Session 24. Lung Isolation (Double Lumen and Bronchial Blockers) Flashcards by Kira Harms

trachea

anterior: C shaped rings
posterior: smooth muscle (trachealis)

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right lung

3 lobes
upper
middle
lower

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left lung

2 lobes
upper
lower

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which lung is larger

right

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lung lobes

are further divided

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right bronchus length

1-2.5cm

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left bronchus length

5cm

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left bronchus vs right bronchus angle

left is more acute than right
(more horizontal than right)

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left bronchus vs right bronchus diamter

right typically larger diameter than left

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right upper lobe takeoff

short
can occur above carina at level of trachea

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right upper lobe takeoff can cause

easy occlusion
difficult to visualize

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what indicates a right upper lobe short takeoff

mercedes sign

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lung isolation indications: pt condition

infection
bleeding
bronchopleura fistula
cyst
hypoxia due to unilateral lung process

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what can a bronchopleural fistual cause

decreased negative pressure

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lung isolation indications: procedures

thoracic aortic aneurysm repair
lung resection
thoroscopy
esophageal surgery
single side pulmonary transplant
rib fixation
thoracic spine surgery anterior approach

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lung isolation contraindications

none

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what should you be mindful of during lung isolation

dont palce left DLT if left bronchus lesions (etc)

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lung isolation issues

similar to laryngoscopy

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left double lumen tube

std for lung isolation
goes into left bronchus

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right double lumen tube

not common
oblique bronchial cuff (allows RUL ventilation)

not interchangeable with left DLT

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double lumen sizing

35-41Fr

most common: 37-39Fr
female: 37
male: 39

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right double lumen tube indications

left bronchus lesions/stenosis
surgery involving high up on left bronchus

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types of right double lumen tubes

mallinckrodt: oblique
protex: bean
sheridan: 2 cuffs
rusch: oblique

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tracheal lumen

clear
10ml syringe

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bronchial lumen

blue 3ml syringe

stylet is placed in what lumen

bronchial (blue) lumen

compressible adapter (DLT)

allows for clamping (Isolation) allows for bronchoscopy

y piece (DLT)

connects lumens to circuit bronchial: left tracheal: right

where can you get a tube clamp for DLT

ask scrub tech

kids (8+) DLT size

26Fr

peds DLT

typically not used isolate w/regular ETT mainstem

women DLT size

37Fr

men DLT size

39Fr

where do you lubricate DLT

base of cuffs

why is pre-ox important prior to DLT insertion?

extra pre-ox needed bc pts have lung pathology pts more susceptible to apnea DLT insertion typically involves longer apneic period

when do you remove stylet from DLT

once bronchial tip past cords

what can happen if you fail to remove sylet from DLT

trachea perforation

how do you get bronchial cuff into left bronchus?

exaggerated counter clockwise rotation (90-180 deg) of tube towards pts left

typical DLT insertion depth

28-31cm (dont rely on this)

how do you verify DLT placement?

bronchoscope down tracheal lumen

what should you avoid when inflating bronchial cuff?

avoid herniating over carina

what should you hear when you clamp the tracheal lumen on a Left DLT?

left side breath sounds (left is bronchia lumen right is tracheal)

what should you hear when you clamp the bronchial lumen on right DLT?

left side breath sounds (right is bronchial left is tracheal)

what can happen if DLT moves a few milimeters?

can have a leak risk loss of lung isolation

Left DLT is placed bronchial lumen is clamped you hear breath sounds on left what does this tell you?

bronchial: left tracheal: right if i clamp the bronchial, i should hear breath sounds on the right I am hearing breath sounds of the left because the DLT has been placed too deep. - tracheal cuff is in the bronchus - bronchial cuff is in a lobe

Left DLT is placed bronchial lumen is clamped you do not hear breath sounds on the left clamp tracheal to isolate right lung surgeon says that right lung is inflating what does this tell you?

bronchial: left tracheal; right if i clamp the bronchial, i should not hear breath sounds on the left. I am not hearing breath sounds on the left because the tracheal cuff is in the correct spot My right lung is still inflating because the bronchial cuff is in the wrong bronchus.

bronchial blocker types

cohen EZ arndt uniblocker

cohen blocker

wire w/wheel

ez blocker

2 cuffs one on either side of carina

arndt blocker

wire loop that grabs bronchoscope

uniblocker

not commonly used

bronchial blocker adapter ports

ETT circuit blocker bronchoscope

bronchial blocker adapter is essential for

simultaneous: ventilation securing blocker bronchoscopy

which blockers have murphy eyes

cohen arndt

what sixe ETT are needed to use bronchial blockers?

larger size (8.0+)

what FiO2 is required when placing bronchial blocker

100% FiO2

most common bronchial blocker

EZ blocker

EZ blocker cuff syringe

10mL

risk of right bronchial blocker

air trapped in right upper lobe

what are bronchial blockers great at?

lobe isolation

confirmation of blocker placement

bronchoscopy auscultation direct visualization via VAT or thorocotomy

gold std for bronchial blocker confirmation

VAT thorocotomy

what is suction used for in bronchial blockers?

helps deflate lung

why do you increase insufflation pressure during bronchial lung isolation?

presses down on lung

increase pressure in thorax causes

decreased CVP decreased preload decreased CO increased HR

how do you compensate for decreased CVP?

give fluids

why should you avoid placing catheters into lung?

surgeon could staple through it

hypoxic pulmonary vasoconstriction

blood shunted from hypoxic alvoli to the ones exposed to O2 (isolates the lung)

volatile agent impact on HPV

decrease minimal impacts <1MAC

tidal volume for lung isolation

3ml/kg allows HPV to occur

increased RR can cause

air trapping

how to prevent air trapping

increase I:E ratio

what happens with a higher tidal volume in lung isolation

incr PIP incr PEEP compress vessels (incr Resistance) decr BF decr O2 capacity/exhange incr hypoxia

lung isolation fluid management

keep dry (<3L in 24 hrs) ignore 3rd space losses use inotropes to manage hemodynamics

increased fluids causes

increased shunting depended pulmonary edema decreased O2/CO2 diffusion

N2O in lung isolation cases

no benefit causes atelectasis incr pulm artery pressures inhibits hPV

N2O contraindicated in pts

w/blebs or blullae

hypothermia and HPV

inhibits HPV

why do you use 100% FiO2 in lung isolation

it induces atelectasis on operative side (deflates lung being worked on)

hypoxia level in lung isolation

>90% SpO2 PaO2 >60mmHg (no actual low level - some pts can tolerate lower levels)

why should you maintain 70-80% FiO2 in lung isolation

gives quick method to increase O2 delivery while you fix the issue

HPV and CO2

HPV more effective in respiratory acidosis HPV less effective in respiratory alkalosis (CO2 is acidic - keep pt slightly higher on CO2)

Lung isolation ventilation management

1. ensure 100% FiO2 2. check DLT/blocker positiion 3. ensure optimal CO decrease VA <1MAC 4. apply recruitment maneuver to ventilated lung 5. apply PEEP 5cmH2O to vent. lung 6. apply CPAP 1-2cmH2O to nonvent lung 7. intermittent reinflaction of non-vent lung 8. partial vent techniques of non-vent lung 9. mech restriction of blood flow to non-vent ung

what pts should you not apply PEEP to?

COPD/emphysema pts

partial ventilation techniques of non-vent lung

o2 insufflation high-freq ventilation lobar collapse vs entire lung collapse