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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Royal Devon and Exeter NHS Foundation Trust
15th November 2010
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
Comparison to DLT
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
Is OLV required?
How far to insert the DLT
Brodsky JB et al. Depth of placement of left double lumen endobronchial tubes. Anaesthesia and Analgesia 1991; 73:570-2
Russell WJ. A blind guided technique for placing double lumen endobronchial tubes. Anaesthesia and Intensive Care 1992; 20: 71-4
Is DLT positioned correctly?
Consider: Not in far enough Too far in Intubation of 2 carina
Consider: Cuff deflation Suction Pathology Tube clamp
PCVFailure ofOLV High inflation pressures
Is DLT positioned correctly?
Consider: Paralysis Suction
Consider: Too far in Intubation of 2 carina
Consider: Reduce TV Increase inspiratory time Reduce PEEP Try PCV
Exclude a ‘ventilatory’ problem
Strategies to improve oxygenation
AI Levin, JF Coetzee, A Coetzee. Arterial oxygenation and one-lung anaesthesia. Current Opinion in Anesthesiology 2008; 21: 28-36
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
Is DLT positioned correctly? *RUL bronchus
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
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
and better side-effect profile