascular, and nonthoracic surgical settings in the perioperative period. The purpose of this review is to provide an update on the current use of (1) doublelumen tube (DLT) technology (leftand right-sided double-lumen endotracheal tubes) and (2) bronchial blocking technology, including Fogarty occlusion catheters, the Univent bronchial blocker (Vitaid, Lewiston, NY), and a wire-guided endobronchial blocker (WEB; Cook, Bloomington, IN) to achieve lung isolation. More than 50 yr ago, Björk and Carlens introduced a practical method of lung isolation to facilitate lung surgery or to prevent contamination of the contralateral lung while maintaining one-lung ventilation (OLV) with a DLT. Today, rubber DLTs continue to be used extensively throughout the world, while in the United States most DLTs are plastic and disposable. Ginsberg reported the use of a Fogarty catheter as an endobronchial blocker to achieve OLV. Inoue et al. introduced a new device for OLV, using a single-lumen endotracheal tube with an incorporated bronchial blocker (Univent) so that when OLV is no longer needed the tube can be left in situ (i.e., for postoperative mechanical ventilation). Arndt et al. introduced the wire-guided endobronchial blocker (WEB), which consists of a single bronchial blocker that is advanced through a standard single-lumen endotracheal tube. Although these different devices are designed to achieve OLV, there is no randomized trial demonstrating one to be superior over the others during elective thoracic cases. There are widely accepted indications for lung isolation, including

Comparison of a modified double-lumen endotracheal tube with a single-lumen tube with enclosed bronchial blocker

Purpose of review One-lung ventilation in the thoracic surgical patient can be achieved with the use of a double-lumen endotracheal tube or an independent bronchial blocker. A number of patients requiring lung isolation have a potentially difficult airway because of previous radiation to the neck or previous surgery to the tongue and larynx. This review will focus on the management of patients who have a difficult airway and require lung isolation. Recent findings Identification of the potentially difficult airway during the preoperative evaluation allows the preplanning and selection of the appropriate lung isolation device. Common devices used to achieve one-lung ventilation in patients with difficult airways include independent bronchial blockers (Arndt, Cohen, and Fuji Uniblocker). Summary In patients who require one-lung ventilation and who present with a difficult airway, the safest way to establish an airway is by placing a single-lumen endotracheal tube orally or nasotracheally while the patient is awake with the aid of a flexible fiberoptic bronchoscope. Lung isolation in these patients then is achieved by using an independent bronchial blocker; an alternative technique is to use a double-lumen endotracheal tube while using an airway catheter exchange technique. For the patient with a tracheostomy in place, an independent bronchial blocker is recommended.

Is there a better right-sided tube for one-lung ventilation? A comparison of the right-sided double-lumen tube with the single-lumen tube with right-sided enclosed bronchial blocker

Hypoxemia is common during anesthesia with one-lung ventilation (OLV). This study tested the hypothesis that selective lobar blockade would result in higher PaO2 values compared with those found with total lung collapse independent of continuous positive airway pressure (CPAP) application. Thirty patients undergoing lobectomy were randomly assigned to one of four groups with the following maneuvers during OLV: Group 1 (n = 8) total lung collapse (TLC) plus 5 cm H2 O of CPAP to the nonventilated operative lung for 15 mins, followed by selective lobe collapse plus 5 cm H2 O of CPAP (during selective collapse only the surgical lobe was collapsed and the rest of that lung was ventilated); Group 2 (n = 6) selective lobar collapse plus 5 cm H2 O of CPAP to the operative lung, followed by TLC plus 5 cm H2 O of CPAP; Group 3 (n = 8) total lung collapse without CPAP, followed by selective lobe collapse and no CPAP; Group 4 (n = 8) selective lobe collapse without CPAP, followed by TLC and no CPAP. To obtain selective lobe collapse, the bronchial blocker of the Univent[registered sign] (Vitaid, Lewiston, NY) endotracheal tube was guided into the operative bronchus with the aid of a fiberoptic bronchoscope. Blood pressure, heart rate, and arterial blood gas measurements were obtained during the following times: Time 1 - while the patient was awake; Time 2 - two-lung ventilation (2LV) in the supine position; Time 3 - after 30 min of OLV in the lateral decubitus position (no CPAP or selective blockade); Time 4 and Time 5 - during maneuvers described above (see group description); Time 6 - 2LV resumed; Time 7 - 30 min after extubation. Twenty-eight patients completed the study. There were no differences among groups with regard to arterial blood pressure, heart rate, or arterial oxygen saturation during the experimental maneuvers. All four groups showed a decrease in PaO2 from 2LV to OLV (P < 0.05). Both with and without CPAP application, oxygenation was improved with selective lobe collapse compared with TLC. When selective lobe collapse with 5 cm H2 O of CPAP followed TLC (group 1), PaO2 values increased to values similar to those found for 2LV (PaO2 449 +/- 122 vs 394 +/- 105 mm Hg). This study indicates that by using a bronchial blocker, changing from total lung collapse to selective lobar blockade improves PaO2 during lung surgery. Implications: This study examines how oxygen tension in arterial blood can be higher during one-lung ventilation. The use of a bronchial blocker, which changes a total lung collapse to selective lobar blockade, improves oxygenation during lung surgery. (Anesth Analg 1997;85:583-6)