Thoracic Anaesthesia Post-Fellowship Study Day

1. Thoracic AnaesthesiaPost-Fellowship Study Day Bruce McCormick Royal Devon and Exeter NHS Foundation Trust 15th November 2010

2. Overview • Overview of thoracic anaesthesia • One-lung ventilation (OLV) • Double lumen tube (DLT) placement • Regional analgesia • Paravertebral block • Assessment for lung resection

3. Overview – A typical list

4. Others

5. Double lumen tube placement • Left DLT unless…. • Which side is op? • Clamp it • Allow lung to collapse

6. Double lumen tube placement Benumof JL. The position of a double lumen tube should be routinely determined by fibreoptic bronchoscopy (editorial). J Cardiothor Vasc Anesth 1993; 7: 513-4

7. Failure of  One-lung ventilation • Unable to site DLT • Unable to collapse operative lung • High inflation pressures ventilating non-operative lung • Hypoxia during OLV

8. Bronchial blockers Effectiveness Comparison to DLT • Blocker takes longer (19-26 versus 17 min) • Clinical performance similar • May not apply to non-thoracic anaesthetists Campos JH, Kernsteine KH. A comparison of a left sided Bronchocath with the torque control blocker Univent and the wire guided blocker. Anesth Analg 2003; 96: 283-9 Campos JH et al. Devices for lung isolation used by anesthesiologists with limited thoracic experience. Anesthesiology 2006; 104: 261-6

9. Bronchial blockers Effectiveness • Indications above DLT • Difficult intubation • Rapid sequence induction • Tracheostomy • Disadvantages • Requires fibrescope • Slow deflation • Cuff damage less likely

10. Difficult intubation • Difficult airway • SLT / CAE catheter

11. Difficult intubation • Difficult airway • SLT / CAE catheter • Airtraq • Optical laryngoscope (C-MAC)

12. Failure of  One-lung ventilation • Unable to site DLT • Unable to collapse operative lung • High inflation pressures ventilating non-operative lung • Hypoxia during OLV

13. Failure ofOLV Unable to collapse operative lung Is OLV required? • Lung collapse essential • Some VATS • Lung collapse desirable • Majority of procedures • Lung collapse • VATS for malignant effusion

14. Failure ofOLV Unable to collapse operative lung How far to insert the DLT • Based on patient’s height: • 170cm (5’7”) – 29cm • 1cm for every 10cm (4”) height above or below this • ‘Until it stops’ Brodsky JB et al. Depth of placement of left double lumen endobronchial tubes. Anaesthesia and Analgesia 1991; 73:570-2

15. Failure ofOLV Unable to collapse operative lung

16. Double lumen tube placement Russell WJ. A blind guided technique for placing double lumen endobronchial tubes. Anaesthesia and Intensive Care 1992; 20: 71-4

17. Double lumen tube placement • Bronchial cuff is ‘plugged’ • Deflate bronchial cuff • Advance length of cuff + 1cm

18. Failure ofOLV Unable to collapse operative lung

19. Failure ofOLV Unable to collapse operative lung • Intubation of the secondary carina • High inflation pressures • ‘Less space’ • Cartilage rings less well defined • Angle at airway divisions less acute

20. Failure ofOLV Unable to collapse operative lung • DLT is in correct position • Cuff leak • Obstruction – suction • Pathology - COPD

21. Failure ofOLV Unable to collapse operative lung - Summary Is DLT positioned correctly? No Yes Consider: Not in far enough Too far in Intubation of 2 carina Consider: Cuff deflation Suction Pathology Tube clamp

22. Failure of  One-lung ventilation • Unable to site DLT • Unable to collapse operative lung • High inflation pressures ventilating non-operative lung • Hypoxia during OLV

23. Failure ofOLV High inflation pressures • Usual checks: • Paralysis • Check DLT position: • Usually DLT in too far • May be intubation of 2o carina • Suction: • Direct vision/blind

24. Failure ofOLV High inflation pressures

25. PAW VCV PCV Failure ofOLV High inflation pressures • Strategies to reduce PAW: • Reduce tidal volume • Increase I:E ratio • PEEP – reduce • Change to PCV (from VCV) Time

26. Failure ofOLV High inflation pressures - Summary Is DLT positioned correctly? No Yes Consider: Paralysis Suction Consider: Too far in Intubation of 2 carina Consider: Reduce TV Increase inspiratory time Reduce PEEP Try PCV

27. Failure of  One-lung ventilation • Unable to site DLT • Unable to collapse operative lung • High inflation pressures ventilating non-operative lung • Hypoxia during OLV

28. Failure ofOLVHypoxia Exclude a ‘ventilatory’ problem • Check R upper lobe bronchus Strategies to improve oxygenation • Increase FIO2 • PEEP to ventilated lung • Increase I:E ratio • Increase cardiac output • PaO2 is dependent on the CvO2, which is reliably increased by increasing the cardiac output. AI Levin, JF Coetzee, A Coetzee. Arterial oxygenation and one-lung anaesthesia. Current Opinion in Anesthesiology 2008; 21: 28-36

29. Failure ofOLVHypoxia • CPAP to operative lung • Improves hypoxia and reduces incidence of ALI/ARDS after OLV • May be tolerated during thoracotomy (intermittent) • Poorly tolerated during VATS • Clamp pulmonary artery

30. Failure ofOLVHypoxia McGlade DP, Slinger PD. The elective combined use of a DLT and endobronchial blocker to provide selective lobar isolation for lung resection following contralateral lobectomy. Anesthesiology 2003; 99: 1021-2

31. Failure ofOLV Hypoxia - Summary Is DLT positioned correctly? *RUL bronchus No Yes Reposition Consider: Increase FiO2 PEEP to non-op lung Increase inspiratory time Increase cardiac output Consider: CPAP to operative lung or selected lobe Clamp PA ? abandon procedure

32. www.bronchoscopy.org

33. Overview • Overview of thoracic anaesthesia • One-lung ventilation (OLV) • Double lumen tube (DLT) placement • Regional analgesia • Paravertebral block • Assessment for lung resection

34. Paravertebral catheters (PVC) • Traditional use of epidural • PVC in Exeter since late 90s • Good evidence base showing equivalent efficacy Joshi GP et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 2008; 107:1026-40. Davies RG, Myles PS, Graham JM. A comparison of the analgesia efficacy and side-effects of paravertebral versus epidural blockade for thoracotomy – a systematic review and meta-analysis of randomized trials. BJA 2006; 96: 418-26

35. Paravertebral catheters (PVC) • Traditional use of epidural • PVC in Exeter since late 90s • Good evidence base showing equivalent efficacy and better side-effect profile • Surgically placed • Epidural use: • Pectus carinatum/excavatum repair (open or MI) • Pleurectomy

36. Paravertebral catheters

37. Paravertebral catheters • Bupivavcaine 0.5% • Load with 20ml • 0.1ml/kg/hr for 24hr • Bupivavcaine 0.25% • 0.1ml/kg/hr for up to 5 days • Morphine PCA

38. Overview • Overview of thoracic anaesthesia • One-lung ventilation (OLV) • Double lumen tube (DLT) placement • Regional analgesia • Paravertebral block • Assessment for lung resection

39. Assessment for lung resection

40. Assessment for lung resection

41. Assessment for lung resection

42. Assessment for lung resection

43. Summary • DLT positioning • Paravertebral analgesia • Review available radiology • Communication