Use of the Arndt wire-guided endobronchial blocker via nasal for one-lung ventilation in patient with anticipated restricted mouth opening for esophagectomy.
ABSTRACT Functional separation of the lungs may be accomplished by several methods. Patient with restricted mouth opening has limited options for one-lung ventilation. We report the use of wire-guided endobronchial blockade, a new tool for achieving one-lung ventilation in a patient with restricted mouth opening requiring nasotracheal, fiberoptic intubation for esophagectomy and reconstruction with gastric tube substitution.
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ABSTRACT: Difficulty in managing the airway is the single most important cause of major anesthesia-related morbidity and mortality. Successful management of a difficult airway begins with recognizing the potential problem. All patients should be examined for their ability to open their mouth widely and for the structures visible upon mouth opening, the size of the mandibular space, and ability to assume the sniff position. If there is a good possibility that intubation and/or ventilation by mask will be difficult, then the airway should be secured while the patient is still awake. In order for an awake intubation to be successful, it is absolutely essential that the patient be properly prepared; otherwise, the anesthesiologist will simply fulfill a self-defeating prophecy. Once the patient is properly prepared, it is likely that any one of a number of intubation techniques will be successful. If the patient is already anesthetized and/or paralyzed and intubation is found to be difficult, many repeated attempts at intubation should be avoided because progressive development of laryngeal edema and hemorrhage will develop and the ability to ventilate the lungs via mask consequently may be lost. After several attempts at intubation, it may be best to awaken the patient, do a semielective tracheostomy, or proceed with the case using mask ventilation. In the event that the ability to ventilate via mask is lost and the patient's lungs still cannot be ventilated, TTJV should be instituted immediately. Tracheal extubation of a patient with a difficult airway over a jet stylet permits a controlled, gradual, and reversible (in that ventilation and reintubation is possible at any time) withdrawal from the airway. Significant advances in the management of the difficult airway have occurred in recent years. Eighty percent of the 127 references in this article were published after 1985. However, there is much more to learn with regard to recognition of the difficult airway, preparation of the patient for an awake intubation, new techniques of endotracheal intubation, and establishment of gas exchange in patients who cannot be intubated or ventilated by mask. As the anesthesiologist's ability to manage the difficult airway significantly improves, respiratory-related morbidity and mortality will decrease.Anesthesiology 01/1992; 75(6):1087-110. · 5.16 Impact Factor
- Anesthesiology 06/1999; 90(5):1484-6. · 5.16 Impact Factor
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ABSTRACT: One-lung ventilation utilizing a double-lumen endotracheal tube may be technically difficult or inappropriate in morbidly obese or critically ill patients. In patients requiring awake fiberoptic intubation, double-lumen tube placement may be impossible. Wire-guided endobronchial blockade through a conventional endotracheal tube is a new alternative for these patients. A 44-year-old, 133 kg female patient was scheduled to undergo a thoracotomy for transthoracic fundoplication. A wire-guided endobronchial blocker (WEB) was placed following rapid-sequence induction and intubation with an 8.0 OD single-lumen endotracheal tube with the aid of a pediatric bronchoscope. The WEB, using a guiding loop, was placed with ease and allowed effective one-lung ventilation. The WEB system allows one-lung ventilation to be achieved with a conventional endotracheal tube. The need for reintubation at the end of surgery is eliminated and endotracheal tube cross-sectional area is conserved.Acta Anaesthesiologica Scandinavica 04/1999; 43(3):356-8. · 2.36 Impact Factor
Use of the Arndt wire-guided endobronchial blocker via nasal
for one-lung ventilation in patient with anticipated restricted
mouth opening for esophagectomy
Chee-Yueh Angie Ho*, Chun-Yu Chen, Min-Wen Yang, Hung-Ping Liu
Department of Anesthesia, Chang Gung Memorial Hospital, 5, Fu-shin Street, Kweishan, Taoyuan 333, Taiwan, ROC
Received 19 October 2004; received in revised form 10 March 2005; accepted 11 March 2005; Available online 18 April 2005
Functional separation of the lungs may be accomplished by several methods. Patient with restricted mouth opening has limited options for
one-lung ventilation. We report the use of wire-guided endobronchial blockade, a new tool for achieving one-lung ventilation in a patient with
restricted mouth opening requiring nasotracheal, fiberoptic intubation for esophagectomy and reconstruction with gastric tube substitution.
Q 2005 Elsevier B.V. All rights reserved.
Keywords: Wire-guided endobronchial blockade; Restricted mouth opening; One-lung ventilation
One-lung ventilation is a commonly used technique to
facilitate surgical visualization during thoracic surgical
procedures. In some circumstances, lung isolation is
mandatory; it may be difficult to achieve in restricted
mouth opening or critically ill patients. These anticipated
difficult endotracheal intubation complicated one-lung
ventilation. We report the successful one-lung ventilation
in restricted mouth opening patient by using the new
2. Case report
A 65-year-old man was scheduled for esophagectomy and
reconstruction with gastric tube substitution because of
esophageal cancer. Four years ago, he suffered from left
buccal cancer and received radical neck dissection, free flap
reconstruction following marginal mandibulectomy. Post-
operative radiotherapy was completed. After radiotherapy,
trismus was noted with limited neck movement and mouth
opening of only 0.5 cm. All preoperative laboratory values,
In the operating room, routine monitors and a radial
arterial catheter were placed. Anesthesia and relaxation
were induced with fentanyl 150 mg, propofol 100 mg
and rocuronium 40 mg. A flexible fiberoptic bronchoscope
was (FOB) used as a guide to pass a conventional endo-
tracheal tube (inner diameter, 7.0 mm) through the right
nostril into the tracheal. An Arndt wire-guided endobron-
chial blocker (WEB) (Arndt Endobronchial-Blocker Set, Cook,
Inc., Bloomington, IN) was placed coaxially through the nasal
endotracheal tube using a pediatric bronchoscope and a
special bronchoscopy port. The special bronchoscopy port
offers multiple access ports. The proximal end of the
endotracheal tube was attached to a multiport adapter
that allow simultaneous introduction of the bronchoscope
and the endobronchial blocker while maintaining ventilation
of the lungs. The endobronchial port (WEB blocker port),
which is oriented at 308 to the bronchoscopy port, has a
Tuohy–Borst type valve that locks the blocker in place and
maintain an airtight seal. Prior to placement WEB, the
elliptical balloon of the blocker must be deflated. By using
fiberoptic guidance, the blocker was advanced until it could
be seen below single-lumen tube, and then twirled the
fingertips until the distal tip entered the right main
bronchus. The elliptical balloon of the blocker was inflated
under direct visualization and the FOB withdrawal. Lung
separation was accomplished without difficulty with
inflation of the blocker balloon. A right thoracotomy was
performed. The airway pressure under one-lung ventilation
was up to 31 cmH2O, and no desaturation was noted through
the whole procedure. The surgical procedure proceeded
uneventfully with good visualization of the operative field.
After completion of surgery, the blocker balloon was
European Journal of Cardio-thoracic Surgery 28 (2005) 174–175
1010-7940/$ - see front matter Q 2005 Elsevier B.V. All rights reserved.
*Corresponding author. Tel.: C886 3 328 1200 2389; fax: C886 3 328 1200
E-mail address: firstname.lastname@example.org (C.-Y. Angie Ho).
deflated and the WEB was removed. Right lung was
reexpanded and the trachea was extubated after obtaining
sufficient spontaneous ventilation.
Selective ventilation of one-lung ventilation has been
accomplished by several methods [1,2]. Tracheal intubation
of patients with restricted mouth opening may be difficult
and challenging because the maximum mouth opening
cannot be increased, even by administering neuromuscular
blocking drugs . Fiberoptic intubation remains a rec-
ommended technique for airway management . Nasal
intubation may be advantageous for this purpose and easier
to place, especially in patients with difficult airway [4,5].
This patient’s restricted mouth opening has limited option
for one-lung ventilation. The larger outer diameter and
distal curvature of the double-lumen tube would have made
nasal intubation difficult, if not impossible. Nasotracheal
intubation and one-lung ventilation using a Univent tube has
been previously reported . However, Univent placement
may be traumatic because of the larger outer diameter of
these tubes . The short length of a conventional single-
lumen tube also prohibits endobronchial intubation via nasal
route. The Fogarty occlusion embolectomy catheter as a
bronchial blockade to achieve lung isolation has been
described , but it also has several disadvantages .
Placement may be difficult, as it is lack of guide-wire device,
lack of communication channel in the center, therefore
suction or oxygen insufflation is not possible. An air leak from
the breathing circuit can be a common problem, especially
when the Fogarty tube is placed inside single-lumen
We describe a patient with anticipated anatomical
constraint of mouth opening, which disallowed the passage
of the double-lumen tube or Univent. The Arndt WEB and the
special bronchoscopy port have been proved to overcome
many of the pitfalls of current endobronchial blocker
technology. Selective WEB through a conventional endo-
tracheal tube has been described in many literatures as a
new alternative method to achieve one-lung ventilation in
morbidly obese or critically ill patient [9,10]. Advantage of
the Arndt device is the airway adaptor that contains ports for
anesthesia circuit, the bronchoscope, the bronchial blocker
as well as attachment to the endotracheal tube. Ventilation
is easily maintained during placement of the blocker.
Removal of the wire following placement provides a central
channel that allow some degree of suctioning through the
channel to deflate the operative lung and improve surgical
visualization. The bronchial blocker port has a self-sealing
diaphragm that can be tightened down around the bronchial
blocker to hold it in place, thereby preventing movement of
the blocker and its potential dislodgement from the desired
site. Because the Arndt blocker requires a single-lumen
endotracheal tube, it maximizes the cross-sectional diam-
eter, and eliminates the need for tube exchange if
mechanical ventilation is contemplated in the postoperative
The Arndt wire-guided endobronchial blocker system
offers a new tool to achieve one-lung ventilation in adults.
It offers the clinician alternative for managing one-lung
ventilation in a challenging patient who required nasal
intubation because of severe restricted mouth opening.
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C.-Y. Angie Ho et al. / European Journal of Cardio-thoracic Surgery 28 (2005) 174–175 175