Sequential Bilateral Lung Isolation with a Single Bronchial Blocker Jay B. Brodsky, MD,* Alex Tzabazis, MD,* Jennifer Basarb-Tung, MD,* and Joseph B. Shrager, MD† Sequential bilateral lung separation and selective lung collapse can be accomplished with either a double-lumen tube, a single bronchial blocker (BB) that must be repositioned during the operation, or by using 2 BBs, 1 placed in each main bronchus. We provided sequential bilateral lung collapse using a single BB without the need to reposition during surgery. (A&A Case Reports 2013;1:17–8.)
T
he ability to safely isolate and selectively ventilate the lungs is essential for the modern practice of thoracic anesthesia. Sequential bilateral lung separation and selective lung collapse have been accomplished with either a double-lumen tube (DLT), with a single bronchial blocker (BB) that must be repositioned during the procedure, or with 2 BBs, 1 in each main bronchus. We used the new EZ-Blocker® (Teleflex, Reading, PA) which allowed us to provide sequential bilateral lung collapse with a single BB without the need to reposition during surgery. This case report was in compliance with IRB requirements, and the patient gave permission to report and publish this case.
CASE REPORT
A 51-year-old woman (1.65 m, 78.5 kg, ASA physical status II) presented with an anterior mediastinal mass and a history of nonproductive cough. She was scheduled to undergo a median sternotomy for resection of the mass. The patient did not have any symptoms consistent with tracheal or major vessel obstruction. Her medical and surgical histories were nonsignificant. In the operating room, standard ASA monitors were applied. After oxygen administration, an IV anesthetic induction was performed with fentanyl 150 μg and propofol 150 mg, and rocuronium 50 mg was used to facilitate tracheal intubation. Direct laryngoscopy revealed a Cormack-Lehane grade 2 view and an 8.0-mm endotracheal tube (ETT) was placed atraumatically and secured with the tip 20 cm from the teeth line. Placement of the ETT was confirmed by capnography and bilateral auscultation. Anesthetic maintenance was with sevoflurane (2%) and oxygen, with IV fentanyl boluses. Both lungs were initially ventilated. However, 45 minutes into the operation, the surgeon entered the pleura and requested that we collapse the right lung to improve operative conditions. An EZ-Blocker was placed through 1 port of a multiport adaptor connected to the ETT, and under From the Departments of *Anesthesia and †Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California. Accepted for publication February 26, 2013. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Jay B. Brodsky, MD, Department of Anesthesia, Stanford University School of Medicine, H 3580, Stanford University Medical Center, Stanford, CA 94305. Address e-mail to [email protected]. Copyright © 2013 International Anesthesia Research Society DOI: 10.1097/ACC.0b013e318291d364
October 1, 2013 • Volume 1 • Number 1
fiberoptic bronchoscopic guidance the BB was advanced into the trachea. Correct placement with deployment of the 2 distal ends of the EZ-Blocker, 1 in each bronchus, was visually confirmed. The balloon on the blocker in the right main bronchus was then inflated while ventilation continued to the left lung. The nonventilated, immobile right lung collapsed providing a quiet surgical field. Several times during the next 60 minutes, the surgical team requested sequential collapse of and reexpansion of each lung to optimize operative field exposure. This was accomplished by deflation of the inflated balloon followed by inflation of the balloon in the opposite bronchus without the need to reposition the BB. At no time was ventilation interrupted. The patient tolerated these maneuvers and maintained a satisfactory oxyhemoglobin saturation (>98%) throughout the entire case. At the completion of surgery, with both balloons deflated, the BB was withdrawn from the ETT. General anesthesia was discontinued, and the patient’s trachea was extubated in the operating room. The patient had no complaints of hoarseness or sore throat on postoperative day 1.
DISCUSSION
For the majority of thoracic procedures, either a DLT or BB can be used to achieve lung separation with equal success. The choice depends on the specific surgical requirements, the patient’s airway, the individual preferences, and experience of the anesthesiologist.1 Recently, several balloon-tipped catheters (Arndt® Endobronchial Blocker, Cook Medical Inc, Bloomington, IN; Cohen® Flexi-tip Blocker, Cook Medical Inc, Bloomington, IN; Uniblocker®, LMA North America, San Diego, CA) designed specifically for bronchial blockade have become available. Their ease of placement and the quality of the lung isolation are similar to that achieved with a DLT.2 However, since a BB is used with a conventional ETT, it is often chosen for the patient with a “difficult” airway when placement of a DLT could be challenging or perhaps not possible, or when intraoperative exchange of an existing ETT to a DLT could be potentially dangerous.3 Isolation and collapse of the right lung was requested midway through the procedure. We wanted to avoid the risks of losing the airway or interrupting ventilation by attempting to exchange the ETT for a DLT. The unique properties of the EZ-Blocker made it the ideal choice for our patient. It can be used with a 7-mm id or larger ETT. It consists of a 7 Fr polyurethane catheter with 4 lumens. Two of the lumens are for inflation of the blocker balloons, while the other 2 can be used to insufflate oxygen to the cases-anesthesia-analgesia.org
17
Bilateral Lung Isolation with a Bronchial Blocker
Figure 1. The EZ-Blocker® Y-shaped distal end consists of two 4 cm long extensions, each with a spherically shaped balloon. The extensions are symmetrical and colored blue and green for easy identification by bronchoscopy. The catheter is advanced through a multiport adaptor connected to the endotracheal tube until the Y engages the tracheal carina. In this position, each balloon-tipped extension will be in 1 of the 2 main bronchi. Either balloon can then be inflated to isolate and collapse the lung on that side.
nonventilated lung or for suctioning.4 The Y-shaped distal end consists of two 4 cm long extensions, each with a spherically shaped balloon. (Fig. 1) The extensions are symmetrical with one colored blue and the other yellow for easy identification. The tip of the ETT must be at least 4 cm above the carina for the self-expanding extensions to fully deploy. The blocker is advanced until it engages the tracheal carina with each balloon-tipped extension entering 1 of the 2 main bronchi. Often during surgery the operated lung needs to be deflated and then reexpanded, a maneuver easily accomplished with a DLT but difficult or impossible with a BB. BBs can be displaced when changing patient position, from surgical manipulation, or with deflation and/or inflation. If the balloon slips into the trachea, it can obstruct ventilation to both lungs and/or fail to protect the healthy lung from contamination. Any BB could be used to perform bilateral sequential lung collapse and reexpansion, but to do so would require frequent repositioning of the BB during surgery.5 This is both time consuming and potentially dangerous if the balloon herniates into the trachea. Owing to its Y shape, the EZ-Blocker remains in position with little chance of balloon displacement. A study comparing the EZ-Blocker with DLTs reported that placement was somewhat longer with the blocker, but operative conditions were equal.6 Previous reports have described using 2 independent BBs, 1 placed in each of the 2 main bronchi for sequential lung isolation.7,8 A single EZ-Blocker allowed us to
18 cases-anesthesia-analgesia.org
provide safe, reliable bilateral lung collapse eliminating the need for 2 blockers or the risk of exchanging an ETT for a DLT. Collapse and isolation of either lung was easily and safely accomplished without risk of balloon displacement. For these reasons, the EZ-Blocker should be considered in instances when sequential bilateral lung isolation is required. E REFERENCES 1. Narayanaswamy M, McRae K, Slinger P, Dugas G, Kanellakos GW, Roscoe A, Lacroix M. Choosing a lung isolation device for thoracic surgery: a randomized trial of three bronchial blockers versus double-lumen tubes. Anesth Analg 2009;108:1097–101 2. Campos JH, Kerstine KH. A comparison of left-sided Bronchocath® with the torque control blocker Univent® and the wire-guided blocker. Anesth Analg 2003;96:283–9 3. Brodsky JB. Lung separation and the difficult airway. Br J Anaesth 2009;103:66–75 4. Mungroop HE, Wai PT, Morei MN, Loef BG, Epema AH. Lung isolation with a new Y-shaped endobronchial blocking device, the EZ-Blocker. Br J Anaesth 2010;104:119–20 5. Ruiz P. Sequential lobar-lung-lobar isolation using a deflecting tip bronchial blocker. J Clin Anesth 2006;18:620–3 6. Ruetzler K, Grubhofer G, Schmid W, Papp D, Nabecker S, Hutschala D, Lang G, Hager H. Randomized clinical trial comparing double-lumen tube and EZ-Blocker for single-lung ventilation. Br J Anaesth 2011;106:896–902 7. Amar D, Desiderio DP, Bains MS, Wilson RS. A novel method of one-lung isolation using a double endobronchial blocker technique. Anesthesiology 2001;95:1528–30 8. Culp WC Jr, Kinsky MP. Sequential one-lung isolation using a double arndt bronchial blocker technique. Anesth Analg 2004;99:945–6
A & A case reports
T
he ability to safely isolate and selectively ventilate the lungs is essential for the modern practice of thoracic anesthesia. Sequential bilateral lung separation and selective lung collapse have been accomplished with either a double-lumen tube (DLT), with a single bronchial blocker (BB) that must be repositioned during the procedure, or with 2 BBs, 1 in each main bronchus. We used the new EZ-Blocker® (Teleflex, Reading, PA) which allowed us to provide sequential bilateral lung collapse with a single BB without the need to reposition during surgery. This case report was in compliance with IRB requirements, and the patient gave permission to report and publish this case.
CASE REPORT
A 51-year-old woman (1.65 m, 78.5 kg, ASA physical status II) presented with an anterior mediastinal mass and a history of nonproductive cough. She was scheduled to undergo a median sternotomy for resection of the mass. The patient did not have any symptoms consistent with tracheal or major vessel obstruction. Her medical and surgical histories were nonsignificant. In the operating room, standard ASA monitors were applied. After oxygen administration, an IV anesthetic induction was performed with fentanyl 150 μg and propofol 150 mg, and rocuronium 50 mg was used to facilitate tracheal intubation. Direct laryngoscopy revealed a Cormack-Lehane grade 2 view and an 8.0-mm endotracheal tube (ETT) was placed atraumatically and secured with the tip 20 cm from the teeth line. Placement of the ETT was confirmed by capnography and bilateral auscultation. Anesthetic maintenance was with sevoflurane (2%) and oxygen, with IV fentanyl boluses. Both lungs were initially ventilated. However, 45 minutes into the operation, the surgeon entered the pleura and requested that we collapse the right lung to improve operative conditions. An EZ-Blocker was placed through 1 port of a multiport adaptor connected to the ETT, and under From the Departments of *Anesthesia and †Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California. Accepted for publication February 26, 2013. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Jay B. Brodsky, MD, Department of Anesthesia, Stanford University School of Medicine, H 3580, Stanford University Medical Center, Stanford, CA 94305. Address e-mail to [email protected]. Copyright © 2013 International Anesthesia Research Society DOI: 10.1097/ACC.0b013e318291d364
October 1, 2013 • Volume 1 • Number 1
fiberoptic bronchoscopic guidance the BB was advanced into the trachea. Correct placement with deployment of the 2 distal ends of the EZ-Blocker, 1 in each bronchus, was visually confirmed. The balloon on the blocker in the right main bronchus was then inflated while ventilation continued to the left lung. The nonventilated, immobile right lung collapsed providing a quiet surgical field. Several times during the next 60 minutes, the surgical team requested sequential collapse of and reexpansion of each lung to optimize operative field exposure. This was accomplished by deflation of the inflated balloon followed by inflation of the balloon in the opposite bronchus without the need to reposition the BB. At no time was ventilation interrupted. The patient tolerated these maneuvers and maintained a satisfactory oxyhemoglobin saturation (>98%) throughout the entire case. At the completion of surgery, with both balloons deflated, the BB was withdrawn from the ETT. General anesthesia was discontinued, and the patient’s trachea was extubated in the operating room. The patient had no complaints of hoarseness or sore throat on postoperative day 1.
DISCUSSION
For the majority of thoracic procedures, either a DLT or BB can be used to achieve lung separation with equal success. The choice depends on the specific surgical requirements, the patient’s airway, the individual preferences, and experience of the anesthesiologist.1 Recently, several balloon-tipped catheters (Arndt® Endobronchial Blocker, Cook Medical Inc, Bloomington, IN; Cohen® Flexi-tip Blocker, Cook Medical Inc, Bloomington, IN; Uniblocker®, LMA North America, San Diego, CA) designed specifically for bronchial blockade have become available. Their ease of placement and the quality of the lung isolation are similar to that achieved with a DLT.2 However, since a BB is used with a conventional ETT, it is often chosen for the patient with a “difficult” airway when placement of a DLT could be challenging or perhaps not possible, or when intraoperative exchange of an existing ETT to a DLT could be potentially dangerous.3 Isolation and collapse of the right lung was requested midway through the procedure. We wanted to avoid the risks of losing the airway or interrupting ventilation by attempting to exchange the ETT for a DLT. The unique properties of the EZ-Blocker made it the ideal choice for our patient. It can be used with a 7-mm id or larger ETT. It consists of a 7 Fr polyurethane catheter with 4 lumens. Two of the lumens are for inflation of the blocker balloons, while the other 2 can be used to insufflate oxygen to the cases-anesthesia-analgesia.org
17
Bilateral Lung Isolation with a Bronchial Blocker
Figure 1. The EZ-Blocker® Y-shaped distal end consists of two 4 cm long extensions, each with a spherically shaped balloon. The extensions are symmetrical and colored blue and green for easy identification by bronchoscopy. The catheter is advanced through a multiport adaptor connected to the endotracheal tube until the Y engages the tracheal carina. In this position, each balloon-tipped extension will be in 1 of the 2 main bronchi. Either balloon can then be inflated to isolate and collapse the lung on that side.
nonventilated lung or for suctioning.4 The Y-shaped distal end consists of two 4 cm long extensions, each with a spherically shaped balloon. (Fig. 1) The extensions are symmetrical with one colored blue and the other yellow for easy identification. The tip of the ETT must be at least 4 cm above the carina for the self-expanding extensions to fully deploy. The blocker is advanced until it engages the tracheal carina with each balloon-tipped extension entering 1 of the 2 main bronchi. Often during surgery the operated lung needs to be deflated and then reexpanded, a maneuver easily accomplished with a DLT but difficult or impossible with a BB. BBs can be displaced when changing patient position, from surgical manipulation, or with deflation and/or inflation. If the balloon slips into the trachea, it can obstruct ventilation to both lungs and/or fail to protect the healthy lung from contamination. Any BB could be used to perform bilateral sequential lung collapse and reexpansion, but to do so would require frequent repositioning of the BB during surgery.5 This is both time consuming and potentially dangerous if the balloon herniates into the trachea. Owing to its Y shape, the EZ-Blocker remains in position with little chance of balloon displacement. A study comparing the EZ-Blocker with DLTs reported that placement was somewhat longer with the blocker, but operative conditions were equal.6 Previous reports have described using 2 independent BBs, 1 placed in each of the 2 main bronchi for sequential lung isolation.7,8 A single EZ-Blocker allowed us to
18 cases-anesthesia-analgesia.org
provide safe, reliable bilateral lung collapse eliminating the need for 2 blockers or the risk of exchanging an ETT for a DLT. Collapse and isolation of either lung was easily and safely accomplished without risk of balloon displacement. For these reasons, the EZ-Blocker should be considered in instances when sequential bilateral lung isolation is required. E REFERENCES 1. Narayanaswamy M, McRae K, Slinger P, Dugas G, Kanellakos GW, Roscoe A, Lacroix M. Choosing a lung isolation device for thoracic surgery: a randomized trial of three bronchial blockers versus double-lumen tubes. Anesth Analg 2009;108:1097–101 2. Campos JH, Kerstine KH. A comparison of left-sided Bronchocath® with the torque control blocker Univent® and the wire-guided blocker. Anesth Analg 2003;96:283–9 3. Brodsky JB. Lung separation and the difficult airway. Br J Anaesth 2009;103:66–75 4. Mungroop HE, Wai PT, Morei MN, Loef BG, Epema AH. Lung isolation with a new Y-shaped endobronchial blocking device, the EZ-Blocker. Br J Anaesth 2010;104:119–20 5. Ruiz P. Sequential lobar-lung-lobar isolation using a deflecting tip bronchial blocker. J Clin Anesth 2006;18:620–3 6. Ruetzler K, Grubhofer G, Schmid W, Papp D, Nabecker S, Hutschala D, Lang G, Hager H. Randomized clinical trial comparing double-lumen tube and EZ-Blocker for single-lung ventilation. Br J Anaesth 2011;106:896–902 7. Amar D, Desiderio DP, Bains MS, Wilson RS. A novel method of one-lung isolation using a double endobronchial blocker technique. Anesthesiology 2001;95:1528–30 8. Culp WC Jr, Kinsky MP. Sequential one-lung isolation using a double arndt bronchial blocker technique. Anesth Analg 2004;99:945–6
A & A case reports
