Double lumen tubes were developed in the 1950s-60s to enable lung isolation during thoracic surgery. The Carlens and Bryce-Smith tubes were some of the earliest designs, featuring curves and cuffs to isolate the left or right mainstem bronchus. Modern tubes like the Robertshaw are widely used and come in varying sizes from 26-41 French. Placement requires careful advancement and confirmation via auscultation, cuff inflation, and bronchoscopy to avoid malposition and injury. Double lumen tubes allow selective ventilation and treatment of each lung but require replacement with a single tube after surgery.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Intro to Hypoxic pulmonary vasoconstriction Arun Shetty
Hypoxic pulmonary vasoconstriction, a seldom heard phenomenon but very effective physiologic property which helps lungs utilise ventilation to the maximum
A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.
Here is a presentation about the double lung ventilation or independent lung ventilation
I hope it will be helpful
There are some videos in the presentation , here is the links :)
http://www.youtube.com/watch?v=w1cgx2AVC6k&list=UUUIWCsRV3siWB-jzBmNg6pA
http://www.youtube.com/watch?v=JZkOiy4PXxg&list=UUUIWCsRV3siWB-jzBmNg6pA
http://www.youtube.com/watch?v=mlS35eUUxqA&list=UUUIWCsRV3siWB-jzBmNg6pA
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Intro to Hypoxic pulmonary vasoconstriction Arun Shetty
Hypoxic pulmonary vasoconstriction, a seldom heard phenomenon but very effective physiologic property which helps lungs utilise ventilation to the maximum
A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.
Here is a presentation about the double lung ventilation or independent lung ventilation
I hope it will be helpful
There are some videos in the presentation , here is the links :)
http://www.youtube.com/watch?v=w1cgx2AVC6k&list=UUUIWCsRV3siWB-jzBmNg6pA
http://www.youtube.com/watch?v=JZkOiy4PXxg&list=UUUIWCsRV3siWB-jzBmNg6pA
http://www.youtube.com/watch?v=mlS35eUUxqA&list=UUUIWCsRV3siWB-jzBmNg6pA
Anaesthetic problems of open chest and pathophysiology of one lung ventilation aratimohan
Mechanics and physiology of lung isolation/ one-lung ventilaion,
Anaesthetic implications of one-lung ventilation and management strategies
West zones of the lung
Ventilation-perfusion mismatch, V-Q
Hypoxic pulmonary vasoconstriction
Bag and Mask Ventilation By Sakun Rasaily @Ram K Dhamalaramdhamala11
Bag and mask Ventilation Presented by Sakun Rasaily,
(Pediatric Nurse, Pediatric ward , B.P. Koirala Institute of Health Science
Dharan, Sunsari (Nepal)
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon dioxide.
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
2. INTRODUCTIONINTRODUCTION
• The development of double lumen tubes
between 1950s and 1960s was a response to
fast growing capabilities in thoracic surgery.
• The Bjork and Carlens bronchospirometric
double lumen tube was first used during
anaesthesia in 1950.
3. DATE NAME DISTINCTIVE CHARACTERSTICS BRONCHIAL
INTUBATIO
N
TECHNIQUE
1950 Carlens Double lumen catheter with two inbuilt curves tracheal
and a bronchial cuff for left main bronchus, carinal hook
and cross sectional shape oval in horizontal plane
Blind
1959 Bryce
Smith
Modification of carlens catheter with no carinal hook,
cross sectional shape oval in horizontal plane
Blind
1960 Bryce
smith and
Salt
Right sided version of Bryce Smith tube possessing slit in
the endobronchial cuff. No carinal hooks
Blind
1960 White Right sided version of Carlens catheter possessing slit in
the endobronchial cuff and a carinal hooks
Blind
1962 Robert
Shaw
Right and left DLT larger lumen, slotted right endo
bronchial cuff, no carinal hook, cross sectional shape, D
shaped in horizontal plane.
Blind
1979 National
Catheter
corpn.
Right and left Robert Shaw type disposable DLT, with low
pressure high volume cuff
Blind
6. METHODS OF LUNG SEPARATIONMETHODS OF LUNG SEPARATION
• DOUBLE-LUMEN ENDOBRONCHIAL TUBESDOUBLE-LUMEN ENDOBRONCHIAL TUBES
– Robert-Shaw (R or L), Carlens (R), White (L)
– Carlens and White both have carinal hooks
– From 35Fr to 41Fr (35, 37, 39, 41)
– 26Fr smallest size
• Used for children as young as 8 years
– 28Fr and 32Fr used for pediatric patients 10 and older
• BRONCHIAL BLOCKERSBRONCHIAL BLOCKERS
– Single-lumen tracheal tubes w/ a bronchial blocker (Univent)
– Arterial embolectomy catheter (ie Fogarty)
• SINGLE-LUMEN ENDOBRONCHIAL TUBESSINGLE-LUMEN ENDOBRONCHIAL TUBES
– Gordon-Green tube (carinal hook)
7. DLT
• Type:
– Carlens, a left-sided + a carinal hook
– White, a right-sided Carlens tube
– Bryce-Smith, no hook but a slotted cuff/Rt
– Robertshaw, most widely used
• All have two lumina/cuffs, one
terminating in the trachea and the
other in the mainstem bronchus
• Right-sided or left-sided available
• Available size: 41,39, 37, 35, 28 French
(ID=6.5, 6.0, 5.5, 5.0 and 4.5 mm
respectively)
8. LEFT DLT…
• Most commonly used
• The bronchial lumen is longer, and a simple round
opening and symmetric cuff .Better margin of
safety than Rt DLT
• Easy to apply suction and/or CPAP to either lung
• Easy to deflate lung
• Lower bronchial cuff
volumes and pressures
• Can be used
– Left lung isolation:
clamp bronchial +
ventilate/ tracheal lumen
– Right lung isolation:
clamp tracheal +
ventilate/bronchial
lumen
9. …Left DLT
• More difficult to insert (size and curve, cuff)
• Risk of tube change and airway damage if kept in
position for post-op ventilation
• Contraindication:
– Presence of lesion along DLT pathway
– Difficult/impossible conventional direct vision intubation
– Critically ill patients with single lumen tube in situ who
cannot tolerate even a short period of off mechanical
ventilation
– Full stomach or high risk of aspiration
– Patients, too small (<25-35kg) or too young (< 8-12 yrs)
10. LUNG SEPARATION is achieved by
either;
-Double lumen ETT (DLT)
-Bronchial blocker
-Endobronchial tube
20. DLT PLACEMENT
• Prepare and check tube
– Ensure cuff inflates and deflates
• Lubricate tube
• Insert tube with distal concave curvature facing anteriorly
• Remove stylet once through the vocal cords
• Rotate tube 90 degrees (in direction of desired lung)
• Advancement of tube ceases when resistance is encountered.
Average lip line is 29 ± 2 cm.
• *If a carinal hook is present, must watch hook go through cords to
avoid trauma to them.
21. DLT PLACEMENT
• Check for placement by auscultation
• Inflate tracheal cuff- expect equal lung ventilation
• Clamp the white side (marked "tracheal" for left-sided tube) and remove
cap from the connector
– Expect some left sided ventilation through bronchial lumen, and some
air leak past bronchial cuff, which is not yet inflated
• Slowly inflate bronchial cuff until minimal or no leak is heard at uncapped
right connector
– Go slow- it only requires 1-3 cc of gas and bronchial rupture is a risk
• Remove the clamp and replace the cap on the tracheal side
• Check that both lungs are ventilated
• Selectively clamp each side, and expect visible chest movement and audible
22. DLT PLACEMENT
• Checking tube placement with the fiberoptic bronchoscope
• Several situations exist where auscultation maneuvers are impossible
(patient is prepped and draped), or when they do not provide
reliable information (preexisting lung disease so that breath sounds
are not very audible, or if the tube is only slightly malpositioned)
• The double-lumen tube's precise position can be most reliably
determined with the fiberoptic bronchoscope
• In patients with double-lumen tubes whose position seemed
appropriate to auscultations, 48% had some degree of malposition.
So always check position with fiberoptic
• After advancing the fiberoptic scope thru the “tracheal” tube you
should see the “bronchial blue balloon” in a semi lunar shape, just
peeking out of the bronchus
27. GUIDE FOR LENGTH AND SIZE OF DLTGUIDE FOR LENGTH AND SIZE OF DLT
LENGTH OF TUBE
For 170 cm height, tube depth of 29 cm
For every 10 cm height change , 1 cm depth change
Patient characteristics Tube size (Fr gauge)
Tracheal width (mm):
18
16
15
14
41
39
37
35
Patient height
4’ 6”-5’5”
5’5”-5’10”
5’11”-6’4”
35-37
37-39
39-41
Patient age (year)
13-14
12
10
8
35
32
28 (lt only)
26 (lt only)
28. CHECK POSITION OF LT -DLT
Checklist for tracheal
placement
A. Inflate tracheal cuff
B. Ventilate rapidly by hand
C. Check that both lungs are
being ventilated
D. If not, withdraw 2-3 cm &
repeat
Checklist for Lt side
A. Inflate lt cuff > 2ml
B. Ventilate and check
bilateral breath sounds
C. Clamp rt tube
D. Check unilateral (lt)
breath sounds
Checklist for Rt side
A. Clamp lt tube
B. Check unilateral
(rt) breath sounds
29. Major Malpositions of a Lt- DLT
Both cuffs
inflated
Clamp Rt lumen
Both cuffs
inflated
Clamp Lt lumen
Deflate Lt cuff
Clamp Lt lumen
Left
None /Very minimal
left
Left
Right
Both
Both
None / Very minimal
Both
Right
None /Very minimal
Right
Breath Sounds Heard
Lt
30. To ensure correct position of DLT clinically :
breath sounds are
- normal (not diminished) &
- follow the expected unilateral pattern with unilateral clamping
the chest rises and falls in accordance with the breath sounds
the ventilated lung feels reasonably compliant
no leaks are present
respiratory gas moisture appears and disappears with each tidal
ventilation
N.B even if the DLT is thought to be properly positioned by clinical
signs, subsequent FOB may reveal an incidence of malposition ( 38 -78
%)
33. Relationship of FOB Size to Adult DLT
FOB Size (mm)
(OD)
Adult DLT Size
(French)
Fit of FOB inside DLT
5.6 All sizes Does not fit
4.9
41
39
37
35
Easy passage
Moderately easy passage
Tight fit, need lubricant, hard
push
Does not fit
3.6–4.2 All sizes Easy passage
34. Other Methods to Check DLT Position
Chest radiograph
May be more useful than conventional auscultation and clamping in some
patients, but it is always less precise than FOB. The DLT must have
radiopaque markers at the end of rt and lt lumina.
Comparison of capnography
Waveform and ETCO2 from each lumen may reveal a marked discrepancy
(different degree of ventilation).
Surgeon
May be able to palpate, redirect or assist in changing dlt position from
within the chest (by deflecting the dlt away from the wrong lung, etc..).
36. ADVANTAGESADVANTAGES
Relatively easy to place
Allow conversion back and forth from OLV to two-
lung ventilation
Allow suctioning of both lungs individually
Allow CPAP to be applied to the non-dependent lung
Allow PEEP to be applied to the dependent lung
Ability to ventilate around scope in the tube
37. DISADVANTAGESDISADVANTAGES
• Cannot take patient to PACU or the Unit
• Must be changed out for a regular ETT if post-op
ventilation
• Correct positioning is dependent on appropriate size for
height of patient
Length of trachea
38. COMPLICATIONS OF DLTCOMPLICATIONS OF DLT
Impediment to arterial oxygenation for OLV
Tracheobronchial tree disruption, due to
-Excessive volume and pressure in bronchial balloon
-Inappropriate tube size
-Malposition
Traumatic laryngitis (hook)
Inadvertent suturing of the DLT
39. TO AVOID TRACHEOBRONCHIAL TREE DISRUPTION …
1. Be cautious in patients with bronchial wall abnormalities.
2. Pick an appropriately sized tube.
3. Be sure that tube is not malpositioned ; Use FOB.
4. Avoid overinflation of endobronchial cuff.
5. Deflate endobronchial cuff during turning.
6. Inflate endobronchial cuff slowly.
7. Inflate endobronchial cuff with inspired gases.
8. Do not allow tube to move during turning.
40. RELATIVE CONTRAINDICATIONS TO USE OF DLTRELATIVE CONTRAINDICATIONS TO USE OF DLT
Full stomach (risk of aspiration);
Lesion (stricture, tumor) along pathway of dlt (may be traumatized);
Small patients;
Anticipated difficult intubation;
Extremely critically ill patients who have a single-lumen tube already in place and
who will not tolerate being taken off mechanical ventilation and peep even for a
short time;
Patients having some combination of these problems.
Under these circumstances, it is still possible to separate the lungs by :
-using a single-lumen tube + FOB placement of a bronchial blocker ; or
-FOB placement of a single-lumen tube in a main stem bronchus.
41. Bronchial Blockers
(With Single-Lumen Endotracheal Tubes)
Lung separation can be effectively achieved with the use of a
single-lumen endotracheal tube and a FOB placed bronchial
blocker.
Often necessary in children as DLTs are too large to be used in
them. The smallest DLT available is a left-sided 26 Fr tube,
which may be used in patients 8 -12 years old and weighing
25 -35 kg.
Balloon-tipped luminal catheters have the advantage of
allowing suctioning and injection of oxygen down the central
lumen.
42. INDICATIONS FOR USE OF BRONCHIAL BLOCKERS
1st
LIMITATIONS TO DLT
( severely distorted airway, small patients , anticipated difficult intubation)
2nd
TO AVOID A RISKY CHANGE OF DLT TO SINGLE-LUMEN TUBE
• whenever postoperative ventilation is anticipated
• in cases of thoracic spine surgery in which a thoracotomy in the supine or
LDP is followed by surgery in the prone position.
3rd
SITUATIONS IN WHICH BOTH LUNGS MAY NEED TO BE BLOCKED
(e.g., bilateral operations, indecisive surgeons).
43. TYPES OF BRONCHIAL BLOCKERSTYPES OF BRONCHIAL BLOCKERS
Univent bronchial blocker system
Arndt endobronchial blocker
Cohen Flexitip Endobronchial Blocker
BB independent of a single-lumen tube
45. Univent Tube...
• Developed by Dr. Inoue
• Movable blocker shaft in
external lumen of a single-lumen
ET tube
46. STEPS OF FOB-AIDED METHOD OF POSITIONING THE UNIVENT BRONCHIALSTEPS OF FOB-AIDED METHOD OF POSITIONING THE UNIVENT BRONCHIAL
BLOCKER IN LT MAIN STEM BRONCHUSBLOCKER IN LT MAIN STEM BRONCHUS
One- or two-lung ventilation is achieved simply by inflating or deflating,
respectively, the bronchial blocker balloon
47. ADVANTAGES OF THE UNIVENT BRONCHIAL BLOCKER TUBEADVANTAGES OF THE UNIVENT BRONCHIAL BLOCKER TUBE
( RELATIVE TO DLT )( RELATIVE TO DLT )
1. Easier to insert and properly position.
2. Can be properly positioned during continuous ventilation and
in the lateral decubitus position.
3. No need to change the tube when turning from the supine to
prone position or for postoperative mechanical ventilation.
4. Selective blockade of some lobes of each lung.
5. Possible to apply CPAP to non ventilated operative lung.
48. Limitations to the Use of Univent Bronchial Blocker
LIMITATION SOLUTION
1. Slow inflation time (a) Deflate BB cuff and administer +ve pressure breath
through the main single lumen;
(b) carefully administer one short high pressure (20–30 psi)
jet ventilation
2. Slow deflation time (a) Deflate BB cuff and compress and evacuate the lung
through the main single lumen;
(b) apply suction to BB lumen
3. Blockage of BB
lumen
( blood, pus,..)
Suction, stylet, and then suction
4. High-pressure cuff Use just-seal volume of air
5. Leak in BB cuff Make sure BB cuff is subcarinal, increase inflation volume,
rearrange surgical field
51. ARNDT ENDOBRONCHIAL BLOCKER SETARNDT ENDOBRONCHIAL BLOCKER SET
• Invented by Dr. Arndt, an anesthesiologist
• Ideal for diff intubation, pre-existing ETT and postop
ventilation needed
• Requires ETT > or = 8.0 mm
• Similar problems as Univent
• Inability to suction or ventilate the blocked lung
52. ADVANTAGESADVANTAGES
• Quickly and precisely navigate the airway
• The guide wire loop couples the pediatric fiberoptic bronchoscope and the wire-
guided endobronchial blocker
– yet both remain able to move independently of each other and the pediatric
fiberoptic bronchoscope may navigate the airway independent of its role in
carrying the endobronchial blocker
• The pediatric bronchoscope acts as a guide, allowing the endobronchial blocker to
be advanced over it into the correct position
• In addition, the wire-guided endobronchial blocker allows one-lung ventilation
with a single-lumen endotracheal tube
– Thus, one-lung ventilation is not dependent on installing a special device in the
airway, such as a double-lumen tube or a Univent endotracheal tube
– Allows one-lung ventilation in the critically ill patient in whom reintubation
may be difficult or impossible and in patients with a known difficult airway
requiring fiberoptic intubation with a conventional endotracheal tube
– Unnecessary to convert from a conventional double-lumen endotracheal tube
to a single-lumen tube at the end of surgery
53. DISADVANTAGESDISADVANTAGES
• Satisfactory bronchial seal and lung separation are sometimes difficult to
achieve
• The “blocked” lung collapses slowly (and sometimes incompletely)
• The balloon may become dislodged during surgery and enter the trachea
proper, causing a complete airway obstruction
– In situations of acute increases in airway pressure, the endobronchial
blocker balloon should be immediately deflated and the blocker re-
advanced
– It will then re-enter the correct segment (as the tip remains in the
correct bronchus and only the proximal balloon portion has entered the
trachea)
– In this case, a pediatric fiberoptic bronchoscope should be re-introduced
into the airway and the balloon re-positioned
– In order to prevent barotrauma, the initial balloon inflation volume
should not be exceeded
– It is important that the balloon be fully deflated when not in use and
only be re-inflated with the same volume used during positioning and
54. INDICATIONS FOR WIRE-GUIDEDINDICATIONS FOR WIRE-GUIDED
ENDOBRONCHIAL BLOCKERS VS. DLTENDOBRONCHIAL BLOCKERS VS. DLT
• Critically ill patients
• Rapid sequence induction
• Known and unknown difficult airway
• Postoperative intubation
• Small adult and pediatric patients
• Obese adults
63. BRONCHIAL BLOCKERS THAT ARE INDEPENDENT OF ABRONCHIAL BLOCKERS THAT ARE INDEPENDENT OF A
SINGLE-LUMEN TUBESINGLE-LUMEN TUBE
ADULTSADULTS
Fogarty (embolectomy) catheter with a 3 ml balloon.
It includes a stylet so that it is possible to place a curvature at the distal tip to
facilitate entry into the larynx and either mainstem bronchus .
Balloon-tipped luminal catheters (such as foley type) may be used as bronchial
blockers.
VERY SMALL CHILDRENVERY SMALL CHILDREN (10 kg or less)
Fogarty catheter with a 0.5 ml balloon
Swan-ganz catheter (1 ml balloon)
* These catheters have to be positioned under direct vision; a FOB method is
perfectly acceptable; the FOB outside diameter must be approximately 2 mm to
fit inside the endotracheal tube (3 mm internal diameter or greater).
Otherwise, the bronchial blocker must be situated with a rigid bronchoscope.
* Paediatric patients of intermediate size require intermediate size occlusion
catheters and judgment on the mode of placement (i.E., Via rigid versus FOB).
65. FOGARTY EMBOLECTOMY CATHETERFOGARTY EMBOLECTOMY CATHETER
• Single-lumen balloon tipped catheter with a removable stylet
• In the parallel fashion, the Fogarty catheter is inserted prior to intubation
• In the co-axial fashion, the Fogarty catheter is placed through the
endotracheal tube
• Both techniques require fiberoptic bronchoscopy to direct the Fogarty
catheter into the correct pulmonary segment
• Once the catheter is in place, the balloon is inflated, sealing the airway
• Clinical limitations to the Fogarty technique
– Difficult to direct and cannot be coupled to a fiberoptic bronchoscope
– No accessory lumen for either removal of gas from the blocked segment or
insufflation of oxygen to reverse hypoxemia
– Ventilate w/ 100% O2 prior to balloon inflation to aid in gas removal
66. DISADVANTAGES OF A BLOCKER THAT IS INDEPENDENT OFDISADVANTAGES OF A BLOCKER THAT IS INDEPENDENT OF
THE SINGLE-LUMEN TUBE AS COMPARED WITH DLTTHE SINGLE-LUMEN TUBE AS COMPARED WITH DLT
Inability to suction and/or to ventilate the lung distal to the
blocker.
Increased placement time.
The definite need for a fiberoptic or rigid bronchoscope.
If bronchial blocker backs out into the trachea, the seal
between the two lungs will be lost and the trachea will be at
least partially obstructed by the blocker, and ventilation will
be greatly impaired.
67. ENDOBRONCHIAL INTUBATION WITH SINGLE-LUMEN TUBESENDOBRONCHIAL INTUBATION WITH SINGLE-LUMEN TUBES
In adults often the easiest,quickest way for lung separation in
patients presenting with haemoptysis , either
-BLIND, OR
-FOB , OR
-guidance by surgeon from within chest
In children it may be the simplest way to achieve OLV
DISADVANTAGESDISADVANTAGES
Inability to do suctioning or ventilation of operative side.
Difficult positioning bronchial cuff with inadequate ventilation of
Rt upper lobe after Rt endobronchial intubation.
68. IN SUMMARY….
DLT is the method of choice for lung separation in most adult
patients.
The precise location can be determined by FOB .
In situations where insertion of a DLT may be difficult and/or
dangerous, separating the lungs is achieved either with a single-
lumen tube alone or in combination with a bronchial blocker (e.g.,
the Univent tube).
Therefore, regardless of what method of lung separation chosen,
there is a real need of a small-diameter FOB (for checking the
position of the DLT, placing a single-lumen tube in a mainstem
bronchus, and placing a bronchial blocker) .