1. Dip. Software statistics PhD ( physiology), IDRA , FICA
Lung isolation
Dr. S. Parthasarathy
MD., DA., DNB,
MD (Acu), Dip. Diab.
Dip. Software statistics
PhD ( physiology), IDRA , FICA

3. Isolation of Lungs Indications - absolute
To avoid spillage in presence of
Infection
Massive haemorrhage
To control distribution of ventilation
Bronchopleural fistula
Tracheo bronchial disruption
Surgery on the airways
-- Lavage

4. Indications - Relative
To enhance surgical exposure
High priority
Pneumonectomy
Thoracoscopy
Upper lobectomy
Thoracic aneurism
Low priority
Middle and lower lobectomy
Esophageal resections
Thoracic spine surgery
Severe hypoxemia related to unilateral lung disease

5. Anatomy of Bronchial Tree

6. Techniques Endobronchial tubes Double lumen tubes (dlt)
Bronchial blockers
Endotracheal tubes with blockers

7. Endobronchial Tubes Magill Machray Green and gordon Brompton
Macintosh - leatherdale

8. Brompton Endobronchial tube
Gordon Green Endobronchial tube

9. Endobronchial Tubes Pediatric patients Urgent isolation in hemoptysis
Where we cant introduce double lumen tube
Eg. Difficult airway
Rapidity is the key advantage

10. Disadvantages Positioning Collapse full is not possible CPAP ?
Expand again ??
Suctioning ?

11. Double Lumen Tubes Reusable Disposable Carlens White Bryce smith
Bryce smith salt
Robertshaw
Disposable
Broncho cath
Portex DLT
Sheridan DLT
Rusch DLT

12. Now everything is disposable !

13. Markers , connectors colour cuffs and balloons
Double lumen tubes
DLT is essentially two single-lumen tubes bonded together and designated either as right- or left-sided, depending on which mainstem bronchus the tube is designed to fit.
35 to 41 French - 26, 28, and 32 Fr also rare
External diameter * 3
Markers , connectors colour cuffs and balloons
Internal is D shaped , so french gauge

14. Plus and minus of DLT

15. Adapters for FOL and suctioning

16. Carinal hook – sit in the carina
Carlen’s tube
Usually left sided
Massive hemoptysis
Carinal hook – sit in the carina
Carinal hooks make passage
through the glottis difficult and often injure the airway

17. Carlens and dr white counterpart

18. Portex

19. Sher I DLT –---- broncho cath
Two bronchial cuffs
Slot in between the doughnut single bronchial cuff

20. Silbroncho Flexibility and strength No tearing by teeth
No injury of the airway

22. Which side when ? Intubate the non operated bronchus !!
But -- The human airway is asymmetrical.
left bronchus is about 5.0 cm, right bronchus is less than 2.0cm long,
Many anesthesiologists prefer a left DLT for both right and left operations in order to reduce the chance of obstructing the upper lobe bronchus

23. Only right sided tube ? an intrinsic (tumor, stenosis) or
extrinsic (tumor, aortic aneurysm) obstruction of the left bronchus.
A right DLT is also used for sleeve resections of the left bronchus and during left single-lung transplants.

24. Rt pneumonectomy
Left tube
Lt pneumonectomy
Left tube
But withdraw
Lt pneumonectomy
Right tube

26. Technique of introduction
Stylet and tube well lubricated
DL scopy with macintosh
Bronchial curve anterior
Pass the vocal cords
Turn the DLT towards the side – stylet removal
Push till resistance
Use FOB after tracheal insertion

28. Double lumen Connectors and Checking

29. Common malpositions

30. Common malpositions

31. Use FOL through tracheal lumen
See the tracheal carina and the blue cuff inside bronchus
Remove FOL and put in the bronchial lumen to visualize secondary carina

34. FOL views

36. DLT – dangers Malposition – common complication
Other complications include traumatic laryngeal injury, tracheobronchial tree disruption, inadvertent suturing of the DLT to thoracic structures, and direct vocal cord injury

37. Dangers unexpected air leak, subcutaneous emphysema,
massive airway bleeding into the lumen of the DLT,
protrusion of the endotracheal or endobronchial cuffs into the surgical field

38. Total separation is possible !! – advantage

39. Bronchial blockers Fogarty’s, Foley’s Swan‑Ganz catheters,
Univent tubes
Torque Control Blocker
Univent (TCBU) blockers
Coopdech blockers,
Cohen’s tip‑deflecting blockers,
Arndt wire‑guided endobronchial blockade (WEB) blockers
EZ‑blockers.

40. When should we use ? DLT is not possible or advisable
nasal intubation,
small patient,
difficult intubation,
the patient with a tracheostomy,
subglottic stenosis,
thick and excessive secretions,
need for continued postoperative intubation.

41. Outside the tube – previously
Already on single lumen tube and getting ventilated ?
Patient on anticoagulants
Can block a segment
Can go through to other side
Outside the tube – previously
Inside the tube now

42. A lot of names

43. Craford’s Tampoon
Magill,s Blocker

44. Tips of various blockers

46. The Arndt blocker comes in various sizes.
It has a small central lumen to allow minimal insufflation and suctioning. It is to be directed by snaring the monofilament guide loop through an FOB and upon placement in the desired position, release of the snare, which is often easier said than done.

47. EZ blocker Two cuffs as Y shaped Blind insertion possible
Automatic to carina
See in FOL
Inflate whichever we want
Tracheal tube tip should be more than 4 cm from carina

48. Univent tube
The Univent tube is a Silastic SLT that has a built-in internal chamber allowing the advancement of the integrated blocker.. blocker has a small lumen along the entire length to facilitate lung deflation and limited suctioning...

49. 7. 5-mm Univent tube has an outer diameter size of 11. 2 mm versus a 7
7.5-mm Univent tube has an outer diameter size of 11.2 mm versus a 7.5-mm SLT, which has an outer diameter of 10.2 mm. Sizing aside, these tubes are very useful—
Withdraw before insertion
FOB may be difficult due to silastic tube
Not used much nowadays

51. Advantages and disadvantages !!

53. Alsharani and Eldawlatly algorithm

54. In children !
The simplest means of providing SLV is to intubate the ipsilateral main stem bronchus with a conventional single-lumen ET–
Univent tube
DLT of 26 G for 8 years
A Fogarty embolectomy catheter or an end-hole, balloon wedge catheter may be used for bronchial blockade to provide SLV.

55. Mararo tube

57. ROLE OF ULTRASONOGRAPHY IN LUNG ISOLATION
Lung sliding
Absence of lung slide
Lung pulse sign ( collapse )

58. Something has entered into your brain !!
Thank you all