One lung ventilation

 

Indications for lung isolation:

Exposure

·     Lungs

·     Mediastinum

Distribution

·     Unilateral lung pathology (if life-threatening hypoxia)

·     Unilateral airway damage

·     Unilateral fistula

·     Unilateral cyst

Contamination

·     Pus

·     Blood

·     Lavage (sort of)

 

Ways to achieve lung isolation:

(Left) DLETT

·     Default in adults

·     Faster and more complete collapse

·     Can CPAP the isolated lung

·     Can do normal ETT -> exchange catheter -> DLETT if difficult airway

Right DLETT

·     Left main bronchus surgery

o   Pneumonectomy

o   Transplant

·     Left main bronchus pathology

o   Tumour

o   Trauma

·     Left-sided anything (controversial)

o   Gravity will push it in (better) rather than pull it out (worse)

o   Surgical manipulation less likely to displace it

o   Not that hard to position with a flexible bronchoscope

Bronchial blocker

·     Critically ill patient already intubated

·     RSI + OLV

·     Difficult airway

·     Nasotracheal intubation

·     Selective lobar ventilation

·     Size 8 ETT goes with size 9 Arndt BB

Univent ETT

·     Similar to bronchial blocker

ETT in too far

·     Only option in very small children

 

DLT vs SLT + bronchial blocker:

DLT pros:

SLT + bronchial blocker pros:

Less fiddly isolation

Easier intubation

Complete isolation

Smaller

Complete collapse

Less traumatic

Can CPAP operative lung

 

 

Double lumen ETT:

Device

·     L vs R: designates the location of the bronchial tip

·     Size: 37Fr woman, 39Fr man (N.B. outer, not inner diameter)

·     Equivalent: 9.0 -> 37Fr, 9.5 -> 39Fr, 10.0 -> 41Fr (!)

·     Depth: 29cm for 175cm; ±1cm per 10cm increment

·     Lumens: blue is for bronchial, white for trachea. Half circles.

·     Cuffs: bronchial 3mL, tracheal not sure
N.B. right bronchial cuff is eccentric to allow RUL ventilation

Insertion (left)

·     Macintosh-shaped blade to see in a straight line

·     Hold with tip pointing anterior, top end pointing right

·     Insert tip through the glottis

·     Push a bit past the resistance

·     Remove stylet

·     Push and rotate 90° left at the same time

·     Stop at next resistance

·     Inflate tracheal cuff

Confirmation

1.Capnography (!)

2.Flexible bronchoscope:

·     Go down tracheal lumen

·     Check depth: a) trachealis b) carina c) RUL bronchus (3 holes)

·     Check bronchial cuff position: just inside the left main

·     Inflate bronchial cuff: ~3mL

3.Blind technique:

·     Ventilate both lungs: look + listen

·     Ventilate one lung: look + listen

 

Arndt bronchial blocker:

Device

·     Size: BB 9Fr -> 7.5 ETT, BB 7Fr -> 6.0 ETT, BB 5Fr -> 4.5 ETT

·     Adaptor: bronchoscope vertical, BB diagonal, circuit horizontal

·     Preparation: insert scope and BB into adaptor, tighten lasso

Insertion

·     Prepare equipment

·     Pre-oxygenation

·     Induction

·     Intubation

·     Connect adaptor

·     Pass bronchial blocker

·     Inflate balloon

·     Release lasso

·     Tighten adaptor around BB catheter

Confirmation

·     ETT: capnography

·     BB: look + listen + bronchoscope

 

EZ-blocker

Device

·     Size: BB 7Fr -> ? ETT

·     Adaptor: bronchoscope vertical, BB diagonal, circuit right angle

Insertion (left)

·     Prepare equipment

·     Pre-oxygenation

·     Induction

·     Intubation

·     Connect adaptor

·     Connect circuit, pass BB, pass bronchoscope

·     Wedge BB at carina

·     Inflate balloon

·     Retract bronchoscope

·     Tighten adaptor around BB catheter

Confirmation

·     ETT: capnography

·     BB: look + listen + bronchoscope

 

 

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