Difficult airway and one lung ventilation Mojca Drnovsek Globokar, MD Vesna Novak Jankovic, MD,PhD, Prof University Medical Centre, Ljubljana

Discussed items Which patient with request for one lung ventilation is at risk for difficult intubation? Is one lung ventilation absolutelly indicated? (patient safety/surgeon exposure) What technique would you select for lung isolation? (advantages/disadvantages) Scenario/algorithm ?

Preoperative airway evaluation UPPER AIRWAY NECK: short/increased neck, limited mobility TEETH: prominent incisors, big molars Small mandibula,poor mouth opening Tumor/resection/radiation in oropharingeal region LOWER AIRWAY Tracheostomy Distordet anatomy (trachea/bronchus) Compression of the left main bronchus (tumor/descending thoracic aortic aneurism)

Indications for lung isolation ABSOLUTE=really need it protecting healthy lung from contamination (blood, pus, water) prevention of wasting ventilation (broncho-pleural fistula) protective ventilation (ARDS) RELATIVE=like to have it Surgical exposure VATS procedures

Lung isolation techniques Double lumen tubes (DLT) Bronchial blockers (BB) Single lumen endobronchial tubes (SLT) Classic tracheal tubes (TT)

Double lumen tube (DLT) ☺ gold standard for lung isolation ☺ true lung protection, when needed ☺ less displacement, comparing to BB ☺ faster deflation of the lung (DLT:17 min vs BB:19-26 min) ☺ effective suction ☺ CPAP application ☹ “difficult tube”

Difficult tube in difficult airway DLT : larger size, rigidity and shape Awake fiberoptic intubation with DLT is not prohibited but also not recomended. Why?

AWAKE INTUBATION with DLT and FOB Long,thick,rigid tube/ small pediatric bronhoscope (working lenght 20 cm) Use DLT without hook or cut it Aritenoid displacement, major tracheobronchial trauma Not suitable for nasal awake intubation

Bronchial blocker (BB) ☺ easy to use? (bronchoscopy!) ☹ easy dislodged →what if blood/pus/VATS?! ☹ slow deflation/incomplete collaps (VATS) ☹ less suction/no bronchoscopy to non-ventilated lung

nasotracheal intubation pediatric use Bronchial blockers ☺ Indications: difficult airway tracheostomy nasotracheal intubation pediatric use Campos JH. Lung isolation techniques in patient with difficult airway. Curr Opin Anesthesiol 2010;23:12-17.

Bronchial blockers Arndt with Multiport Adaptor (Cook Critical Care) Cohen (Cook Critical Care) Fuji (Fuji Sistem Corporation) Coopdech (Daiken Medical) EZ bloker (Teleflex) Fogarty embolectomy catheter (Edward Lifesciences)

Coopdech Arndt with Multiport Adaptor EZ Blocker

DLT vs BB: some facts 1 …equivalent in providing lung collapse in normal airway… Campos JH, Kernstine KH. A comparison of a left-sided BronchoCath with the torque control blocker, Univent and thr wire-guided blocker. Anesth Analg 2003; 96:283-286. …each of them provides advantages depending upon the case : ✎ DLT: absolute lung protection ✎ BB: difficult airway Campos JH. Which device should be considered the best for lung isolation: double-lumen endobronshial tube versus bronchial blockers. Curr Opin Anaesthesiol 2007; 20:27-31.

DLT vs BB: some facts 2 …minor differences during lung collapse used by thoracic anaesthesiologists… Campos JH. Which device should be considered the best for lung isolation: double-lumen endotracheal tube versus bronchial blockers. Curr Opin Anaesthesiol 2007; 20:27-31. …none of the devices show any advantage, when used by nonthoracic anaesthesiologists (39% unrecognised malpositions). Campos JH, HallamEA, Van Natta T, Kerstine KH. Devices for lung isloation used by anesthesiologists with limited thoracic experience. Anesthesiology 2006; 104:261-266.

Difficult airway and one lung ventilation Algorithms? Recommendations? Guidelines? ASA (www.asahq.org)? EAMS (www.eamsoline.org) ? DAS ( www.das.uk.com) ?

Brodsky JB. Lung separation and difficult airway Brodsky JB. Lung separation and difficult airway. Br J Anaesth 2009 Dec; 103 Suppl 1: i66-i75.

Algorithm Campos JH. Lung isolation techniques for patients with difficult airways. Curr Opin Anaesthesiol.2010;23:12-7

Predicted difficult airway General anesthesia Tube exchanger (AEC) DLT Campos JH. Lung isolation techniques for patients with difficult airways. Curr Opin Anaesthesiol.2010;23:12-7

Airway exchange catheter (AEC) ≥ 70 cm long/ 12 or 14 Fr Gum bougie/Aintree/Frova compatible with bronchial lumen of DLT lubricate AEC

Unpredicted difficult airway Campos JH.Lung isolation techniques for patients with difficult airways. Curr Opin Anaesthesiol.2010;23:12-7

From our practise Obesitas, COPD, sleep apnea- Airtraq + SLT + BB Unpredicted difficult intubation- Airtraq DL + DLT + FOB positioning

Tracheostomy Campos JH. Lung isolation techniques for patients with difficult airways. Curr Opin Anaesthesiol.2010;23:12-7

Bronchoscopy

Intrathoracic procedures in difficult airway-other options One lung ventilation using Igel + BB 19AP5-6 One lung ventilation using an i-gel supraglottic device and a bronquial blocker J. Arévalo Ludeña, R. Alvarez-Rementería Carbonell, V. López Pérez, J.J. Arcas Bellas, A. Cuarental García Department of Anaesthesiology, Fundacion Jimenez Diaz, Madrid, Spain 2. Double lung HFJV vs OLV rr 150-200/min,driving pressure 1 atm-safe option for vent. ,comparable surgical condition Misiolek H, Knapik P, Swanevelder J, Wyatt R, Misiolek M. Comparison of double-lung yet ventilation and one lung ventilation for thoracotomy. EJA 2008;25: 15-21.

Intrathoracic procedure in difficult airway-other options 3. Awake thoracic surgery

Conclusions In elective intrathoracic procedures we can achive the airway and isolate the lung safelly through wide spectrum of alimentarium. But in emergency situations (i.e. absolute indication, airway bleeding) combined with respiratory distress, lung isolation can be challenging and stressfull......

HVALA, THANK YOU, ….