|Lines and access|
|Primary anesthetic considerations|
Displacement Airway injury/obstruction Interference with staple line
Definition: High-pressure low-volume balloon device utilized for complete one-lung isolation or selective lobar blockade
- Wire-guided bronchial blocker
- Tip-deflecting bronchial blocker
- Double-cuffed bronchial blocker with bifurcated end
- Bronchial blocker with attached stylet
- 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
- 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
- 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
- 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)
- Compared to DLT:
- Requires placement of SLT > 7.5 mm inner diameter
- Limits size of fiberoptic bronchoscope
- 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
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.
- Cohen, Edmond (2021-08-23). "Current Practice Issues in Thoracic Anesthesia". Anesthesia & Analgesia. Publish Ahead of Print. doi:10.1213/ane.0000000000005707. ISSN 0003-2999.
- Campos, Javier H (2010-02). "Lung isolation techniques for patients with difficult airway". Current Opinion in Anaesthesiology. 23 (1): 12–17. doi:10.1097/aco.0b013e328331e8a7. ISSN 0952-7907. Check date values in:
- Kosarek, L (2013). "Effective use of bronchial blockers in lung isolation surgery: an analysis of 130 cases". Ochsner. 13: 389–393.
- Campos, Javier (2011), "Anesthesia for Robotic Thoracic Surgery", Principles and Practice of Anesthesia for Thoracic Surgery, New York, NY: Springer New York, pp. 445–451, ISBN 978-1-4419-0183-5, retrieved 2023-07-14
- Clayton-Smith, Ana; Bennett, Kyle; Alston, Robin Peter; Adams, George; Brown, Greg; Hawthorne, Timothy; Hu, May; Sinclair, Angus; Tan, Jay (2015-08). "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". Journal of Cardiothoracic and Vascular Anesthesia. 29 (4): 955–966. doi:10.1053/j.jvca.2014.11.017. ISSN 1053-0770. Check date values in:
- Brodsky, Jay B. (2020-12-03), "Lung Separation", Core Topics in Airway Management, Cambridge University Press, pp. 243–249, retrieved 2023-07-14
- Narayanaswamy, M. (April 2009). [doi: 10.1213/ane.0b013e3181999339 "Choosing a lung isolation device for thoracic surgery: a randomized trial of three bronchial blockers versus double-lumen tubes"] Check
|url=value (help). Anesth Analg. 108(4): 1097–1101.