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

2. 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

3. 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

4. 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

5. 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

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

7. 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

8. 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

9. 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

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

11. Placement technique
Alpe Adria, Bled 2011

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

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

14. 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

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

16. Arndt Endobronchial Blocker
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17. Alpe Adria, Bled 2011

18. 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

19. 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

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

21. 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

22. DIFFICULT AIRWAY
Alpe Adria, Bled 2011

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

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

25. 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

26. FOB and single lumen tube
Awake intubation
FOB and single lumen tube ↓
General anesthesia
↓ ↓
BB AEC
OLV ← DLT
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27. “Difficult” tubes
Alpe Adria, Bled 2011

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