ALTERNATIVES TO DLT ’S IN ONE LUNG VENTILATION bronchial blockers, alternatives to double lumen tubes

1. ALTERNATIVES TO DLT ’S IN ONE LUNG
VENTILATION
DR. ANANYA NANDA
ASSISTANT PROFESSOR, Department Of Anaesthesiology & Critical Car
ESIC MEDICAL COLLEGE & HOSPITAL, Hyderabad.

2. HISTORY…
Wolffberg isolated the two lungs using the
catheter in 1871 which is the first reported
concept of an endobronchial single-lumen tube.
The first instance of clinical use in humans was
by Loewy and von Schrotter with lower lobe
bronchus catheterized under fluoroscopic control.
Gale and Waters endobronchial tube-1932
Magills- cuffed endobronchial tube 1936 (1st
attempt to compensate for the different anatomy
of L and R bronchus
'One Lung' ventilation, is a method of ventilation which was first conceptualized by physiologists Eduard
Pflüger and Claude Bernard who studied gas exchange in dogs using a lung isolation catheter.

3. SUB HEADINGS
Types of lung isolation devices
Bronchial Blockers
Other Modalities
Paediatric Concerns
Complications associated
Future trends

4. • PVC TUBES
• ROBERTSHAW
• CARLENS
• WHITE
DOUBLE LUMEN TUBES
• ARNDT
• COHEN S FLEXITIP
• FUJI UNIBLOCKER
• EZ BLOCKER
BRONCHIAL BLOCKERS
• UNIVENT TUBE
• COOPDECH Endobronchial Blocker(DAIKEN)
SPECIAL TUBES
• Fogarty S Embolectomy Catheter
• Swan Ganz Catheter
• Atrioseptostomy Catheters
• Endobronchial intubation with ET tube
OTHERS
Lung Isolation Can Be Achieved By

5. The Arndt wire-
guided
endobronchial
blocker (Arndt®
Cook Critical Care)
Cohen® tip
deflecting
endobronchial
blocker (Cook
Critical Care)
the Fuji
Uniblocker®
(Fuji Corp,
Tokyo, Japan)
EZ-blocker

6. INDICATIONS FOR BRONCHIAL
BLOCKERS
Cervical spine injuries
Who cannot tolerate period of apnea
on anticoagulants
Endotracheal tube in situ
When only a lobe is needed to be blocked
When sequential blockage of both lungs is needed
To apply CPAP to a selective lobe

7. WHEN DLT INSERTION IS NOT
POSSIBLE
Bronchial blockers are indicated where DLT insertion is not
possible or advisable as in patients with
 Difficult airway / Tracheostomized patients
 Lesions within the trachea
 Severely distorted tracheobronchial anatomy
History of previous oral or neck surgery presenting with difficult
airway anatomy
Cancer patients with a previous contralateral pulmonary
resection
Patients requiring postoperative ventilation ( after prolonged
thoracic or esophageal surgeries)

8. FIBREOPTIC BRONCHOSCOPE SIZE
FOR BB
For an ADULT - 9 French bronchial blocker + bronchoscope < 4mm(D) requires
an ETT of size 7.0 or more
Larger bronchoscope require
ETT > 7.5

9. COHEN FLEXITIP BRONCHIAL BLOCKER
Size 9F external diameter, 1.4mm inner lumen and length of 65cm with angle tip
• High volume low pressure blue spherical balloon at the tip. spherical “pear”
shape and provides both a good seal and generous contact with the bronchial
wall.
WHEEL CONTROLLING TIP
Average inflation volume is 5–8 ml.
• Murphy eye in the distal tip
• Lumen may be used for limited
suctioning or insufflation of oxygen
to the collapsed lung in case of hypoxia.

10. COHEN FLEXITIP INSERTION

11. COHEN FLEXITIP – METHOD OF
PLACEMENT
The Cohen blocker kit contains an
Multi-Port Adaptor that permits
simultaneous ventilation, fiberoptic
bronchoscopy, and manipulation of
the BB with an airtight seal.

12. ARNDT BLOCKER ( DR. GEORGE A.ARNDT, AN
ANESTHESIOLOGIST)
 Sizes 5Fr, 7Fr & 9Fr (adult), wire-guided, yellow catheter, 65 and 78cm length, with
centimeter markings from 10-60 . Side holes are present only in the 9 F Arndt blocker.
A flexible nylon wire passes through the proximal end of snare-guided BB and extends to
the distal end then exits as a small loop.
The blocker is advanced along the FB blindly and may be engaged at the level of the ETT
Murphy eye or at the tracheal carina.
The external diameter is 9F, which requires a minimum 8.0-mm ETT to be able to
accommodate the deflated cuff of the BB when it is passed over the FB
Used in children 2 yrs and above

13. METHOD OF PLACEMENT
Placement of an Arndt blocker through a single-
lumen endotracheal tube with the fiberoptic
bronchoscope advanced through the guide wire
loop. Optimal position of a bronchial blocker in the
right or left mainstem bronchus as seen with a
fiberoptic bronchoscope
Right mainstem
blocker
Left mainstem blocker

14. AN ARNDT
BLOCKER
Patient with a previous right pneumonectomy where selective lobar blockade is used to
occlude the left upper lobe. or as a selective blocker during severe pulmonary bleeding.
It is important to remove the wire loop to avoid inclusion in the stapling line of the bronchus
R stump of right mainstem
bronchus;
C main carina;
L left mainstem bronchus;
LUL left upper lobe;
LLL left lower lobe

15. 15 mm port that attaches to the ETT
ventilation port that
connects to the
breathing circuit
port for a flexible
fiberoptic scope
port angled
approximately 30º
for the blocker.

16. FUJI UNIBLOCKER
an independent bronchial blocker that is available in 4.5 and 9 F size and is 65 cm in
length. made from wire mesh coated with polyurethane with fixed distal curve
has a high-volume balloon made of silicone with a gas barrier property to reduce
diffusion of gas into or out of the cuff. maximal inflation of 6 mL of air.
Its equipped with a swivel connector allowing easy insertion.
The Fuji Uniblocker has a torque control blocker with an incorporated shaft that
allows the guidance through the desired bronchus
Facilitate easy removal without disconnection from the anaesthesia circuit

18. PLACEMENT METHOD
size 9 F is advanced
through an 8.0 ETT after
full deflation and
lubrication.
the fiberoptic
bronchoscope is used to
observe the direction of
the blocker into a
mainstem bronchus.
Fuji Uniblocker with stylet,
which allows flexible high
torque control and good
controllability of the
catheter tip

19. EZ-BLOCKER
 7.0 F size 75-cm, 4-lumina Y-shaped semi rigid endobronchial blocker, made of
polyurethane material and combines some of the advantages of the DLT and the BB.
The Y-shape of the distal portion allows the blocker to anchor on the carina.
 Two limbs color coded (yellow/ blue) which are fitted with an inflatable balloon and a
central channel in each to allow suction.
DISADVANTAGE-
 both limbs initially enter the right mainstem bronchus- requires withdrawing the
blocker above the carina and re-advancement under direct vision with the
bronchoscope.

20. Proper and optimal position is when the outer
surface of the balloon is seen 5–10 mm below
the entrance of the bronchus.
 The optimal size of endotracheal tube should be 7.5 or
8.0 mm internal diameter
 Proper deployment of the BB requires a minimum of 4 cm
distance between the distal end of the ETT and the carina
 After advancing the blocker, the Y-shaped end should be
seated in the tracheal carina and each independent tip
should be located in the entrance of right and left bronchus.
 the balloon should be inflated under direct FOB.

21. (A ) View on the main carina. The bifurcation of the distal extensions rests on the main carina. The yellow extension is in the right mainstem bronchus and the
blue extension is in the left mainstem bronchus
(B ) The balloon in the right mainstem bronchus is insufflated with 7 ml of air and is blocking the bronchus intermedius. The aperture of the right upper lobe
bronchus is still visible.
(C ) An additional 7 ml is insufflated and the balloon is also blocking the right upper lobe bronchus.
(D ) The balloon in the left mainstem bronchus is insufflated with 10 ml of air.
Efficiency, Efficacy, and Safety of EZ-Blocker Compared with Left-sided Double-lumen Tube for One-lung Ventilation . Anesthesiology. 2013;118(3):550-561.
View with a 3.7-mm videobronchoscope of an EZ-Blocker situated in the trachea and bronchi of a patient

22. COMPARISON OF BRONCHIAL
BLOCKERS

23. Advantages
Disadvantages

24. Univent Bronchial Blocker
System

25. UNIVENT TUBE DR.
INOUE
 Developed in 1982 Can be used with tracheal tubes
 It is a single-lumen silicone tube with a small separate lumen along the anterior
concave wall containing the small hollow non-latex bronchial blocker that can extend
about 8-10 cm beyond the tip and it has a blue colored high pressure and low volume
cuff.
The lumen of the bronchial blocker is 2 mm in internal diameter. Available in 6.0-9.0
mm internal diameter.
Typical cuff inflation volume is 5-6cc

26. UNIVENT
Cuff should be inflated with minimum amount of air that would provide seal.
This can be achieved by attaching by sample line from Co2 analyser to the
proximal end of the blocker and noting when the waveform disappears

27. FEATURES
Advantages
1. Displacement less since it is
attached to the tube
2. No need to change tube –
postoperative period
3. Selective lobar blockade
4. Rapid sequence induction that
requires OLV
5. Difficult airways requiring OLV
Disadvantages
1. Low volume high pressure cuff
2. 8.5–9.0 size- tight fit through vocal
cords
3. Enclosed channel of 2.0 mm ( aspirate
secretions) High resistance to gas flow
4. expensive
5. Potential for inclusion in the stapling
line
6. Cannot use in < 6 years of age
7. No suction, oxygen or CPAP to
collapsed lung
8. Lung collapse slow

28. HOW TO PLACE A UNIVENT BLOCKER
TUBE???

29. COOPDECH ENDOBRONCHIAL
BLOCKER(DAIKEN, JAPAN)
Similar to the fuji uniblocker
 Features a unique automatic inflation system
enables the operator to inflate the cuff with
one hand and operate FOB simultaneously

30. OTHER BLOCKERS…
Fogarty catheters –vascular embolectomy catheters
Balloon wedge catheters –Swan Ganz catheters
Atrioseptostomy catheter
Arndt Cook bronchial blockers (end hole) – specifically
designed for bronchi

31. IN SMALL CHILDREN (<10KG)
Fogarty catheter with 0.5 ml balloon
Swan ganz catheter with a 1ml balloon
2mm FOB guidance, in a ETT of 4.5mm
MARRARO
BILUMEN TUBE

32. FOGARTY EMBOLECTOMY
CATHETER
Single-lumen balloon tipped catheter with a removable stylet . (Edwards Life sciences).
Can be placed parallel or through the endotracheal tube coaxially.
 Both techniques require fiberoptic bronchoscopy Clinical limitations of the Fogarty
catheter
No accessory lumen- No Suction , Oxygen insuffulation or applying CPAP to the
blocked lung
Sizes (Pediatric ) -3Fr, 4 Fr, 5 Fr
Low volume high pressure cuff .
lack a directing mechanism
or a suction lumen

33. STANDARD ENDOTRACHEAL TUBE
Can be used as in direct ENDOBRONCHIAL INTUBATION, through TRACHEAL TUBES, and
in PAEDIATRIC PATIENTS or in EMERGENCIES when DLET or BB are not available
Advancing the endotracheal tube into the main stem bronchus opposite to site of
surgery
Collapse of lung in surgical area is by absorption atelectasis
VivaSight™ single-lumen tube (SLT) (ETView Ltd., Misgav, Israel) is the new generation
of endotracheal tubes incorporating a high-resolution imaging camera and a light source
in its tip to guide the placement of bronchial blocker without the aid of fiberoptic
bronchoscopy.

34. VIVA SIGHT

35. the Phycon single-lumen
endotracheal/endobronchial tube
standard endotracheal tube
Long (36 cm) single-lumen tube has a short cuff and does not have a Murphy eye

36. LUNG SEPARATION AND THE DIFFICULT
AIRWAY
If placement of a Bronchial blocker is problematic, one must consider the
safety and need for lung separation.
Surgical preference alone is an insufficient reason to jeopardize a patient.
An airway guide or airway exchange catheter (AEC) - gum elastic bougie, an
Aintree catheter or Frova intubating catheter used with CL grade II- III at
laryngoscopy.

37. Limited mouth opening or in whom only a nasotracheal intubation is possible -
Bronchial blockers.
Patient with a tracheostomy
COHEN & ARNDT
BLOCKER

38. REPORTED COMPLICATIONS
Univent blocker -
 Structural complication has been reported in the torque control with fracture of the
blocker cap connector
 Failure to achieve lung separation because of abnormal anatomy
 Inclusion of the enclosed bronchial blocker into the stapling line has been reported
during a right upper lobectomy
 The cuff of the bronchial blocker was inflated mistakenly near the tracheal lumen,
precluding all airflow and producing respiratory arrest.
Fuji Blocker-
 Balloon of the fuji blocker failed to deflate at the conclusion of the surgery
Peragallo RA, Swenson JD. Congenital tracheal bronchus: the inability to isolate the right lung with a univent bronchial blocker tube. Anesth Analg.
2000;91:300–1.
Asai T. Failure of the Univent bronchial blocker in sealing the bronchus. Anaesthesia. 1999;54:97

39. REPORTED COMPLICATIONS
ARNDT BRONCHIAL BLOCKER
 A sheared balloon of the arndt blocker that occurred when the blocker was removed
through the multiport channel. It is advised that when an independent bronchial
blocker is not in use, it needs to be removed with the multiport connector.
 Fully inflated balloon of the blocker dislodged into the patient’s trachea, leading to a
complete airway obstruction
 Inadvertent resection of the guide wire and part of the tip of the ARNDT bronchial
blocker during stapler resection of the left lower lobe; REQUIRING surgical
reexploration after unsuccessful removal of the bronchial blocker after extubation.
Sandberg WS. Endobronchial blocker dislodgement leading to pulseless electrical activity. Anesth Analg. 2005;100:1728–30.
Honikman R, Rodriguez-Diaz CA, Cohen E. A ballooning crisis: three cases of bronchial blocker malfunction and a review. J Cardiothorac Vasc Anesth. 2017;31:1799–804.

40. WHAT DO THE STUDIES SAY???
In a study comparing left-sided DLT with the Univent torque control blocker and the Arndt blocker, it was
shown that the average time for lung collapse is 17 min for a DLT (spontaneous lung collapse without
suction) versus 19–26 min for EBB (assisted with suction), BUT overall clinical performance was similar
for the three devices studied
Narayanaswamy M, McRae K, Slinger P, et al. Choosing a lung isolation device for thoracic surgery: a randomized trial of three bronchial blockers versus double-lumen tubes.
Anesth Analg. 2009;108:1097–101.
Study comparing left-sided DLTs with BB showed BB are an effective alternative for left one-lung
ventilation in right VATS, but requires a longer time to achieve complete lung collapse. Moreover, the use
of BB caused less hemodynamic perturbation and can reduce postoperative hoarseness and sore throat.
Lu Y, Dai W, Zong Z, Xiao Y, Wu D, Liu X, Chun Wong GT. Bronchial Blocker Versus Left Double-Lumen Endotracheal Tube for One-Lung Ventilation in Right
Video-Assisted Thoracoscopic Surgery. J Cardiothorac Vasc Anesth. 2018 Feb;32(1):297-301. doi: 10.1053/j.jvca.2017.07.026. Epub 2017 Jul 27. PMID:
29249583.
Bussières JS, Moreault O, Couture EJ, Provencher S. Optimizing Lung Collapse With a Bronchial Blocker: It's Not What You Use, but How You Use It, Part II. J Cardiothorac Vasc Anesth. 2019
Jan;33(1):255. doi: 10.1053/j.jvca.2018.09.025. Epub 2018 Sep 28. PMID: 30377052.
Emphasized the need for involving at least one senior thoracic anesthesiologist
with broad experience with lung isolation devices.

41. FUTURE : ACQUIRED SKILLS DECREASE WITHOUT PRACTICE
Advances in thoracic, cardiac,
esophageal surgery, and minimally
invasive surgery- need for high-
fidelity Anesthesia simulators to
enhance learning and to improve
performance.
Training in fiberoptic
bronchoscopy
Development of a pulmonary
workstation along with simulator
training facility
Mentoring by an experienced
thoracic anesthesiologist

42. TAKE HOME MESSAGE…
1. Knowledge of patient’s airway anatomy
recognition of tracheobronchial anatomy with a CT/XRAY in the preoperative evaluation and with flexible fiberoptic
bronchoscopy in the perioperative period,
2. Physiology of single lung ventilation
3. Details of surgical procedure
4. Proper selection of lung isolation device-
Focus on the Patient’s Gender, Size, Height, and Preoperative Chest Radiograph
5. Final Check of all equipments before use
6. Always recruit help if needed. Trouble Shooting For Misplacement Of Tube/ Blocker And
Hypoxemia During OLV Must Be Specific
Every lung isolation device placement requires auscultation and clamping maneuvers followed by a fiberoptic bronchoscopy to obtain 100% success during
lung separation techniques.