Session 24. Lung Isolation (Double Lumen and Bronchial Blockers) Flashcards
trachea
anterior: C shaped rings
posterior: smooth muscle (trachealis)
right lung
3 lobes
upper
middle
lower
left lung
2 lobes
upper
lower
which lung is larger
right
lung lobes
are further divided
right bronchus length
1-2.5cm
left bronchus length
5cm
left bronchus vs right bronchus angle
left is more acute than right
(more horizontal than right)
left bronchus vs right bronchus diamter
right typically larger diameter than left
right upper lobe takeoff
short
can occur above carina at level of trachea
right upper lobe takeoff can cause
easy occlusion
difficult to visualize
what indicates a right upper lobe short takeoff
mercedes sign
lung isolation indications: pt condition
infection
bleeding
bronchopleura fistula
cyst
hypoxia due to unilateral lung process
what can a bronchopleural fistual cause
decreased negative pressure
lung isolation indications: procedures
thoracic aortic aneurysm repair
lung resection
thoroscopy
esophageal surgery
single side pulmonary transplant
rib fixation
thoracic spine surgery anterior approach
lung isolation contraindications
none
what should you be mindful of during lung isolation
dont palce left DLT if left bronchus lesions (etc)
lung isolation issues
similar to laryngoscopy
left double lumen tube
std for lung isolation
goes into left bronchus
right double lumen tube
not common
oblique bronchial cuff (allows RUL ventilation)
not interchangeable with left DLT
double lumen sizing
35-41Fr
most common: 37-39Fr
female: 37
male: 39
right double lumen tube indications
left bronchus lesions/stenosis
surgery involving high up on left bronchus
types of right double lumen tubes
mallinckrodt: oblique
protex: bean
sheridan: 2 cuffs
rusch: oblique
tracheal lumen
clear
10ml syringe
bronchial lumen
blue
3ml syringe
stylet is placed in what lumen
bronchial (blue) lumen
compressible adapter (DLT)
allows for clamping (Isolation)
allows for bronchoscopy
y piece (DLT)
connects lumens to circuit
bronchial: left
tracheal: right
where can you get a tube clamp for DLT
ask scrub tech
kids (8+) DLT size
26Fr
peds DLT
typically not used
isolate w/regular ETT mainstem
women DLT size
37Fr
men DLT size
39Fr
where do you lubricate DLT
base of cuffs
why is pre-ox important prior to DLT insertion?
extra pre-ox needed bc pts have lung pathology
pts more susceptible to apnea
DLT insertion typically involves longer apneic period
when do you remove stylet from DLT
once bronchial tip past cords
what can happen if you fail to remove sylet from DLT
trachea perforation
how do you get bronchial cuff into left bronchus?
exaggerated counter clockwise rotation (90-180 deg) of tube towards pts left
typical DLT insertion depth
28-31cm
(dont rely on this)
how do you verify DLT placement?
bronchoscope down tracheal lumen
what should you avoid when inflating bronchial cuff?
avoid herniating over carina
what should you hear when you clamp the tracheal lumen on a Left DLT?
left side breath sounds
(left is bronchia lumen
right is tracheal)
what should you hear when you clamp the bronchial lumen on right DLT?
left side breath sounds
(right is bronchial
left is tracheal)
what can happen if DLT moves a few milimeters?
can have a leak
risk loss of lung isolation
Left DLT is placed
bronchial lumen is clamped
you hear breath sounds on left
what does this tell you?
bronchial: left
tracheal: right
if i clamp the bronchial, i should hear breath sounds on the right
I am hearing breath sounds of the left because the DLT has been placed too deep.
- tracheal cuff is in the bronchus
- bronchial cuff is in a lobe
Left DLT is placed
bronchial lumen is clamped
you do not hear breath sounds on the left
clamp tracheal to isolate right lung
surgeon says that right lung is inflating
what does this tell you?
bronchial: left
tracheal; right
if i clamp the bronchial, i should not hear breath sounds on the left.
I am not hearing breath sounds on the left because the tracheal cuff is in the correct spot
My right lung is still inflating because the bronchial cuff is in the wrong bronchus.
bronchial blocker types
cohen
EZ
arndt
uniblocker
cohen blocker
wire w/wheel
ez blocker
2 cuffs
one on either side of carina
arndt blocker
wire loop that grabs bronchoscope
uniblocker
not commonly used
bronchial blocker adapter ports
ETT
circuit
blocker
bronchoscope
bronchial blocker adapter is essential for
simultaneous:
ventilation
securing blocker
bronchoscopy
which blockers have murphy eyes
cohen
arndt
what sixe ETT are needed to use bronchial blockers?
larger size
(8.0+)
what FiO2 is required when placing bronchial blocker
100% FiO2
most common bronchial blocker
EZ blocker
EZ blocker cuff syringe
10mL
risk of right bronchial blocker
air trapped in right upper lobe
what are bronchial blockers great at?
lobe isolation
confirmation of blocker placement
bronchoscopy
auscultation
direct visualization via VAT or thorocotomy
gold std for bronchial blocker confirmation
VAT
thorocotomy
what is suction used for in bronchial blockers?
helps deflate lung
why do you increase insufflation pressure during bronchial lung isolation?
presses down on lung
increase pressure in thorax causes
decreased CVP
decreased preload
decreased CO
increased HR
how do you compensate for decreased CVP?
give fluids
why should you avoid placing catheters into lung?
surgeon could staple through it
hypoxic pulmonary vasoconstriction
blood shunted from hypoxic alvoli to the ones exposed to O2
(isolates the lung)
volatile agent impact on HPV
decrease
minimal impacts <1MAC
tidal volume for lung isolation
3ml/kg
allows HPV to occur
increased RR can cause
air trapping
how to prevent air trapping
increase I:E ratio
what happens with a higher tidal volume in lung isolation
incr PIP
incr PEEP
compress vessels (incr Resistance)
decr BF
decr O2 capacity/exhange
incr hypoxia
lung isolation fluid management
keep dry (<3L in 24 hrs)
ignore 3rd space losses
use inotropes to manage hemodynamics
increased fluids causes
increased shunting
depended pulmonary edema
decreased O2/CO2 diffusion
N2O in lung isolation cases
no benefit
causes atelectasis
incr pulm artery pressures
inhibits hPV
N2O contraindicated in pts
w/blebs or blullae
hypothermia and HPV
inhibits HPV
why do you use 100% FiO2 in lung isolation
it induces atelectasis on operative side
(deflates lung being worked on)
hypoxia level in lung isolation
> 90% SpO2
PaO2 >60mmHg
(no actual low level - some pts can tolerate lower levels)
why should you maintain 70-80% FiO2 in lung isolation
gives quick method to increase O2 delivery while you fix the issue
HPV and CO2
HPV more effective in respiratory acidosis
HPV less effective in respiratory alkalosis
(CO2 is acidic - keep pt slightly higher on CO2)
Lung isolation ventilation management
- ensure 100% FiO2
- check DLT/blocker positiion
- ensure optimal CO
decrease VA <1MAC - apply recruitment maneuver to ventilated lung
- apply PEEP 5cmH2O to vent. lung
- apply CPAP 1-2cmH2O to nonvent lung
- intermittent reinflaction of non-vent lung
- partial vent techniques of non-vent lung
- mech restriction of blood flow to non-vent ung
what pts should you not apply PEEP to?
COPD/emphysema pts
partial ventilation techniques of non-vent lung
o2 insufflation
high-freq ventilation
lobar collapse vs entire lung collapse
