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

Thoracic AnaesthesiaPost-Fellowship Study Day

Bruce McCormick

Royal Devon and Exeter NHS Foundation Trust

15th November 2010


Overview

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

Overview – A typical list


Others

Others


Double lumen tube placement

Double lumen tube placement

  • Left DLT unless….

  • Which side is op?

    • Clamp it

    • Allow lung to collapse


Double lumen tube placement1

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


One lung ventilation

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

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 effectiveness1

Bronchial blockers Effectiveness

  • Indications above DLT

    • Difficult intubation

    • Rapid sequence induction

    • Tracheostomy

  • Disadvantages

    • Requires fibrescope

    • Slow deflation

    • Cuff damage less likely


Difficult intubation

Difficult intubation

  • Difficult airway

    • SLT / CAE catheter


Difficult intubation1

Difficult intubation

  • Difficult airway

    • SLT / CAE catheter

    • Airtraq

    • Optical laryngoscope (C-MAC)


One lung ventilation1

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 of olv unable to collapse operative lung

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 of olv unable to collapse operative lung1

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 of olv unable to collapse operative lung2

Failure ofOLV Unable to collapse operative lung


Double lumen tube placement2

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 placement3

Double lumen tube placement

  • Bronchial cuff is ‘plugged’

  • Deflate bronchial cuff

  • Advance length of cuff + 1cm


Failure of olv unable to collapse operative lung3

Failure ofOLV Unable to collapse operative lung


Failure of olv unable to collapse operative lung4

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 of olv unable to collapse operative lung5

Failure ofOLV Unable to collapse operative lung

  • DLT is in correct position

    • Cuff leak

    • Obstruction – suction

    • Pathology - COPD


Failure of olv unable to collapse operative lung summary

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


One lung ventilation2

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 of olv high inflation pressures

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 of olv high inflation pressures1

Failure ofOLV High inflation pressures


Failure of olv high inflation pressures2

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 of olv high inflation pressures summary

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


One lung ventilation3

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 of olv hypoxia

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 of olv hypoxia1

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 of olv hypoxia2

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 of olv hypoxia summary

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

www.bronchoscopy.org


Overview1

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

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 pvc1

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


Paravertebral catheters1

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


Overview2

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 resection1

Assessment for lung resection


Assessment for lung resection2

Assessment for lung resection


Assessment for lung resection3

Assessment for lung resection


Summary

Summary

  • DLT positioning

  • Paravertebral analgesia

  • Review available radiology

  • Communication


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