Thoracic anaesthesia post fellowship study day
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Thoracic Anaesthesia Post-Fellowship Study Day. Bruce McCormick Royal Devon and Exeter NHS Foundation Trust 15 th November 2010. Overview. Overview of thoracic anaesthesia One-lung ventilation (OLV) Double lumen tube (DLT) placement Regional analgesia Paravertebral block

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Thoracic Anaesthesia Post-Fellowship Study Day

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Thoracic AnaesthesiaPost-Fellowship Study Day

Bruce McCormick

Royal Devon and Exeter NHS Foundation Trust

15th November 2010


Overview

  • Overview of thoracic anaesthesia

  • One-lung ventilation (OLV)

  • Double lumen tube (DLT) placement

  • Regional analgesia

    • Paravertebral block

  • Assessment for lung resection


Overview – A typical list


Others


Double lumen tube placement

  • Left DLT unless….

  • Which side is op?

    • Clamp it

    • Allow lung to collapse


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


Failure of

One-lung ventilation

  • Unable to site DLT

  • Unable to collapse operative lung

  • High inflation pressures ventilating non-operative lung

  • Hypoxia during OLV


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


Bronchial blockers Effectiveness

  • Indications above DLT

    • Difficult intubation

    • Rapid sequence induction

    • Tracheostomy

  • Disadvantages

    • Requires fibrescope

    • Slow deflation

    • Cuff damage less likely


Difficult intubation

  • Difficult airway

    • SLT / CAE catheter


Difficult intubation

  • Difficult airway

    • SLT / CAE catheter

    • Airtraq

    • Optical laryngoscope (C-MAC)


Failure of

One-lung ventilation

  • Unable to site DLT

  • Unable to collapse operative lung

  • High inflation pressures ventilating non-operative lung

  • Hypoxia during OLV


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


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


Failure ofOLV Unable to collapse operative lung


Double lumen tube placement

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


Double lumen tube placement

  • Bronchial cuff is ‘plugged’

  • Deflate bronchial cuff

  • Advance length of cuff + 1cm


Failure ofOLV Unable to collapse operative lung


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


Failure ofOLV Unable to collapse operative lung

  • DLT is in correct position

    • Cuff leak

    • Obstruction – suction

    • Pathology - COPD


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


Failure of

One-lung ventilation

  • Unable to site DLT

  • Unable to collapse operative lung

  • High inflation pressures ventilating non-operative lung

  • Hypoxia during OLV


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


Failure ofOLV High inflation pressures


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


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


Failure of

One-lung ventilation

  • Unable to site DLT

  • Unable to collapse operative lung

  • High inflation pressures ventilating non-operative lung

  • Hypoxia during OLV


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


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


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


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


www.bronchoscopy.org


Overview

  • Overview of thoracic anaesthesia

  • One-lung ventilation (OLV)

  • Double lumen tube (DLT) placement

  • Regional analgesia

    • Paravertebral block

  • Assessment for lung resection


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


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


Paravertebral catheters


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


Overview

  • Overview of thoracic anaesthesia

  • One-lung ventilation (OLV)

  • Double lumen tube (DLT) placement

  • Regional analgesia

    • Paravertebral block

  • Assessment for lung resection


Assessment for lung resection


Assessment for lung resection


Assessment for lung resection


Assessment for lung resection


Summary

  • DLT positioning

  • Paravertebral analgesia

  • Review available radiology

  • Communication


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