DIFFICULT AIRWAY AND ONE LUNG VENTILATION Mojca Drnovsek Globokar UKC Ljubljana Alpe Adria, Bled 2011

Introduction results in higher incidence of difficult airway Expansion of indications for lung separation results in higher incidence of difficult airway with coincident request for lung separation. Alpe Adria, Bled 2011

Anaesthetic Considerations for OLV and Difficult Airway precise airway assessment thoracic anaesthesia practise knowledge of bronchial anatomy familiar with bronchoscope good plan alert for help Alpe Adria, Bled 2011

Equipment needed Difficult airway equipment Different tubes, different sizes: double lumen tubes (DLT), single lumen tubes (SLT) Bronchial blocker (BB) Airway tube exchanger (ATC) for DLT Two bronchoscopes Alpe Adria, Bled 2011

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 Alpe Adria, Bled 2011

Lung isolation techniques Double lumen tubes (DLT) Bronchial blockers (BB) Single lumen endobronchial tubes (SLT) Classic tracheal tubes (TT) Alpe Adria, Bled 2011

Double lumen tube ☺ gold standard for lung isolation ☺ true lung protection, when needed ☺ less displacement, comparing to BB ☺ easy deflation of the lung ☺ effective suction ☺ CPAP application Alpe Adria, Bled 2011

Double lumen tube ☹ difficult insertion ☹ good airway exposure ☹ airway trauma ☹ tears of cuffs during insertion ☹ no for short stature ☹ no for pediatric use Alpe Adria, Bled 2011

Double lumen tube Choice of DLT ? ( left /right, with/without carinal hook) Size of DLT ? Placement technique ? Depth of insertion? Proper position? Alpe Adria, Bled 2011

Size of DLT 1. CT: left bronchus diameter ( available?) 3. anthropometric parameters 2. x-ray: calculation from tracheal diameter Alpe Adria, Bled 2011

Placement technique Alpe Adria, Bled 2011

Insertion depth for DLT Inserting DLT until resistance is felt can lead to incorrect position and trauma possibility. DLT depth (cm) = 12.5 + (0.1 x heigh (cm)) Alpe Adria, Bled 2011

Correct position LF-DP Olympus (3.1 mm) Alpe Adria, Bled 2011

Bronchial blockers Arndt with Multiport Adaptor (Cook Critical Care) Cohen (Cook Critical Care) Fuji (Fuji Sistem Corporation) Univent tube (Fuji Sistem Corporation) Coopdech (Daiken Medical) Fogarty embolectomy catheter (Edward Lifesciences) Alpe Adria, Bled 2011

Fuji Uniblocker and Univent tube Conventional TT with a second lumen containing blocker. “difficult tube” Alpe Adria, Bled 2011

Arndt Endobronchial Blocker Alpe Adria, Bled 2011

Alpe Adria, Bled 2011

Bronchial blocker ☺ tracheal tube ≥ 7,5 mm ID → intraluminal position of BB ☺ for smaller tubes → through glottis beside TT ☺ lung/selective lobar blockade ☺ no cuff tears ☺ easy to use? Alpe Adria, Bled 2011

Bronchial blocker ☹ easy dislodged →what if blood/pus/VATS?! ☹ bronchoscopy ☹ slow deflation/incomplete collaps (VATS) ☹ less suction of non-ventilated lung ☹ no air application to non-ventilated lung Alpe Adria, Bled 2011

Indications for BB difficult airway tracheostomy nasotracheal intubation no need for tube exchange pediatric use Alpe Adria, Bled 2011

Recommendations for BB non-pulmonary procedures open thoracotomy prefer for left lung blockade position the deflated BB when supine as distal as possible in the main bronchus Alpe Adria, Bled 2011

DIFFICULT AIRWAY Alpe Adria, Bled 2011

Campos JH, Curr Opin Anaesthesiol 2010; 23:12-17. Alpe Adria, Bled 2011

Failed laryngoscopy Glidescope WuScope Air Craft Bullard laryngoscope Bonfils fiberscope … SPECIAL TECHNIQUES REQUIRE PRACTISE ! Alpe Adria, Bled 2011

Airway exchange catheter (AEC) ≥ 70 cm long/ 12 or 14 Fr Gum bougie/Aintree/Frova compatible with bronchial lumen of DLT lubricate AEC anesthetised patient glottis expossure as much as possible Alpe Adria, Bled 2011

FOB and single lumen tube Awake intubation FOB and single lumen tube ↓ General anesthesia ↓ ↓ BB AEC OLV ← DLT Alpe Adria, Bled 2011

“Difficult” tubes Alpe Adria, Bled 2011

Conclusion First secure the airway! Protect the patient! Surgical preference alone is not enough to jeopardize the patient. Alpe Adria, Bled 2011