Lung Isolation Techniques Tutorial

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Lung Isolation Techniques Tutorial

• Jerry Hogan CRNA, MSN Assistant Professor

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Indications for Lung Isolation

• Control of Foreign material
• Lung Abcess, Bronchiectasis, Hemoptysis
• Airway Control
• Bronthopleural-cutaneous (B-p) fistula
• Surgical exposure
• Lung resection
• Esophageal surgery or Vascular (aortic) surgery
• Video Assisted Thoracic Surgery (VATS)
• Special procedures
• Lung lavage, Differential ventilation

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Isolation Techniques

• Endobronchial Blockers
• Single-Lumen Endobronchial Tubes
• Double-Lumen Endobronchial Tubes

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Endobronchial Blockers

• First utilized in 1930s
• Indications
• Upper airway pathology
• Difficult intubation
• Laryngeal disease
• Lower airways pathology
• Prior tracheal/pulmonary surgery
• Anatomic abnormality
• Multiple surgical approaches

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Endobronchial Blockers

• Types of Bronchial blockers
• McGill catheter
• Fogerty catheter
• Foley catheter
• Univent tube

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UNIVENT TUBE
UNIVENT TUBE
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Positioning Univent Tube
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Univent Tube CPAP
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Single-Lumen Endobronchial Tubes

• Utilized for several decades
• Replaced by double-lumen tubes today
• Two versions
• MacIntosh-Leatherdale left tube
• Gordon-Green right tube
• Disadvantages
• Inability to clear material from operative lung
• Potential for limited ventilation - nonintubated
  surgical lung

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Double-Lumen Endobronchial tubes

• Used since late1940s
• Available in right- and left-sided versions
• Some use only L tube, others always intubate the
  nonoperative bronchus
• Placed with or without aid of fiberoptic
  bronchoscope (FOB)
• 39-41 Fr Men and 35-37 Fr Women

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Tube placement and position

• 1st check tube, cuffs, valves and connectors
• Laryngoscopy, curve up to larynx, stylette
  removed, rotate towards L or R bronchus, advance
  tube till resistance is felt
• Avg depth is 29cm for 170cm person
• Ventilate bilateral and unilateral, check breath
  sounds, chest rise and ETCO2

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Tube placement and position
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Tube placement and position
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Tube placement and position
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Tube placement and position
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FOB placement and position

• FOB down bronch tube, insert both in oropharnyx
  and advance FOB to carina
• Advance FOB to appropriate bronchus then advance
  bronch tube
• Inflate tracheal cuff and ventilate
• Clamp tracheal port and open vent, inflate
  broncheal cuff and ventilate bronchial tube
• Advance FOB down each tube and confirm position

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Placement Errors

• Most common error with insertion is advancement
  of DLT too far in bronchus causing only distal
  lumen ventilation of one lung

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Lung Isolation Complications

• Trauma
• Dental and soft tissue injury
• Large tube diameter causes laryngeal injury
• TracheoBronchial wall ischemia/stenosis
• Malposition
• Advancement of tube too far or too proximal
• Hypoxemia
• Aspiration

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High-frequency ventilation

• Ventilatory excursions of the lungs are of low
  amplitude
• May facilitate surgical exposure and resection
  during intrathoracic procedures
• Used successfully where airway is impaired
• Success or failure depend on following
• Type of HFV used
• Whether one-lung or two-lung ventilation is
  applied
• Type of surgical procedure

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High-frequency ventilation

• High frequency positive pressure ventilation
  60/min, sml tidal volume
• High frequency jet ventilation 100-400/min jet
  burst
• High frequency oscillation 400-4000/min

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Patient Positioning Lateral position and flexed
table

• Secure tubes and lines, take command of turning
  procedures
• Proper padding and assessment of pressure points
  essential
• Head, neck, eyes neutral position
• Padding for axilla and lower extremities
• Reassess breath sounds, vital signs, monitors,
  arterial and PA lines, IVs

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One Lung Ventilation

• Ventilation/Perfusion is altered by
• General anesthesia
• Lateral positioning
• Open chest and one lung ventilation
• Surgical manipulation
• Numerous factors affect oxygenation and
  ventilation

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One Lung Ventilation

• Oxygenation
• Amount of shunt is main component of oxygenation
• Hypoxic Pulmonary Vasoconstriction may limit
  shunting unless HPV is blunted
• Pulmonary pathology may limit shunting
• Lateral position decreases blood flow to
  NonDependent lung by gravity
• Monitor with consistant pulse oximeter and
  frequent ABGs

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One Lung Ventilation

• Ventilation
• Maintain ETCO2 as with 2-lung ventilation
• Maintain PIP below 35 cmH2O
• Maintain minute ventilation w/o causing Auto-PEEP
• Always hand-ventilate prior to switching to or
  from 2-lung and 1-lung ventilation

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One Lung Ventilationcont.

• Use large TV (10-12 ml/kg)
• Ventilation rate adjusted to avoid
  hyperventilation
• Compliance is reduced and resistance is increased
• (one lumen instead of two)
• PIPs will be higher
• Some auto PEEP may be generated, depend on size
  of DLT
• If pulse oximetry is lt94 or PO2 lt100, recheck
  DLT or BB

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O2 Management duringOne Lung Ventilation

• Decrease shunt minimize VL atelectasis
• D/C or avoid N2O prn to maintain PaO2
• Check tube position and suction, frequently
• PEEP to vented lung (may shunt blood to NVL)
• CPAP to nonventilated lung (5-8 cmH2O)
• Apneic oxygenation to NVL q 10-20 minutes
• Revent NVL w/ 100 FiO2 prn, 2-lung vent
• Have surgeon clamp NVL PA or go to Bypass

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Emergence

• Prior to closing chest - Inflate lungs to 30 cm
  H2O to reinflate atelectactic areas and to check
  for leaks
• Surgeon inserts chest tube to drain pleural
  cavity and aid lung reexpansion
• Patient is extubated in OR, or exchange DL-ETT
  for SL-ETT (HV-LP) if patient is to remain
  intubated
• Chest tubes to water seal and 20 cmH2O suction,
  except in pneumonectomy gt water seal only
• Patient transferred in head elevated position to
  ICU on monitors and nonrebreathing mask O2