David Feller-Kopman, MD, FCCP

1
Endoscopic Airway Control A Focus on
Double-Lumen Tubes and Bronchial Blockers
David Feller-Kopman, MD, FCCP Director,
Interventional Pulmonology Associate Professor of
Medicine Johns Hopkins Hospital
2
Overview

• Review indications for lung isolation
• Describe available methods
• double-lumen tubes
• single-lumen tubes with bronchial blocker
• independent bronchial blockers
• rigid bronchoscope

3
Indications for Lung Isolation

• Isolation avoid spillage / contamination
• massive hemorrhage
• infection
• Control the distribution of ventilation
• unilateral bronchopulmonary lavage
• Unilateral lung disease requiring differential
  lung ventilation / PEEP strategies

4
Indications cont.

• Surgical exposure
• pneumonectomy / lobectomy / segmentectomy /
  sleeve resections / BPF repair
• thoracoscopy
• thoracic aortic aneurysm
• transplantation
• LVRS
• pulmonary embolectomy
• esophageal resection
• procedures on the thoracic spine

5
Double-Lumen Tubes

• Most common technique
• Have high-volume, low-pressure cuffs
• Available in right or left-sided varieties
• Distal bronchial cuff and a proximal tracheal
  cuff
• bronchial cuff separates the lungs from each
  other
• tracheal cuff separates the lungs from atmosphere
• All DLTs have two curves at 90o to each other
• proximal curve for oropharyngeal curve
• distal curve to facilitate bronchial placement

6
Right vs. Left

• Main problem with right-sided DLTs is obstruction
  of the RUL
• Occasionally need a right-sided DLT
• LMSt obstruction
• LMSt sleeve resection
• tracheobronchial disruption
• anatomic distortion making LMSt intubation
  difficult
• left pneumonectomy
• surgeon / anesthesiologist dependant

7
Carlens DLT

• 1st DLT
• Carinal hook for placement and to prevent
  dislodgement
• can cause trauma
• can get fractured and migrate distally
• Cross sectional shape of each lumen is oval
• Can be difficult to pass suction catheter through
  the tube

8
Bryce-Smith tube

• Developed as a modification of Carlens tube
• no carinal hook
• Rt. Main stem bronchus cuff is slotted for RUL
• Lumens are anterior and posterior and are
  rounded in shape
• no difficulty in suction catheter passage

9
Robertshaw Tubes

• Introduced in 1962 and was made of red rubber
• No carinal hook
• D shaped lumens, lie side by side
• Now available in clear PVC
• blue bronchial tube / cuff

10
BronchoCath / Blueline
11
Size Matters
Campos, Anesth Analg 2003 97 1266
12
Choosing the Proper Sized DLT

• Best fit largest tube ? least Raw and bronchial
  seal with small cuff volume
• Too big ? airway injury
• Too small ? large cuff volume ? herniation across
  carina
• distal tube migration
• more difficult to perform bronchoscopy
• Ideally want 1 3 cc in bronchial cuff
• Women are at higher risk for airway injury
• Some authors recommend
• 41 F for men
• 37 41 F for women

Brodsky et.al., Anesth Analg 1996 82 861
13
Size Based on Airway Measurements (CT)
Measured Tracheal Width (mm) Measured Bronchial Diameter (mm) Left-sided DLT (F)
18 12 41
16 12 39
15 11 37
14 10 35
12.5 lt 10 32
11 not investigated 28

• Cricoid approximates diameter of LMSt

Campos, Anesthesiology Clin North America 2001
455
14
Placement Techniques L-DLT

• Blind rotate the tube counter-clockwise after
  both cuffs have passed the cords
• rotate head slightly contralaterally
• leaving the stylet in increases success AND
  complications
• needs bronchoscopic confirmation
• Bronchoscopic guidance insert the scope through
  the bronchial lumen after the bronchial tip has
  passed the cords
• advance the scope into the bronchus
• advance the tube over the scope
• associated with less misplacement / quicker
  placement
• controversial

Boucek et.al., J Clin Anesth 1998 10 557 Cheong
et.al., Br J Anaesthesia 1999 82 020
15
Bronchoscopic Confirmation

• Tracheal lumen
• no herniation of the bronchial balloon
• patent RMSt / RUL
• Endobronchial lumen
• tube patency
• tip proximal to the LUL / LLL carina
• Underwater seal test

16
Bronchoscopic Confirmation

• Prospective study of 200 blind DLT insertions
• 163 left-sided, 37 right-sided
• 172 clinical correct positions ? 79 bronchoscopic
  malpositions
• 93 migrations after patient repositioning
• In a report from the national confidential
  inquiry of perioperative deaths (GB) 30 were due
  to DLT malpositioning

Klein et.al., Anesthesiology 1998 88 346
17
Campos, Thorac Surg Clin 2005 15 71
18
Right-sided DLTs

• Tube has a ventilation slot for the RUL
• Requires bronchoscopic visualization
• confirm alignment of the ventilation slot and RUL
• confirm patency of the bronchus intermedius
• confirm lack of herniation of the bronchial cuff

19
Campos, Thorac Surg Clin 2005 15 71
20
Complications of DLTs

• Inability to place
• Airway injury
• glottic injury
• tracheal injury from stylet
• saber sheath trachea
• bronchial rupture from balloon
• Misplacement
• lobar atelectasis
• barotrauma / auto-PEEP
• Migration during surgery / patient rotation
• should re-confirm throughout case
• barotrauma due to distal migration of the tube ?
  full VT unilaterally
• especially with tubes that are too small

21
Right vs. Left for Left-sided Surgery

• RCT of 40 patients requiring left lung deflation
• R-DLT associated with
• longer initial tube placement (3.4 vs. 2.1 min)
• cost (1,819 vs. 1,107)
• No difference in
• incidence of malposition
• need for bronchoscopy
• time for left lung collapse

Campos et.al., Anesth Analg 2000 90 535
22
Univent Tubes

• Silicone tube with similar shape as conventional
  ETT
• Includes a movable endobronchial blocker
• Torque Control Blocker Univent contains a 2mm
  lumen for lung deflation / CPAP
• ? larger OD than comparable single-lumen ETT
• advanced into the mainstem bronchi under
  bronchoscopic visualization
• Can place in the bronchus intermedius ? patency
  of the RUL
• Easy conversion to single-lumen tube

23
(No Transcript)
24
(No Transcript)
25
Bronchial Blockers

• Fogarty catheter
• 8F most commonly used
• has wire stylet to help with placement
• can be placed within or external to the ETT
• can be used to obstruct the segmental bronchi
• Foley and PA catheters have also been used

Hiebert, Chest 1974 66 306 Jolliet et.al., Crit
Care Med 1992 20 1730
26
Blockers cont.

• 6F, 170 cm, double-lumen catheter designed to
  pass through the working channel of a flexible
  scope
• has a removable valve to inflate the cuff
• allows removal of bronchoscope
• additional inner channel

Freitag et.al., Eur Respir J 1994 7 2033
27
Blockers cont.

• Arndt endobronchial blocker
• 5, 7 or 9F, 65 78 cm catheter
• elliptical or spherical cuff
• use spherical in the RMSt
• 3-way multi-port ETT adaptor
• anesthesia circuit
• blocker port
• bronchoscopy port
• wire-loop attaches to bronchoscope and placed
  visually
• ideally used with 8mm ID ETT
• can use a 7mm ID ETT with the 7F blocker
• uses existing ETT

28
Bronchial Blocker Placement

• Lubrication !!!
• Attach multi-port adaptor
• Snare bronchoscope
• Advance scope to desired location
• Release snare and advance blocker over scope
• Inflate balloon (5 8ccs, up to 15cc)
• Can remove wire snare to allow lung deflation /
  CPAP
• cant re-insert

29
(No Transcript)
30
(No Transcript)
31
(No Transcript)
32
(No Transcript)
33
The Cohen Bronchial Blocker

• 9F, 65cm, 1.4mm inner lumen, spherical balloon
• Murphy eyes in the distal tip
• Angled tip / wheel-twisting device ? tip
  deflection
• arrow indicates direction of deflection
• Torque grip at 55cm

Campos, Thorac Surg Clin 2005 15 71
34
Comparative Studies

• Left-sided BronchoCath vs. Univent in patients
  undergoing thoracotomy
• no difference in time to position,
  bronchoscopies required or time to lung collapse
• DLT associated with reduced frequency of
  malposition and more rapid lung deflation
• Left-sided Robertshaw vs. Wiruthan bronchial
  blocker
• no difference in unsuccessful placements
• BB associated with more malpositions (LgtR)
• BBL also took longer to place

Campos et.al. Anesth Analg 1996 83 1268 Bauer
et.al., Acta Anaesthiol Scand 2001 45 250
35
Comparisons cont.

• Right-sided BronchoCath vs. Univent in patients
  undergoing thoracotomy
• no difference in time to position,
  bronchoscopies required or time to lung collapse,
  tube migrations, time until lung collapse or
  surgical exposure
• Univent more expensive
• L-BronchoCath vs. TCBU vs. Arndt
• Arndt ? longer to place (86 sec)
• and longer to collapse ( 7 min)
• no difference in tube malposition / surgical
  exposure
• DLTs more prone to cuff tears

Campos et.al., Anesth Analg 1998 86 696 Campos
et.al., Anesth Analg 2003 96 283
36
Other Notes

• Univent significantly more expensive
• Univent and blockers avoid the need to change the
  DLT to a single lumen tube
• evolution of a difficult airway (transfusion etc.)

Campos et.al., Anesth Analg 2003 96 283
37
Massive Hemoptysis

• Intubation with single-lumen ETT
• need to be more careful with RMSt intubation for
  left-sided bleeding

Lordan et.al., Thorax 2003 58 814
38
Massive Hemoptysis cont.

• DLTs
• can be VERY difficult to place
• can place suction catheters but ability to
  suction through a pediatric scope is limited
• Bronchial blockers
• through the tube or parallel to the tube
• 4 6 F can go through the working channel ?
  segmental occlusion
• cant see distally
• poor suction ? hypoxemia
• need to deflate balloon (under vision) at max of
  24h
• follow balloon pressure

Karym-Jones et.al., Chest Surg Glin NA 2001 11
783 Jean-Baptiste, Crit Care Med 2000 28
1642 Cahill, Clin Chest Med 1994 15 147
39
Massive Hemoptysis The Rigid Bronchoscope

• Gustav Killian, 1898
• Ability to
• oxygenate
• ventilate
• large bore suction
• use other therapeutic modalities

40
Summary

• Reviewed the indications for lung isolation
• Reviewed the different available therapeutic
  modalities
• double-lumen ETTs
• Univent
• bronchial blockers
• rigid bronchoscope
• Likely no right tool
• depends upon availability / expertise

41

• David Feller-Kopman, MD
• Director, Interventional Pulmonology
• Johns Hopkins Hospital
• 410-502-2533
• dfellerk_at_jhmi.edu
• www.hopkinsmedicine.org/ip