Abstract
One-lung ventilation (OLV) is essential in some surgical situations. The use of double-lumen tubes (DLTs) can achieve OLV more quickly and more easily than bronchial blockers. The management of a difficult airway is a challenge for anesthesiologists when, at the same time, OLV is needed for a surgical procedure. This report describes the successful application of DLTs in two patients with difficult airways, and who were scheduled for pulmonary decortication. Case 1 already had a permanent tra-cheostomy, while Case 2 had oral cancer with an extremely limited mouth opening and needed elective tracheostomy for anesthesia. Nasal intubation of Case 2 was done with fiberoptic-guided intubation with the patient awake. OLV was achieved uneventfully after inserting the DLT directly through the tracheostomy in both cases. We also describe the appropriate use of airway devices for OLV, focusing on patients with an anticipated difficult airway.
Keywords
intubation; intratracheal: double-lumen tubes; pulmonary ventilation: one-lung; tracheostomy;
1. Introduction
One-lung ventilation (OLV) is a useful technique in many thoracic surgeries where collapse or isolation of one lung is necessary. Several devices are avail-able to facilitate OLV, including double-lumen tubes (DLTs), bronchial blockers and Foley catheters, as previously reported.1−4 Generally, these devices are inserted via the oral cavity into the main bron-chus of the lung subjected to the operation. The position of these devices can be confirmed visually by fiberoptic bronchoscopy (FOB) or by ausculta-tion of breathing sounds with a stethoscope. Some difficulties may occur in some patients with a dif-ficult airway, particularly patients whose oral cav-ity is not suitable for tracheal intubation. Several clinical reports have described methods for man-aging such situations.2−6 Here, we report two cases with a difficult airway who were scheduled to un-dergo thoracic surgery. The DLT was inserted directly through the tracheostomy and intraoperative OLV was successfully achieved in both cases. We also discuss the appropriate use of OLV airway devices, particularly in patients with anticipated difficult airway.
2. Case Reports
2.1. Case 1
A 40-year-old man with hypopharyngeal carcinoma had undergone total laryngectomy and permanent tracheostomy before this admission. He was sched-uled for a right pulmonary decortication procedure due to lung empyema. Because the patient’s airway could only be kept patent through the tracheostomy, we used a small pediatric face mask for preoxygen-ation through the tracheostomy (Figure 1). The tra-cheostomy was well-covered and sealed with this mask, and ventilation was fine. General anesthesia was induced with fentanyl (1 μg/kg), propofol (2 mg/kg) and rocuronium (0.5 mg/kg). A size 28 DLT was inserted through the tracheostomy and correct placement was confirmed by FOB. The intraopera-tive OLV was performed smoothly. After completing surgery, the DLT was replaced with a tracheostomy tube. The patient was transferred to an intensive care unit for postoperative care.
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2.2. Case 2
A 35-year-old man weighing 50 kg had suffered from oral squamous cell carcinoma and had an ex-tremely limited mouth opening. He was scheduled for pulmonary decortication due to left lung em-pyema. The patient’s anticipated difficult airway was initially managed by nasal intubation via a FOB, with the patient awake. After intravenous administration of fentanyl (100 μg), the nasal ca-nals and the oropharynx were anesthetized with 6% cocaine (60 mg) and 10% lidocaine spray (1 spray/10 kg), respectively. The nostril with least resist-ance, as identified during nasal packing, was cho-sen for nasal intubation. Sensory blockade of the trachea was achieved by intratracheal injection of 3 mL of 2% lidocaine. Then, the anesthesiologist began the nasal intubation with a fiberoptic scope (Olympus ENF XP 4.5 mm; Olympus, Tokyo, Japan) encased in the lumen of a 7.0 mm tracheal tube. Once the nasal tracheal intubation was complete and the nasal endotracheal tube was secured, general anesthesia was induced with intravenous propofol (100 mg) and rocuronium (25 mg), and maintained with sevoflurane in oxygen. The sur-geons did the tracheostomy and then inserted a size 28 DLT through the freshly created tracheos-tomy stoma (Figure 2). The correct placement of the DLT was confirmed by FOB. Isolation of the left lung was successfully achieved and the DLT was re-placed by a traditional tracheostomy tube after completing the surgery.
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3. Discussion
Oral cancer is a relatively prevalent disease in Taiwan. It may lead to airway difficulties in the late stage of the disease. These anticipated problems could result from pathologic changes of the oral anatomy, or by cancer therapies, such as surgery and radiotherapy. We encountered two cases with dif-ficult airways, in which the oral cavities were not suitable for DLT insertion. In such circumstances, tracheostomy is necessary, but performed reluctantly, for successful airway management. In the present cases, we separated the two lungs by DLT via the tracheostomy, and all airway instrumentation was performed via the tracheostomy in both cases. Two methods of anesthetic management must be used in such situations. First, the DLT must be success-fully inserted via the tracheostomy.1 Second, a bron-chial blocker is needed to isolate the diseased lung via the tracheostomy tube.2,4,5
DLT is frequently used in thoracic surgery, par-ticularly in procedures that need a placid lung on the operative side by OLV. An increasing number of cases are presenting with difficult airways, mean-ing standard oral intubation is not possible.7 Such cases pose a challenge to anesthesiologists who must perform OLV for the surgical procedure. Bronchial blockers can also be placed via the tracheostomy tube in such situations.2,5,8 We decided to use DLT in our cases because DLT offers several advantages over bronchial blockers to separate the lungs in some surgical procedures. Some of the advantages of DLT over bronchial blockers are discussed below.
First, a DLT is easier and faster to place than bronchial blockers because its placement is almost identical to that of an ordinary endotracheal tube. Thus, any practitioner with experience of endotra-cheal tube placement can quickly learn to place a DLT. Second, a DLT is cheaper than the bronchial blockers and is reimbursed by the National Health Insurance in Taiwan. Third, displacement of the DLT from its correct location is less likely than with bron-chial blockers because its shape is solid, limiting un-wanted movement, and it can be securely attached to the lips by adhesive tape. Bronchial blockers are more prone to displacement when they are subjected to inflation and deflation. Fourth, a DLT has larger capacity cuffs for re-inflation and the airway pres-sure can be effectively controlled while the lung on the surgical side is re-inflated. Fifth, FOB is not essential to confirm the correct placement of the DLT, an important factor because FOB is an expen-sive instrument and may not be available in all op-erating rooms. In some cases, we can confirm the placement of the DLT by auscultation of breathing sounds with a stethoscope if FOB is unavailable. On the other hand, FOB is required in most cases to aid correct placement of bronchial blockers.
A cuffed tracheostomy endotracheal tube is con-ventionally used for ventilation in lieu of an ordinary tracheostomy tube during the induction of anesthe-sia in patients with a tracheostomy. However, con-ducting this procedure may elicit a coughing reflex and induce uncomfortable sensations. We noticed that some infantile round face masks were suitable for covering and sealing the tracheostomy stoma. Thus, we considered these masks useful for the in-duction of anesthesia in tracheostomy cases, with-out changeover of the ordinary tracheostomy tube.
In fact, patients could be well ventilated with this method. This method can also be used in emergency situations in the event of tube function failure (e.g. kinking) or if an appropriately sized tube is not immediately available. Ventilation through the tracheostomy via a face mask can be an expedient in critical situations.
We usually place a size 28 DLT through the tra-cheostomy stoma (sizes 28−32 are suitable for tra-cheostomy). FOB is a helpful tool to confirm correct placement of the tube. We can also use a stetho-scope for auscultation of breathing sounds to check the position if FOB is unavailable or if the proximal lens is blurred due to the presence of blood or other secretions.
In Case 2, a size 28 DLT was placed by the tho-racic surgeons immediately after the tracheostomy was prepared. We checked the position of the tube by FOB, and found that the tube was correctly placed. Although the surgeons were actually inex-perienced of placing a DLT, the tube was success-fully and smoothly placed. It is relatively easy to place a DLT through the stoma as compared with placing a bronchial blocker because the former can be done without the aid of FOB. In both cases presented here, the DLT was replaced by a size 8 tracheostomy tube after surgery. No specific periop-erative complications were noted. To prevent un-wanted displacement of the DLT, we secured it with adhesive tape (Figure 2).
4. Conclusion
Securing the airway is the first priority for patients with a difficult airway. For cases in which an exist-ing tracheostomy prevents oral intubation for DLT, a suitably sized DLT can be placed via the tracheos-tomy stoma because, in our experience, this tech-nique has a higher cost-benefit ratio compared with the placement of bronchial blockers. OLV can be successfully performed in patients with a difficult airway using these methods. We strongly recom-mend the use of FOB to confirm that the DLT is po-sitioned correctly. Traditional cuffed tracheostomy tubes of various sizes should be available in case of any emergency.