Campos JH, Hallam EA, Van Natta T, Kernstine KH. Devices for lung isolation used by anesthesiologists with limited thoracic experience: comparison of double-lumen endotracheal tube, Univent torque control blocker, and Arndt wire-guided endobronchial blocker
Lung isolation is accomplished with a double-lumen tube or a bronchial blocker. Previous studies comparing lung isolation methods were performed by experienced anesthesiologists in thoracic anesthesia. Therefore, the results of these studies may not be relevant to the anesthesiologist with limited experience. This study compared the success rates of lung isolation devices among anesthesiologists with limited experience in thoracic anesthesia.
A prospective, randomized trial was designed to determine the success and time required for proper placement of the left-sided double-lumen tube (n = 22), the Univent tube (Vitaid Ltd., Lewiston, NY; n = 22), and the Arndt Blocker (Cook Critical Care, Bloomington, IN; n = 22). Anesthesiologists with less than two lung isolation cases per month were included (faculty n = 17 and senior residents n = 11). Variables recorded included (1) successful placement (as determined by an independent observer), (2) time of placement, and (3) the number of times the fiberoptic bronchoscope was used.
Participants failed to place or position their assigned device in 25 of 66 patients (failure was 39% among faculty and 36% among senior residents). The failure rate did not differ among the three devices (P = 0.65). The median (25th-75th percentile) times to complete the placement procedures were as follows: (1) double-lumen tube: 6.1 min (4.6-9.5 min), (2) Univent tube: 6.7 min (4.9-8.8 min), and (3) Arndt Blocker: 8.6 min (5.8-17.5 min) (P = 0.45 comparing all devices). After device malposition was identified, it took 1 min or less for the investigating anesthesiologist to achieve optimal position.
Anesthesiologists with limited experience in thoracic anesthesia frequently fail to successfully place lung isolation devices. Rapid successful device placement by an experienced anesthesiologist excluded any contribution of uniquely difficult anatomy. The nature of the malpositions suggests that the most critical factor in successful placement was the anesthesiologist's knowledge of endoscopic bronchial anatomy.
"They established intubation of one main bronchus for resection of distal tracheal and carinal tumors. Nowadays, lungseparation techniques are widely used for surgical operations on the pulmonary tree, to bypass a tracheobronchial injury site, and for protection against contralateral pulmonary secretions  . "
[Show abstract][Hide abstract] ABSTRACT: Paraquat is highly toxic to humans. Peak plasma levels are reached within 1 hour after intentional ingestion of this poison, followed by a rapid decline because of its distribution to the extravascular compartment and renal elimination. It induces generation of free oxygen radicals and consumption of intracellular nicotinamide adenine dinucleotide phosphate in a cyclic single-electron reduction/oxida-tion reaction; consequently, cell death occurs because of lipid peroxidation of the cell membrane. Paraquat selectively accumulates in the lungs, resulting in pulmonary fibrosis, which can eventually lead to respiratory failure in many survivors of the acute phase. It is believed that charcoal hemoperfusion is the best modality for extracorporeal elimination in the acute phase. Afterward, anti-inflammatory and immunosuppressive treatment and even lung radiotherapy have been proposed to alleviate inflammation. Unfortunately, these protocols are unsuccessful in a majority of patients. Because the first hours are critical for treatment and the lungs are the target organs, pulmonary salvage is the aim of the toxicol-ogist. Deep insertion of an endotracheal tube as the first treatment effort can produce alveolar collapse, as well as an arteriovenous pulmonary shunt in one lung. Decreased paraquat uptake, at least in one lung, leads to a reduced inflammatory process in the treated lung after the acute phase of toxicity. Furthermore, preserving a functioning lung is sufficient for life.
Tzu Chi Medical Journal 07/2015; 27(3):99-101. DOI:10.1016/j.tcmj.2015.06.002
"Periodically it is impossible to meet this goal, and anesthesiologists who do not encounter DLTs in their daily practice may anesthetize patients needing LI. Existing literature concerning lung isolation studies evaluate thoracic anesthesiologists or those who are infrequent DLT users and fail to compared infrequent users . "
[Show abstract][Hide abstract] ABSTRACT: Double lumen tubes (DLT) are commonly used to achieve lung isolation (LI). Not all anesthesiologists are frequent DLT users. Our thoracic surgical service is covered by sub-specialty anesthesiologists who are frequent DLT users. Thus, we are in a position to evaluate the performance of infrequent DLT users relative to frequent DLT users. Using statistical methods, we examined the incidence, duration and severity of hypoxia, hypercapnea and high airway pressures for patients receiving LI via DLTs placed by infrequent versus frequent users. The incidence of low SpO2, high EtCO2, or high PIP was not different between frequent and infrequent DLT users. However, when these events do occur, they are more severe (elevated EtCO2 duration, lower SpO2, higher EtCO2, higher airway pressure) among infrequent than frequent DLT users. The practical significance of these differences, which are small, is unproven. However, when episodes of hypercapnea do occur, they last much longer among infrequent than frequent DLT users.
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