Bronchial blocker

Bronchial blocker

Anesthesia type	Thoracic Surgery
Airway
Lines and access
Monitors
Primary anesthetic considerations
Preoperative
Intraoperative	Displacement Airway injury/obstruction Interference with staple line
Postoperative
Article quality
Editor rating	In development
User likes	0

Definition: High-pressure low-volume balloon device utilized for complete one-lung isolation or selective lobar blockade

Types

• Wire-guided bronchial blocker
• Tip-deflecting bronchial blocker
• Double-cuffed bronchial blocker with bifurcated end
• Bronchial blocker with attached stylet

Specific Indications

• Present contraindications for double-lumen endotracheal tube (DLT)^,:
  • Anticipated difficult airway, including present airway trauma
  • Abnormal tracheal anatomy (tracheal stenosis, etc)
  • Airway distortion
• High likelihood of post-operative mechanical ventilation
• Presence of pre-existing tracheostomy, nasotracheal tube, single-lumen endotracheal tube (SLT)
• Restricted mobility (scoliosis, prior radiation)
• Selective lobar blockade
• Pediatric patients who cannot tolerate DLT

Contraindications

• Bilateral thoracic procedures (double-lung transplant)
• Tumors blocking main bronchus, especially right-sided

Operating Room Setup

• Preferred bronchial blocker device
  • Adult sizing: 7 French vs. 9 French
  • Pediatric sizing: 5 French
• SLT > 7.5 cm internal diameter
• Fiberoptic bronchoscope (ensure correct positioning of blocker) < 4.0 mm outer diameter

Placement

• Specific placement technique is dependent on device type
• Before insertion, test integrity of cuff and fully deflate and lubricate blocker
• General instructions:
  • Intubate the patient using SLT>7.5 cm
  • Advance fiberoptic bronchoscope through SLT to the level of the carina
  • Advance bronchial blocker to the same level and direct blocker into right or left mainstem bronchus using clockwise and counterclockwise twisting motion, respectively
  • Place bronchial blocker balloon 5-10 mm below carina for one-lung ventilation under guidance of bronchoscopy
  • Stop PPV to allow complete expiration and deflation of lung
  • Inflate cuff with air (generally 4-8 mL) to secure position and isolate lung
  • Remove fiberoptic bronchoscope after ensuring correct position
  • Syringe can be attached to end of bronchial blocker to further suction out air and deflate lung
• Repositioning of patient requires deflation and re-inflation of balloon to avoid displacement and airway obstruction – reconfirm placement with bronchoscopy
• Additional materials that may be available depending on device:
  • Specialized multi-port adaptor with outlets for bronchoscope, blocker, ETT tube (ventilating possible), and airway circuit
  • Specialized SLT with extra lumen specific for bronchial blocker placement

Advantages

• Available use for any type of secured airway (oral, nasal, tracheostomy)
• No need for tube exchange
• Lower potential for serious airway trauma (airway rupture, etc)

Disadvantages

• Compared to DLT:
  • Higher rate of displacement
  • More prone to repositioning, especially when right-sided blockade is needed
  • Limited suctioning capability due to narrower lumen
  • More expensive
• Requires placement of SLT > 7.5 mm inner diameter
• Limits size of fiberoptic bronchoscope

Reported Complications

• Airway injury (including bronchial rupture)
• Interference with staple line during pulmonary resection, especially during right middle lobe and lower lobectomy
• Complete airway obstruction due to displacement into trachea

References

1. Cohen, Edmond MD, FASA. Current Practice Issues in Thoracic Anesthesia. Anesthesia & Analgesia 133(6):p 1520-1531, December 2021. | DOI: 10.1213/ANE.0000000000005707

2. Campos JH. Lung isolation techniques for patients with difficult airway. Curr Opin Anaesthesiol. 2010 Feb;23(1):12-7. doi: 10.1097/ACO.0b013e328331e8a7. PMID: 19752725.

3. Kosarek L, Busch E, Abbas A, Falterman J, Nossaman BD. Effective use of bronchial blockers in lung isolation surgery: an analysis of 130 cases. Ochsner J. 2013 Fall;13(3):389-93. PMID: 24052770; PMCID: PMC3776516.

4. Campos J. Lung isolation. In: Slinger P (ed). Principles and Practice of Anesthesia for Thoracic Surgery. 2nd edition. Switzerland. Springer Nature. 2019: 283-309.

5. Clayton-Smith A, Bennett K, Alston RP, Adams G, Brown G, Hawthorne T, Hu M, Sinclair A, Tan J. A Comparison of the Efficacy and Adverse Effects of Double-Lumen Endobronchial Tubes and Bronchial Blockers in Thoracic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth. 2015 Aug;29(4):955-66. doi: 10.1053/j.jvca.2014.11.017. Epub 2014 Dec 2. PMID: 25753765.

6. Brodsky, J. (2020). Lung Separation. In T. Cook & M. Kristensen (Eds.), Core Topics in Airway Management (pp. 243-249). Cambridge: Cambridge University Press. doi:10.1017/9781108303477.029

7. 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 Apr;108(4):1097-101. doi: 10.1213/ane.0b013e3181999339. PMID: 19299767.