Double-lumen endotracheal tubes and bronchial blockers exhibit similar lung collapse physiology during lung isolation

Facilitating Lung Collapse for Thoracoscopic Surgery Utilizing Endobronchial Airway Occlusion Preceded by Pleurotomy and One-minute Suspension of Two-lung Ventilation

OBJECTIVES

To assess when and whether clamping the double-lumen endobronchial tube (DLT) limb of the non-ventilated lung is more conducive to a rapid and effective lung deflation than simply allowing the open limb of the DLT to communicate with the atmosphere.

DESIGN

This was a single-center, single-blind, randomized, controlled trial.

SETTING

The trial was performed in a single institutional setting.

PARTICIPANTS

The participants were 60 patients undergoing elective video-assisted thoracoscopic surgery.

INTERVENTIONS

Patients were randomized to the open-clamp airway technique (OCAT group) or control group. Patients in the control group had one-lung ventilation initiated upon being placed in the lateral decubitus position. The OCAT group had two-lung ventilation maintained until the pleural cavity was opened with the introduction of a planned thoracoscopic access port to allow the operated lung to fall away from the chest wall. Thereafter, ventilation was suspended (temporarily ceased) for 1 minute before the DLT lumen of the isolated lung was clamped. The primary outcome of the trial was the time to complete lung collapse scored as determined from video clips taken during surgery. The secondary outcomes were (1) lung collapse score at 30 minutes after pleural incision, (2) surgeon satisfaction with surgery, and (3) intraoperative hypoxemia.

MEASUREMENTS AND MAIN RESULTS

The median time to reach complete lung collapse in the OCAT group was 10 minutes (odds ratio 10.0, 95% CI 6.3-13.7), which was much shorter than that of the control group (25 minutes [odds ratio 25.0, 95% CI 13.6-36.4]). The difference in complete lung collapse at 30 minutes between the 2 groups was significant (p < 0.001). The surgeon's satisfaction with surgery was higher in the OCAT group than in the control group (8.5 ± 0.2 vs 6.8 ± 0.2; p < 0.001). There was no difference regarding intraoperative hypoxemia.

CONCLUSIONS

Suspending ventilation of both DLT limbs for 1 minute after pleural cavity opening and then clamping the DLT lumen of the isolated lung resulted in a more rapid deflation of the surgical lung. This open-clamp airway technique is an effective technique for rapid surgical lung collapse during thoracoscopic surgery.

One-lung ventilation with a bronchial blocker in thoracic patients

BACKGROUND

Lung isolation is a technique used in a multitude of surgeries to ensure single-lung ventilation with collapse of the contralateral lung, as to achieve improved access and visualization of relevant anatomical structures. Despite being accepted and having favorable outcomes, bronchial blockers (BBs) are not to this day the main device of choice among anaesthesiologists.

METHODS

In this retrospective and descriptive study, we analyzed the safety and efficacy of a BB in all types of thoracic surgeries in our centre between 2015 and 2022, excluding patients with massive hemoptysis or empyema, or who had undergone a prior pneumonectomy.

RESULTS

One hundred and thirty-four patients were intervened due to lung cancer (67.9%), respiratory disease (23.9%), and non-respiratory disease (8.2%) undergoing lung surgeries (65.7%), pleural and mediastinal surgeries (29.9%), chest wall surgeries (3.0%) and other surgeries (1.5%). In most cases, lung collapse was considered excellent (63.9%) or good (33.1%) with only 4 cases (3.0%) of poor lung collapse. More than 90% of patients did not present intraoperative or immediate postoperative complications. No statistically significant differences were found between lung collapse and the demographic, clinical or BB-related variables (p > 0.05). However, we found a significatively higher proportion of excellent lung collapses in VATS surgeries and lateral decubitus positioning, as well as a significatively less proportion of poor lung collapses (p < 0.05). Moreover, there was a significantly higher proportion of excellent lung collapses when the BB was placed in the left bronchus (p < 0.05).

CONCLUSIONS

With these results, in our experience BBs constitute an effective alternative, capable of achieving pulmonary collapse in all kinds of thoracic procedures with satisfactory safety rates due to their minimal complications.

Electronic visualized double-lumen endobronchial tube for situs inversus totalis: A case report and literature review

RATIONALE

Using an electronic visualized double-lumen endobronchial tube (E-visual DLT) allows for excellent surgical visualization during one-lung ventilation. Situs inversus totalis (SIT) is a rare autosomal recessive genetic condition wherein the bronchial and pulmonary lobar structures on the left and right sides of individuals are reversed compared to those of the general population. In the case of SIT, placing a left-sided E-visual DLT into the right bronchus might offer more advantageous one-lung ventilation. However, there have been no reported instances of using E-visual DLT single-lung ventilation anesthesia techniques for SIT.

PATIENTS CONCERNS

We present a case report detailing the effective implementation of a visualized single-lung ventilation technique under general anesthesia in a 36-year-old male diagnosed with SIT. The patient had a mediastinal mass and underwent thoracoscopic resection of the mediastinal mass using a left-sided approach.

DIAGNOSES

Based on the findings from the contrast-enhanced chest computed tomography (CT) results, the patient was diagnosed with SIT along with a mediastinal mass. Surgical intervention was proposed to alleviate the cardiac compression caused by the mass. Nevertheless, the administration and handling of anesthesia posed a notable challenge since clinical anesthesiologists encounter contradictory data and a limited number of evidence-based guidelines.

INTERVENTIONS

Convened a multidisciplinary meeting prior to the initiation of anesthesia to formulate a comprehensive strategy. Throughout the anesthetic management, our team ensured meticulous monitoring, delivered sufficient oxygenation, and established hemodynamic equilibrium. The anesthesia team deliberated and devised a plan to employ a left-sided E-visual DLT placement through the right bronchus for right-sided one-lung ventilation in the patient with SIT. The process of anesthesia induction was subjected to repeated simulations to guarantee patient safety.

OUTCOMES

Due to the meticulous and effective administration and supervision of anesthesia, the surgery was completed as planned. Subsequently, the removal of the E-visual DLT was executed without any complications.

LESSONS

Data and literature about SIT are scarce, necessitating thorough pre-planning and preparation.

Recommendations and considerations for speeding the collapse of the non-ventilated lung during single-lung ventilation in thoracoscopic surgery: a literature review

Video-assisted thoracoscopic thoracic surgery has the advantages of less physical damage, less postoperative pain, and a rapid recovery. Therefore, it is widely used in the clinic. The quality of nonventilated lung collapse is the key point of thoracoscopic surgery. Poor lung collapse on the operative side damages surgical exposure and prolongs the process of surgery. Therefore, it is important to achieve good lung collapse as soon as possible after opening the pleura. Over the past two decades, there have been reports of advances in research on the physiological mechanism of lung collapse and several kinds of techniques for speeding up lung collapse. This review will inform the advances of each technique, make recommendations for reasonable implementation and discuss their controversies and considerations.

Left-Sided Double-Lumen Tube vs EZ-Blocker for One-Lung Ventilation in Thoracic Surgery: A Systematic Review and Meta-Analysis

Background. The EZ-Blocker is the newest generation of bronchial blocker and offers a potential alternative to left-sided double lumen tubes for lung isolation and one-lung ventilation during thoracic surgery. Methods. Databases were searched for randomized controlled trials comparing left-sided double lumen tube to the EZ-Blocker for one-lung ventilation during thoracic surgery. The time for placement, incidence of intraoperative displacement, and surgeons' rating of lung collapse quality were designated as coprimary outcomes. The safety profiles of the two devices, including the incidence of airway trauma and post-extubation discomfort were also examined. Results. Six randomized controlled trials (495 patients) were analyzed. Compared to the EZ-Blocker, the left-sided double lumen tube was faster to place by a weighted mean difference of [95% CI] of -61.24 seconds [-102.48, -20.00] (P = .004) and was much less likely to become displaced during lung isolation with an odds ratio [95% CI] of .56 [.34, .91] (P = .02). The left-sided double lumen tube and the EZ-Blocker provided similar surgeon-rated quality of lung isolation. Although the left-sided double lumen tube caused a greater degree of post-extubation sore throat, there was a similar incidence of carinal trauma and post-extubation hoarseness compared to the EZ-Blocker. Conclusion. Our analysis suggests that the left-sided double lumen tube can be placed more quickly and is less prone to intraoperative displacement compared to the EZ-Blocker; the quality of lung collapse is similar. Thus, evidence appears to support the continued utilization of the left-sided double lumen tube for routine thoracic surgery requiring one-lung ventilation.

Role of Lung Ultrasound in Confirmation of Double Lumen Endotracheal Tube Placement for Thoracic Surgeries: A Prospective Diagnostic Accuracy Study

Background

In thoracic surgeries requiring thoracotomy incisions, correct positioning of the double-lumen endotracheal tube (DLT) is mandatory. After the pandemic of novel COVID-19, using simple, noninvasive technology such as lung ultrasound (LUS) can be important in avoiding the possibility of spreading infectious diseases or contagious infections that can follow using fiberoptic bronchoscopy (FOB).

Objectives

We aimed to assess the accuracy of auscultation and LUS in relation to FOB in the assessment of DLT placement and to identify the possibility of using LUS as an alternative to FOB during DLT insertion.

Methods

This diagnostic accuracy study was conducted according to STARD guidelines; enrolled 120 cases requiring DLT intubation. After DLT insertion, all patients were examined by stethoscope, then by LUS for determination of DLT position, and then confirmed by FOB in the same patient.

Results

Three patients dropped out due to failed intubation, and only 117 cases were analyzed. Time was significantly longer for LUS than for auscultation and FOB and was insignificantly different between auscultation and FOB. Auscultation had 76.14% sensitivity, 34.48% specificity, and 65.81% accuracy in the determination of correct DLT placement. LUS had 92.05% sensitivity, 79.31% specificity, and 88.89% accuracy in detecting correct DLT placement. There was substantial agreement between LUS and FOB (κ = 0.705) and poor agreement between auscultation and FOB (κ = 0.104).

Conclusions

LUS can be used as a simple, noninvasive tool for detecting DLT placement with a substantial agreement with FOB.

[Application and Research Progress of Video Double-lumen Tube in Thoracic Surgery]

The rapid development and promotion of minimally invasive thoracic surgery represented by video-assisted thoracoscopy surgery has gradually replaced traditional thoracic surgery technique as the primary choice for the treatment of pulmonary nodules, including early lung cancer. With the clinical application of double-lumen bronchial catheters, the realization of one-lung ventilation technology not only provides a solid anesthesia foundation for the popularization of minimally invasive thoracic surgery, but also provides a guarantee for the rapid and smooth implementation of the operation. However, compared with single-lumen bronchial catheters, the diameter of the double-lumen bronchial catheter is thicker, and the tube body is hard and difficult to shape, which brings inconvenience to anesthesia intubation. The bronchial structure is different, and the incidence of dislocation during anesthesia intubation is also high. With the gradual clinical use of video double-lumen tube (VDLT), it has become a hot spot in thoracic surgery in recent years. This article reviews the application and research progress of VDLT in thoracic surgery.
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Non-ventilated lung deflation during one-lung ventilation with a double-lumen endotracheal tube: a randomized-controlled trial of occluding the non-ventilated endobronchial lumen before pleural opening

PURPOSE

Lung deflation during one-lung ventilation (OLV) is thought to be faster using a double-lumen endotracheal tube (DL-ETT) than with a bronchial blocker, especially when the non-ventilated lumen is opened to allow egress of air from the operative lung. Nevertheless, ambient air can also be entrained into the non-ventilated lumen before pleural opening and subsequently delay deflation. We therefore hypothesized that occluding the non-ventilated DL-ETT lumen during OLV before pleural opening would prevent air entrainment and consequently enhance operative lung deflation during video-assisted thoracoscopic surgery (VATS).

METHODS

Thirty patients undergoing VATS using DL-ETT to allow OLV were randomized to having the lumen of the operative lung either open (control group) or occluded (intervention group) to ambient air. The primary outcome was the time to lung collapse evaluated intraoperatively by the surgeons. The T50, an index of rate of deflation, was also determined from a probabilistic model derived from intraoperative video clips presented in random order to three observers.

RESULTS

The median [interquartile range] time to lung deflation occurred faster in the intervention group than in the control group (24 [20-37] min vs 54 [48-68] min, respectively; median difference, 30 min; 95% confidence interval [CI], 14 to 46; P < 0.001). The estimated T50 was 32.6 min in the intervention group compared with 62.3 min in the control group (difference, - 29.7 min; 95% CI, - 51.1 to - 8.4; P = 0.008).

CONCLUSION

Operative lung deflation during OLV with a DL-ETT is faster when the operative lumen remains closed before pleural opening thus preventing it from entraining ambient air during the closed chest phase of OLV.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT03508050); registered 27 September 2017.