| Background One-lung ventilation(OLV)is vital for open thoracotomy or video-assisted thoracoscopic surgery to facilitate lung exposure for the surgical procedure by collapsing the lung.OLV has been provided by using a double-lumen tube(DLT),an endobronchial tube,a bronchial blocker,or an endotracheal tube with a movable bronchial blocker.Among these,Double-lumen tubes(DLTs)are used commonly.According to previous reports,the incidence of inappropriate DLT positioning is high in conventional manuver,and inappropriate DLT positioning can produce adverse events during OLV.Therefore,proper positioning of DLTs is critical for performing OLV successfully.The use of fiberoptic bronchoscope(FOB)is generally recommended for positoning of DLTs.However,the FOB is relatively expensive and may not always be available in clinical practice;The blood or mucus in the airway may also make it diffulcult to comfirm the position of DLTs.To address above shortcomings,we tried to devise a new and simple method to perform blind DLTs intubation,which could be used when a FOB is unavailable or inapplicable or when its use is difficult.The aim of this study was to determine whether this simple maneuver can be a substitute for FOB verification or guidance in most conditions requiring left-sided or right-sided DLTs.Part one A New and Simple Blind Placement of the Left-sided Double-Lumen TubesObjective To determine whether this simple maneuver can be a substitute for FOB verification or guidance in most conditions requiring left-sided double-lumen tubes(DLTs).Methods 88 adult patients belonging to ASA physical status grade I-?,aged 52-82 yr,undergoing elective thoracic surgery requiring a left-side DLT for OLV were enrolled for this study.we studied 70 men and 18 women.Of patients,22 patients underwent lobectomy,8 underwent exploratory thoracotomy,and 58 patients underwent video-assisted thoracoscopic surgery.The patients were randomly allocated to one of two groups: group I or group II,with 44 patients in each group.In group I,all patients received a new maneuver,and in group II all patients received conventional manuver.Randomization(1:1)based on computer-generated codes that were kept in sequentially numbered opaque envelopes.Patients who required absolutely right-sided DLT and presented with an intraluminal lesion on the left bronchus,who presented an very distorted anatomy of the tracheobronchial tree on chest radiograph,who presented with upper respiratory tract infection ? mellitus gastroesophageal reflux ? severe cardiopulmonary disease or cervical instability,or in whom intubation seemed to be difficult under direct vision were excluded from the study.Patients were monitored with electrocardiography,invasive arterial blood pressure,and pulse oxymetry.After the induction of anesthesia,the patients were intubated with left-sided Robertshaw DLTs by the same thoracic anesthesiologist using 1 of the 2 intubation techniques.After intubation of each DLT,with the patient still in the supine position,flexible bronchoscopy was performed by another anesthesiologist,who was not aware of the intubation methods being used and entered the operating room after the anesthesiologist had completed his evaluation.Optimal position was defined as the bronchial cuff was immediately below the tracheal carina and there was a clear view of the left subcarina,with unobstructed left upper and lower bronchi;Misplacement of the double-lumen tube was diagnosed when the tube had to be moved(in or out)for more than 0.5 cm to correct its position;Critical malposition meant a double-lumen tube dislocated in the trachea or in the right bronchi,requiring immediate re-intubation under bronchoscopic guidance.After bronchoscopic assessment,the DLT was either secured in its position or repositioned according to the bronchoscopic findings,under direct visualization,inserting the video bronchoscope inside the DLT.Eventually,the assessment of the anesthesiologist was recorded in the anesthesiologist's chart.The time for initial tube placement,with the patient in supine position,was defined as the time from passage of the tube past the vocal cords until there was satisfactory placement of DLT.Immediately before the start of surgery,patients were turned to the lateral position,and flexible bronchoscopy was performed again to verify whether the DLT was still well placed or not.The data obtained from this second bronchoscopic evaluation were not used for the analysis because the aim of the study was to compare the incidence of correct blind insertion of DLT in conventional manuver with that in new manuver immediately after intubation.When a procedure was finished,patient was turned from lateral position to supine position and the bronchia-sided tube of DLT was retracted into the trachea,FOB examination was performed to determine how much damage had occurred in the airway by the use of this new maneuver.The trachea under the tip of bronchi-sidedl tube and both main stem bronchi were examined,it was graded as clear,a few petechiae,coaesced,bruised petechiae or erosion.The variables recorded in this study were:1)the number of optimal position,misplacement or critical malposition;2)the time required to place DLT in the correct positon;3)degree of the airway damage.Sample size was based on a pilot study during which we measured the successful rate of double-lumen tube intubation with the new maneuver,and on a previous study.To detect a 30% absolute difference in successful rate of double-lumen tube intubation with the new maneuver,assuming a type I error protection of 0.05 and a power of 0.80,34 patients were needed in each group.Owing to the difficult setting and the potential risk of failure to intubate despite careful preparation,we decided to enroll 88 patients(44 per group)into trial.Data was presented as mean ± SD,or number of patients.The differences of intubation time between two groups were compared using the independent sample t test.Fishier's exact test was used to compare the incidence of misplacement,degree of airway damage and the surgical procedure.All statistical analyses were performed using the SPSS 17.0 software package(SPSS,Chicago,IL,USA)and a p value of less than 0.05 was considered statistically significant.Results 88 patients,44 patients in each group,were enrolled in this study.Both groups were comparable with respect to age,weight,height,sex,ASA physical status grade and DLT selected size(p>0.05).Time for the intubation of DLT took mean(SD)100(16.2)s in group I and 95.1(20.8)s in group II,The difference was not statistically significant(p>0.05).Time for FOB took 22(4.8)s in group I and was statistically faster than that in group II [ 43.6(23.7)s,p<0.01].Nearly 98% of the 44 intubations in group I was considered as an optimal position while only 52% of the the 44 intubations in group II was in optimal position,the difference was statistically significant(p<0.05);The number of misplacement was significantly greater in group II(p<0.05;There was only one critical malposition in each group because of right bronchial intubation.(p>0.05).The difference in grade of bronchial injury between the group I and group II was not statistically significant(p>0.05).Conclusion In conculsion,this new maneuver is rapid?acurate and safe,it may be substituted for the FOB during positioning of a lefe-sided DLT if FOB is unavailable or inapplicable.Part two A New and Simple Blind Placement of the right-sided Double-Lumen TubesObjective The aim of this study was to investigate the success rate of a new maneuvrer for blind placement of right-sided double-lumen tubes(DLTs)in the conditions requiring one lung ventilation(OLV).Methods After getting the approval from the medical ethics committee of the first affiliated hospital of an hui medical university and written consent from patients,46 adult patients,belonging to ASA physical status grade I or II,aged 46-80 yr,undergoing elective thoracic surgery requiring a right-sided DLT for OLV were enrolled in this study.32 men and 14 women patients were observed.The patients were randomly allocated to group I or group II with 23 patients in each group.In group I,the tube was inserted by a thoracic anesthesiologist.The following method was used for the tube placement: the right-sided DLT was introduced into the glottis via direct larygoscopy.A new method was used as follows step by step,Firstly,after the bronchia-sided tube cuff of the DLT had passed the vocal cords,the stylet was removed while the larygoscopy was not removed,and then bronchia-sided tube balloon was inflated with about 5.0 ml of air after the tube was rotated 90o towards the right bronchia.Secondly,the tube was advanced until resistance was felt,in which location the lower edge of left part of the bronchia-sided tube cuff was expected to be just above the carina.Thirdly,bronchia-sided tubel was ventilated,breath sounds should be present on right chest and be absent on the left chest by auscultation and the tip of the bronchia-sided tube was considered to be into the right bronchus,and at this location,the bronchia-sided tube cuff was deflated to advanced 10 mm forward,where the upper edge of bronchial cuff was expected to be just below the carina.If right upper lung could not be auscultated clearly,the DLTs should be withdrawn 1-2 mm every time until right upper lung could be auscultated clearly.If breath sounds was present on the left chest after the bronchial tube was ventilated,it was considered that the bronchia-sided tube was not inserted into the right bronchus,it was then retracted into the trachea and the procedure was repeated.If two attempts to advance the bronchia-sided tube into the right bronchus were unsuccessful,the FOB was used to guide the tube into correct place.In group II,the tube was inserted by the same thoracic anesthesiologist.The detailed procedures were as follows: the first step,after the cuff of the bronchia-sided tube had passed the vocal cords,the stylet was removed,and then the tube was rotated 90o towards the right and advanced until encountering certain resistance;the second step,after successful blind intubation,the anesthesiologist inflated the cuff of the bronchia-sided tube with appropriate volume of air(2-3 ml),observed the chest wall movements,auscultated both lungs before and after selective clamping of bronchial and tracheal lumen,and checked lung compliance by manual ventilation to verify the correct position of the DLT.After intubation of each DLT,with the patient still in the supine position,flexible bronchoscopy(ultra-slim 2.8-mm diameter Olympus video bronchoscope)was performed by another anesthesiologist,who was not aware of the intubation methods to assess DLT position.Optimal position was defined as the tracheal carina was not covered by the cuff of the bronchia-sided tube,the cuff of the bronchia-sided tube was immediately below the tracheal carina with a clear view of the unobstructed right middle and lower bronchi and right upper bronchi should be seen through the side hole of the bronchial tube.Misplacement of the double-lumen tube was diagnosed when the tube had to be moved(in or out)for more than 0.5 cm to correct its position.Critical malposition meant a double-lumen tube dislocated in the trachea or in the left bronchi,requiring immediate re-intubation under bronchoscopic guidance.After bronchoscopic assessment,the DLT was either secured in its position or repositioned according to the bronchoscopic assessment,under direct visualization,with the video bronchoscope.Eventually,the assessment of DLT position was recorded in the anesthesiologist's chart.The time for initial tube placement,with the patient in supine position,was defined as the time from the tube past the vocal cords until there was satisfactory placement of the bronchial lumen subjectively.Immediately before the start of surgery,patients were turned to the lateral position,and flexible bronchoscopy was performed again to verify whether the DLT was still well placed or not.The data obtained from the second bronchoscopic evaluation was also used for the analysis.The variables recorded in this study were: the number of optimal position,misplacement or critical malposition,the time required to place DLT in the correct position and the time for FOB verification.Results Forty-six adult patients undergoing elective thoracic surgery requiring a right-sided DLT for OLV were enrolled in this study with 23 patients in each group.Both groups were comparable with respect to age,weight,height,sex and DLT selected size(p>0.05).Time for the intubation of DLT took mean(SD)103.2(18.3)s in group I and 99.4(16.3)s in group II,the difference was not statistically significant(p>0.05);Time for FOB verification took 38.0(5.4)s in group I and was statistically faster than that in group II [ 60.7(9.2)s,p<0.01].100% of the 23 intubations in group I was considered as an optimal position while only 11(48.3%)of the 23 intubations in group II was in optimal position,the difference was statistically significant(p<0.01);The number of misplacement was significantly greater in group II(p<0.01);There was no critical malposition in each group.(p>0.05).Conclusion In conclusion,this simple maneuver is more rapid and more accurate to position right-sided DLTs than conventional maneuver.It can be substituted for the FOB during positioning of a right-sided DLT if FOB is unavailable or inapplicable. |
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