Thoracic anaesthesia post fellowship study day
Download
1 / 43

Thoracic Anaesthesia Post-Fellowship Study Day - PowerPoint PPT Presentation


  • 138 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Thoracic Anaesthesia Post-Fellowship Study Day' - bela


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
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




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



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 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






Summary
Summary

  • DLT positioning

  • Paravertebral analgesia

  • Review available radiology

  • Communication


ad