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

2. 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 ?

3. 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)

4. 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

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

6. 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”

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

9. 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

10. 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

11. 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.

12. 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)

13. Coopdech
Arndt with Multiport Adaptor
EZ Blocker

14. 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:
…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.

15. 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:

16. Difficult airway and one lung ventilation
Algorithms? Recommendations?
Guidelines?
ASA (
EAMS ( ?
DAS ( ?

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

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

19. 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

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

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

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

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

24. Bronchoscopy

25. 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 /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:

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

27. 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......

28. HVALA, THANK YOU, ….