Lung isolation techniques

INDICATIONS

There are only two absolute indications for lung isolation:

1. Avoiding lung contamination

Healthy lung tissue can be contaminated by hemorrhage or infection.

2. Isolating massive air leaks

These are usually due to bronchopleural fistula

Lung surgery used to be considerd a relative indication for single-lung ventilation, i.e. nice to have but not essential for performing surgery. In cases where lung isolation was difficult to achieve, it was in the past almost always possible to retract lung tissue as most surgery was performed through an 'open' thoracotomy access to the chest. However, more lung (resection) operations are now performed video-assisted through an endoscopic approach. It is much more difficult if not impossible for the surgeon to simply retract lung with endoscopic instruments!


EQUIPMENT

Several devices can be used to achieve lung isolation, namely double-lumen endotracheal tubes and different types of endobronchial blockers.

There are certain advantages and disadvantages to the use of either double-lumen tubes or bronchial blockers:

 

 

Double-lumen tube

Endobronchial blocker

Selectiveness of isolation

Only whole-lung isolation is possible

Selective lobar and segmental blockade possible

Use of lumen accessing isolated lung

Suction catheter or fiberoptic scope can be passed through tracheal or bronchial lumen

Small lumen of blocker does not allow passage of suction catheter or fiberoptic scope

Re-inflation of isolated lung

Re-inflation of isolated lung possible while maintaining lung isolation

Re-inflation of isolated lung only possible by deflating blocker cuff, losing lung isolation at this point

Use in difficult intubation techniques

Not suitable for most difficult intubation techniques

Can be used following nasal intubation, awake fiberoptic intubation, optical stylet-guided intubation, videolaryngoscopy intubation

Use in distorted trachebronchial anatomy

Difficult if not impossible

Device of choice

Use with intraluminal tracheal/ carinal or proximal mainstem bronchial lesion

Contra-indicated (on the side of the bronchial lesion) and in all tracheal lesions

Possible

 


TECHNIQUES

A number of techniques are available which are discussed under the following links:

1. Lung isolation with a double-lumen tube

2. Deliberate main bronchus intubation with a standard ETT

3. Lung isolation with the UNIVENT® tube

Despite the strong preference or dislike many thoracic surgeons (and some anesthesiologists) seem to have for either double-lumen tubes or bronchial blockers, a review of current evidence suggests that both are equally suited to provide one-lung ventilation (Campos, 2007).


REFERENCES

Campos, Javier H. (2007): Which device should be considered the best for lung isolation: double-lumen endotracheal tube versus bronchial blockers. In Curr Opin Anaesthesiol 20 (1), pp. 27–31.