One Lung VentilationFinal FRCA Teaching

UHCW

9th October 2019

Double Lumen Tube

• Double lumen tubes (DLTs) are specialized tubes which allow isolation of a lung and single lung ventilation.

• DLTs are most commonly used to facilitate thoracic surgery, but may also be used on intensive care. There are a number of absolute and relative indications for one lung ventilation; note that the majority of surgery is possible, though more difficult, using two lung ventilation.

DLT -Features

DLT - Indications

Absolute indications

• To protect the good lung from contralateral pathology:• massive haemorrhage

• pus (i.e. empyema or abscess).

• To allow ventilation in the presence of a major air leak:• bronchopleural fistulae

• Tracheobronchial trauma surgery to the major airways (e.g. bronchial sleeve resection).

• Whole lung lavage (as a treatment for pulmonary alveolar proteinosis).

DLT – Relative Indications

Relative indications

• To facilitate surgery:• video assisted thoracoscopy (VATS); this is often stated to be an absolute indication,

but in some circumstances can be carried out with a single lumen tube.

• pneumonectomy

• lobectomy

• thoracic aortic aneurysm

• oesophagectomy

• spinal surgery

• Split lung ventilation on intensive care (in a patient with a single diseased lung, ventilation of each lung at different pressures may be useful).

DLT – Questions

1. What type (i.e. side) of DLT is needed?

• Surgery involving the left main bronchus• Left pneumonectomy

• Left lung transplant

• Left tracheobronchial disruption

• Left sided thoracoscopic surgery

• Distorted anatomy of left main bronchus• Aneurysm of descending thoracic aorta

• Tumour compression of left main bronchus

DLT - Questions

2. What size DLT do we choose?

• Available in 35, 37, 39, 41 Fr

• Fr = French scale (external diameter of the tracheal segment (mm) multiplied by three

DLT - Questions

3. How is the DLT inserted?

• Check the integrity of the tracheal and bronchial cuffs.

• Lubricate the outside of the DLT.

• Lubricate and insert an intubating stylet (usually provided in the pack) into the endobronchial lumen before insertion.

• The stylet can be preshaped to aid placement of the DLT.

• Perform direct laryngoscopy and visualize the glottis.

• Advance the DLT till the endobrochial cuff has passed beyond the vocal cords and then remove the stylet.

• Rotate the DLT 90 clockwise or anticlockwise (depending on the side of DLT placement).

• Pass the tracheal cuff beyond the glottis until resistance is encountered.

• The depth of insertion of the DLT correlates to the height of an average sized patient and is given by the formula 12 + (patient height)/10 cm, measured at the teeth

DLT - Questions

4. How is successful positioning of the DLT confirmed?

Sequential clamping and auscultation: the ‘three-step’ method

• Step 1: Inflate the tracheal cuff with the minimal volume to seal glottic air leak. Perform positive pressure ventilation and auscultate to confirm bilateral air entry. Obtain an acceptable capnography trace.

• Step 2: Clamp the tracheal limb of the breathing circuit connector and disconnect this from the tracheal lumen of the DLT. Inflate the bronchial cuff with 1e3 ml and ventilate through the bronchial lumen. Auscultate to confirm unilateral ventilation and no audible air leak.

• Step 3: Release the tracheal lumen clamp and close the port. Auscultate to confirm resumption of bilateral air entry.

A bronchial blocker is a balloon-tipped catheter used to isolate a lung or lobe.

Bronchial Blockers - Uses

• Used to isolate a lung, or portion of lung in situations in which a double lumen endobronchial tube (DLT) is contra-indicated or difficult to insert.

• An alternate technique to achieve lung isolation involves the use of bronchial blockers to occlude the main-stem bronchus, thereby preventing ventilation distal to the occlusion. In addition, bronchial blockers can be used to provide selective lobar collapse as well.

Bronchial Blockers - Tips

• Collapse of the right upper lobe can be difficult due to the proximal take off of the right upper lobe bronchus, which is easily occluded by the bronchial cuff. BBs are placed either intraluminal within a SLT (i.e. coaxial) or placed separately adjacent and outside the SLT (i.e. independent). In general, they are more prone to movement and displacement than DLTs.

• Some of the currently available BBs are:

• Torque control blocker uninvent

• Arndt wire-guided endobrochial blocker

• Cohen tip-deflecting endobronchial blocker

• Fuji Uniblocker

• Rusch Bifid EZ-blocker

Hypoxia

Hypoxaemia

Hypoxaemia during any anaesthetic is an emergency situation. Alert the theatre team, request help, conduct simultaneous assessment and management of the patient following an ABC approach.

Hypoxaemia during OLV

• Hypoxic Pulmonary Vasoconstriction

• What is your lower limit threshold?

• 100% O2 (beware Bleomycin)

• Recheck DLT position

• Ensure cardiac output is acceptable

• Perform recruitment manoeuvres to ventilated lung

• Adjust PEEP

• Insufflate oxygen to non-ventilated lung (consider PEEP)

• Intermittent reinflation of the non-ventilated lung (HPV)

• Surgical restriction of blood flow to non-ventilated lung

• Resume 2 lung ventilation

PRESSURE GENERATOR VENTILATOR

MANUJETIII

Low Frequency Jet

Ventilation

Laryngoscopy or Bronchoscopy

Needle cricothyroidotomy

Measurement

Oxygen: 80-90% CO2: Inability to measure

Pressure: As per the pressure gauge

Indications

Emergency: CICO

Elective:

Airway

Thoracic Surgery

Non-dependent lung: Improves

oxygenation & CO2

removal

Complications

Barotrauma:

Pneumothorax

Pneumomediastinum

Pneumopericardium

Pneumoperitoneum

Subcutaneous emphysema

Malposition of catheters:

Gastric distension

Gastric rupture

Miscellaneous

Dysrhythmias

Necrotizing tracheo-bronchitis

Increased incidence necrotizing enterocolitis in neonates

Inadequate gas exchange (hypoxaemia, hypercapnia) in patients with severe lung pathology, predominantly restrictive pulmopathy

Summary

◦ High pressure jet ventilator

◦ Indicated for emergency and elective use

◦ Large list of complications if used incorrectly

◦ Inability to monitor oxygen delivery and CO2

clearance