A new technique for lung isolation in acute thoracic trauma

Anesthesia and the patient with pericardial disease

PURPOSE

Pericardial diseases present unique perioperative considerations for the anesthesiologist. The purpose of this review is to provide a summary of the pertinent issues related to the etiology, diagnosis, pathophysiology, and perioperative management of patients presenting for operative treatment of pericardial disease.

SOURCE

A selective search of the anesthesia, cardiology, and cardiothoracic surgical literature was carried out with particular emphasis on acute pericarditis, effusion, tamponade, and constrictive pericarditis.

PRINCIPAL FINDINGS

The anesthesiologist needs to be well versed in the etiology (i.e., differential diagnosis), pathophysiology, and diagnostic modalities in order to best prepare the patient for surgery. Diagnosis and guidance of management requires a working knowledge of the specific associated hemodynamic consequences, particularly of the impaired diastolic function that can occur. Echocardiography is essential in the diagnosis and management of these patients.

CONCLUSIONS

Patients with acute and chronic pericardial diseases often require the need for surgical intervention. Several unique features of acute tamponade and constrictive pericarditis require careful perioperative consideration. With proper preparation and pre-anesthetic optimization, patients with a variety of pericardial diseases can be safely managed before, during, and after their surgical intervention.

The Papworth BiVent tube: a new device for lung isolation

Provision of one lung ventilation can be technically challenging, particularly for anaesthetists who are only occasionally required to isolate one lung from the other. A new double lumen endotracheal tube, the Papworth BiVent Tube, has been designed to enable rapid and reliable lung isolation using any bronchus blocker without the need for fibreoptic endoscopic guidance. In this study, an airway-training manikin was used to assess ease of tracheal intubation and lung isolation using the Papworth BiVent tube. Ease of intubation was compared to a single lumen endotracheal tube and a conventional double lumen endobronchial tube. Ease of lung isolation when using a bronchus blocker was compared to a single lumen tube combined with a bronchial blocker. Tracheal intubation using the Papworth BiVent tube was found to be easier than when using a conventional double lumen endobronchial tube. Lung isolation using the Papworth BiVent tube used in combination with a bronchus blocker was achieved more reliably and rapidly than when using a single lumen tube and bronchus blocker.

Progress in lung separation

The progress in lung separation technology has allowed anesthesiologists to become skillful in fiberoptic bronchoscopy techniques and to provide excellent lung exposure in thoracic surgery patients. Given the availability of two technologies--DLTs (right-sided and left-sided) and bronchial blocker technology (TCBU, Arndt, and Cohen--every case that requires lung collapse and OLV should receive the benefit of these devices. Because of its greater margin of safety, a left-sided DLT is the more common device used in lung separation. If any contraindication to placing a left-sided DLT exists, a right-sided DLT is an option for any specific situation (eg, left lung transplantation). For a patient who requires lung separation and presents with the dilemma of a difficult or abnormal airway, bronchial blockers offer more advantages. Regardless of the device used, the optimal position of these devices (DLTs and bronchial blockers) is achieved best with the use of fiberoptic bronchoscopy techniques first in supine and then in lateral decubitus position or whenever repositioning of the device is needed.

An update on bronchial blockers during lung separation techniques in adults

Techniques for one-lung ventilation (OLV) can be accomplished in two ways: The first involves the use of a double-lumen endotracheal tube (DLT). The second involves blockade of a mainstem bronchus (bronchial blockers). Bronchial blockade technology is on the rise, and in some specific clinical situations (e.g., management of the difficult airway during OLV or selective lobar blockade) it can offer more as an alternative to achieve OLV in adults. Special emphasis on newer information for the use of Fogarty embolectomy catheter as a bronchial blocker, the torque control blocker Univent, and the wire-guided endobronchial blocker (Arndt blocker) is included. Also this review describes placement, positioning, complications, ventilation modalities, and airflow resistances of all three bronchial blockers. Finally, the bronchial blockers can be used in many cases that require OLV, taking into consideration that bronchial blockers require longer time for placement, assisted suction to expedite lung collapse, and the use of fiberoptic bronchoscopy. The current use of bronchial blockers, supported by scientific evidence, dictates that bronchial blockers should be available in any service that performs lung separation techniques.

Endotracheal tubes

A variety of different endotracheal tubes are available for distinct purposes, though the majority of patients will be well served with the standard single-lumen endotracheal tube. Specialized endotracheal tubes have been developed to aid in specific situations and novel tubes continue to be evaluated as clinicians strive for improved outcomes in various clinical conditions. Ultimately, the choice of an endotracheal tube depends on the purpose it is intended to serve.

A comparison of a left-sided Broncho-Cath with the torque control blocker univent and the wire-guided blocker

Lung isolation can be accomplished in two ways: the first, a double-lumen endotracheal tube (DLT) and the second, a bronchial blocker (Univent or Arndt blocker). Previous studies have found that the DLT and the Univent are comparable when providing lung isolation. A new bronchial blocker, the wire-guided endobronchial blocker (Arndt blocker), has been introduced. However, there is no study to report its effectiveness with lung isolation during elective thoracic surgical cases. Therefore, we designed a prospective, randomized trial to compare the effectiveness of lung isolation among the 3 endotracheal tubes: the left-sided DLT Broncho-Cath Group A (n = 16 patients), the torque control blocker Univent Group B (n = 16 patients), and the wire-guided Arndt blocker Group C (n = 32 patients). The following variables were recorded: 1) time to initially position the assigned tube, 2) frequency of malpositions, 3) frequency of use of fiberoptic bronchoscope, 4) overall surgical exposure, and 5) tube acquisition cost. The Arndt blocker took longer to place (3:34 min/s) compared with the other 2 groups: the DLT group (2:08 min/s) or the Univent group (2:38 min/s) (P < 0.0004). There was no statistical difference in tube malpositions among the three groups: two for the DLT group, four for the Univent group, and nine in the Arndt group. Excluding the time for tube placement, the Arndt group also took longer for the lung to collapse (26:02 min/s), compared with the DLT group (17:54 min/s) or Univent group (19:28 min/s) (P < 0.0060). Furthermore, unlike the other two groups, the majority of the Arndt patients required suction to achieve lung collapse. Once lung isolation was achieved, overall surgical exposure was rated excellent for the three groups. Acquisition cost for the DLT group was $1663.20 (21 tubes opened), $2329.00 for the Univent group (17 tubes opened), and $3567.00 for the Arndt group (33 wire-guided blockers opened). This study demonstrates that the Arndt blocker takes longer to position and longer to deflate the isolated lung. For elective thoracic surgical cases, once the lung was isolated, the management seemed to be similar for all three tube groups.

IMPLICATIONS

We compared the latest design of double-lumen tubes Broncho-Cath, Univent, and Arndt blockers during lung isolation. Our results show that the Arndt blocker takes longer to position and longer to deflate the isolated lung. Once the lung was isolated, the management seemed to be similar for all three devices.