An original backup technique to assess the correct positioning of right-sided double-lumen tubes without fiberoptic bronchoscopy: A pilot feasibility study.
ABSTRACT: Background:Accurate positioning of a right-sided double-lumen tube is essential but challenging due to the location and the potential obstruction of the right upper lobe bronchus. Fiberoptic bronchoscopy is, therefore, necessary but requires a specific training period for the anesthesiologist and might not always be available. Objective:We describe an original backup technique to assess the correct placement of these tubes in cases a fiberopetic bronchoscopy is lacking. Design:Prospective pilot feasibility study with 10 adult patients scheduled for a left thoracic surgery. Setting:Operating theater in a universitary hospital. Materials and Methods:The new technique uses a fluoroscopy and an adult central venous catheter wire. The time needed to perform the new technique, its success rate and its efficacy in properly exclude the left lung were evaluated. Any oxygen desaturation episode (SpO2 <90%) was considered. The technique was performed by two anesthesiologists with different experience in thoracic anesthesia. Results:The success rate of our technique was 90%, which did not depend on the anesthesiologist's experience. The range of time to successfully place the tube in the dorsal decubitus position and subsequently in the right lateral decubitus position was respectively 1 min-6 min and 1 min-15 min. None of the patients presented any desaturation episodes. Conclusions:We describe an original, safe, and acceptable backup technique to properly insert right-sided double-lumen endobronchial tubes, whenever a fiberoptic bronchoscopy is not available. Moreover, this technique is easy enough to be performed by anesthesiologists with limited experience in thoracic anesthesia.
Project description:BACKGROUND: We evaluated the ability of 3D-CT and virtual bronchoscopy to estimate trachea stenosis in comparison to conventional axial CT and fiberoptic bronchoscopy, with a view to assist thoracic surgeons in depicting the anatomical characteristics of tracheal strictures. METHODS: Spiral CT was performed in 16 patients with suspected tracheal stenoses and in 5 normal subjects. Tracheal stenoses due to an endoluminal neoplasm were detected in 13 patients, whilst post-intubation tracheal stricture was observed in the other 3 patients. Multiplanar reformatting (MPR), volume rendering techniques (VRT) and virtual endoscopy (VE) for trachea evaluation were applied and findings were compared to axial CT and fiberoptic bronchoscopy. The accuracy of the procedure in describing the localization and degree of stenosis was tested by two radiologists in a blinded controlled trial. RESULTS: The imaging modalities tested showed the same stenoses as the ones detected by flexible bronchoscopy and achieved accurate and non-invasive morphological characterization of the strictures, as well as additional information about the extraluminal extent of the disease. No statistically significant difference was observed between the bronchoscopic findings and the results of axial CT estimations (P = 1.0). No statistically significant differences were observed between bronchoscopic findings and the MPR, VRT and VE image evaluations (P = 0.705, 0.414 and 0.414 respectively). CONCLUSION: CT and computed generated images may provide a high fidelity, noninvasive and reproducible evaluation of the trachea compared to bronchoscopy. They may play a role in assessment of airway patency distal to high-grade stenoses, and represent a reliable alternative method for patients not amenable to conventional bronchoscopy.
Project description:Placing a double-lumen endobronchial tube (DLT) in an appropriate position to facilitate lung isolation is essential for thoracic procedures. The novel ANKOR DLT is a DLT developed with three cuffs with a newly added carinal cuff designed to prevent further advancement by being blocked by the carina when the cuff is inflated. In this prospective study, the direction and depth of initial placement of ANKOR DLT were compared with those of conventional DLT. Patients undergoing thoracic surgery (n = 190) with one-lung ventilation (OLV) were randomly allocated into either left-sided conventional DLT group (n = 95) or left-sided ANKOR DLT group (n = 95). The direction and depth of DLT position were compared via fiberoptic bronchoscopy (FOB) after endobronchial intubation between the groups. There was no significant difference in the number of right mainstem endobronchial intubations between the two groups (p = 0.468). The difference between the initial depth of DLT placement and the target depth confirmed by FOB was significantly lower in the ANKOR DLT group than in the conventional DLT group (1.8 ± 1.8 vs. 12.9 ± 9.7 mm; p < 0.001). In conclusion, the ANKOR DLT facilitated its initial positioning at the optimal depth compared to the conventional DLT.
Project description:Spontaneous pneumothorax following radiotherapy for pulmonary malignancy is an unusual clinical condition. Here, we report a case of a 78-year-old male suffering from dyspnea during radiotherapy for squamous cell lung cancer of the right main bronchus. Imaging studies and fiberoptic bronchoscopy revealed that pneumothorax was due to a bronchopleural fistula.
Project description:Central airway obstruction needs interventional pulmonology and malignant main carinal involvement is one of the most challenging scenarios requiring rigid bronchoscopic intervention under general anesthesia. However, these patients tend to be in poor condition for such interventions. A 91-year-old male patient with lung cancer accompanied by obstructive pneumonia underwent an Ultraflex self-expandable metallic stent placement in the right mainstem bronchus. The extranodal extension of the carcinoma from mediastinal lymph nodes metastases to the carina was so fast that severe stenosis of the bilateral mainstem bronchi was observed 6 weeks later accompanied by the deterioration of dyspnea. To salvage the carina, bilateral Ultraflex covered stents were placed by "side-by-side" method using fiberoptic bronchoscopy under topical anesthesia. This strategy was quite safe and the time needed for the entire procedure was within 20 min. He never experienced dyspnea thereafter and died of a cardiac sudden death 7 months after the initial stenting.
Project description:We evaluated the efficacy of an alternative technique, for insertion of the silicone laryngeal mask airway (LMA) Classic™ in 40 American Society of Anesthesiologists grade ASA I and II patients scheduled for elective surgery. In group I (Index Finger group), the LMA was inserted by the classic index finger technique and, in group T (Thumb Insertion group), the thumb insertion technique was used. Ease of insertion, fiberoptic laryngoscopic position, cuff pressures and laryngopharyngeal morbidity were assessed in both study groups. On statistical analysis, both groups were comparable in all respects. From our study it can be concluded that thumb insertion is an effective insertion technique for the LMA Classic™.
Project description:Comparison of gene and protein expression in the large airway epithelium of never and current smokers. Keywords: gene expression array-based (RNA / in situ oligonucleotide) Overall design: Large airway bronchial epithelial cells were obtained from never and current smokers by brushing the right mainstem bronchus during fiberoptic bronchoscopy.
Project description:PURPOSE:This study investigated the feasibility and efficacy of continuous noninvasive ventilation (NIV) support with 100% oxygen using a specially designed face mask, for reducing desaturation during fiberoptic bronchoscopy (FOB)-guided intubation in critically ill patients with respiratory failure. MATERIALS AND METHODS:This was a single-center prospective randomized study. All patients undergoing FOB-guided nasal tracheal intubation were randomized to bag-valve-mask ventilation or NIV for preoxygenation followed by intubation. The NIV group were intubated through a sealed hole in a specially designed face mask during continuous NIV support with 100% oxygen. Control patients were intubated with removal of the mask and no ventilatory support. RESULTS:We enrolled 106 patients, including 53 in each group. Pulse oxygen saturation (SpO2) after preoxygenation (99% (96%-100%) vs. 96% (90%-99%), p = .001) and minimum SpO2 during intubation (95% (87%-100%) vs. 83% (74%-91%), p < .01) were both significantly higher in the NIV compared with the control group. Severe hypoxemic events (SpO2 < 80%) occurred less frequently in the NIV group than in controls (7.4% vs. 37.7%, respectively; p < .01). CONCLUSIONS:Continuous NIV support during FOB-guided nasal intubation can prevent severe desaturation during intubation in critically ill patients with respiratory failure. TRIAL REGISTRATION:ClinicalTrials.gov, NCT02462668. Registered on 25 May 2015, https://www.clinicaltrials.gov/ct2/results?term=NCT02462668.
Project description:Adequate blood oxygenation and ventilation/perfusion matching should be main goal of anaesthetic and intensive care management. At present, one of the methods of improving gas exchange restricted by ventilation/perfusion mismatching is independent ventilation with two ventilators. Recently, however, a unique device has been developed, enabling ventilation of independent lungs in 1:1, 2:1, 3:1, and 5:1 proportions. The main goal of the study was to evaluate the device's utility, precision and impact on pulmonary mechanics. Secondly- to measure the gas distribution in supine and lateral decubitus position.69 patients who underwent elective thoracic surgery were eligible for the study. During general anaesthesia, after double lumen tube intubation, the aforementioned control system was placed between the anaesthetic machine and the patient. In the supine and lateral decubitus (left/right) positions, measurements of conventional and independent (1:1 proportion) ventilation were performed separately for each lung, including the following: tidal volume, peak pressure and dynamic compliance.Our results show that conventional ventilation using Robertshaw tube in the supine position directs 47% of the tidal volume to the left lung and 53% to the right lung. Furthermore, in the left lateral position, 44% is directed to the dependent lung and 56% to the non-dependent lung. In the right lateral position, 49% is directed to the dependent lung and 51% to the non-dependent lung. The control system positively affected non-dependent and dependent lung ventilation by delivering equal tidal volumes into both lungs with no adverse effects, regardless of patient's position.We report that gas distribution is uneven during conventional ventilation using Robertshaw tube in the supine and lateral decubitus positions. However, this recently released control system enables precise and safe independent ventilation in the supine and the left and right lateral decubitus positions.
Project description:There is an unmet need for a reliable method of airway management for patients in the lateral position. This prospective randomized controlled two-center study was designed to evaluate the feasibility of intubation using a flexible fiberoptic bronchoscope in the lateral position during surgery.Seventy-two patients scheduled for elective nonobstetric surgery in the lateral decubitus position requiring tracheal intubation under general anesthesia at Lishui Central Hospital of Zhejiang Province and Jiaxing First Hospital of Zhejiang Province from April 1, 2015, to September 30, 2015, were enrolled in this study. Patients were randomly assigned to the supine position group (Group S, n = 38) and the lateral position group (Group L, n = 34). Experienced anesthetists performed tracheal intubation with a fiberoptic bronchoscope after general anesthesia. The time required for intubation, intubation success rates, and hemodynamic changes was recorded. Between-group differences were assessed using the Student's t-test, Mann-Whitney U-test, or Chi-square test.The median total time to tracheal intubation was significantly longer in Group S (140.0 [135.8, 150.0] s) compared to Group L (33.0 [24.0, 38.8] s) (P < 0.01). The first-attempt intubation success rate was significantly higher in Group L (97%) compared to Group S (16%). Hemodynamic changes immediately after intubation were more exaggerated in Group S compared to Group L (P = 0.02).Endotracheal intubation with a flexible fiberoptic bronchoscope may be an effective and timesaving technique for patients in the lateral position.Chinese Clinical Trial Register, ChiCTR-IIR-16007814; http://www.chictr.org.cn/showproj.aspx?proj=13183.
Project description:The advances in thoracic procedures require optimum lung separation to provide adequate room for surgical access. This can be achieved using either a double-lumen tube (DLT) or a bronchial blocker (BB). Most thoracic anesthesiologists prefer the use of DLT. However, lung separation in patients with potential difficult airway can be achieved using either BB through a single lumen tube or placement of a DLT over a tube exchanger or a fiberoptic bronchoscope. Numerous videolaryngoscopes (VL) have been introduced offering both optical and video options to visualize the glottis. Many studies reported improved glottis visualization and easier DLT intubation in patients with normal and potential difficult airway. However, these studies have a wide diversity of outcomes, which may be attributed to the differences in their designs and the prior experience of the operators in using the different devices. In the present review, we present the main outcomes of the available publications, which have addressed the use of VL-guided DLT intubation. Currently, there is enough evidence supporting using VL for DLT intubation in patients with predicted and unanticipated difficult airway. In conclusion, the use of VL could offer an effective method of DLT placement for lung separation in patients with the potential difficult airway.