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1.  Effective Use of Bronchial Blockers in Lung Isolation Surgery: An Analysis of 130 Cases 
The Ochsner Journal  2013;13(3):389-393.
Background
One-lung ventilation (OLV) is necessary for selected surgical settings and medical conditions. Different methods have been described and used to isolate 1 lung, including the double-lumen endotracheal tube (DLT) and a variety of bronchial blockers (BBs). This selection is often based on the preferences and experiences of the anesthesiologist and surgeon. Complications associated with OLV isolation tubes have been previously described, but complications specifically associated with the Cohen BB (CBB) (Cook Medical, Bloomington, IN) have not been investigated. The purpose of this retrospective review was to determine the incidence of vocal cord injury, tracheobronchial injury, and hoarseness in adult patients who underwent OLV with the CBB.
Methods
We reviewed electronic anesthesia records, operative dictation, and inpatient progress notes to collect information about vocal cord injury, bronchial injury, hoarseness, and sore throat for adults who underwent surgical and diagnostic procedures requiring OLV. Secondary endpoints were types of surgical procedures, degree of difficulty with orotracheal intubation, ability of the patient to tolerate extubation in the operating room, and whether the thoracic surgeon deemed the lung separation adequate. P<0.05 was considered significant.
Results
Of 130 patients, 113 underwent OLV with a CBB, and 17 patients underwent OLV with a DLT. The thoracic surgeon deemed the lung isolation adequate in all cases. Airway injury occurred in 2 patients with a CBB and none with a DLT (P=0.86). Both airway injuries were attributed to surgical technique. Two cases of postoperative hoarseness occurred in the CBB group (P=0.86). One injury was attributed to vagus nerve transection, and the other injury was diagnosed as vocal cord paralysis of unknown etiology. In 1 case, orotracheal intubation with a DLT was unsuccessful because of intubation difficulty and required conversion to a regular endotracheal tube and CBB for successful lung isolation.
Conclusion
This study demonstrates that the use of CBB can be successful in a wide variety of thoracic operations, has minimal complications, eliminates the need for tracheal tube exchange when postoperative mechanical ventilation is required, and effectively isolates the lungs of critically ill patients.
PMCID: PMC3776516  PMID: 24052770
Bronchi; intubation–intratracheal; one-lung ventilation; thoracic surgical procedures
2.  Management of traumatic pneumothorax with massive air leakage: role of a bronchial blocker: a case report 
Korean Journal of Anesthesiology  2014;67(5):354-357.
Massive air leakage through a lacerated lung produces inadequate ventilation and hypoxemia. Tube exchange from a single to double lumen endotracheal tube (DLT), and lung separation to maintain oxygenation, are challenging for seriously injured patients. In this case report, we aim to describe how a bronchial blocker (BB) makes it easier to perform a lung separation in this situation; it also increases the overall safety of the procedure. A 35-year-old female (163 cm, 47 kg) suffered from blunt chest trauma due to a traffic accident; the accident caused right-sided lung laceration with massive air leakage. Paradoxically, positive ventilation worsened SaO2 and leakage increased through a chest tube. We introduced BB while the patient was still awake: Left-side one-lung ventilation (OLV) was established and anesthesia was induced. After PaO2 was maximized with OLV, we changed the endotracheal tube to DLT without a hypoxic event. By BB placement, we maintained PaO2 at a secure level, conducted mechanical ventilation and exchanged the tube without deterioration.
doi:10.4097/kjae.2014.67.5.354
PMCID: PMC4252350  PMID: 25473467
Bronchial blocker; One-lung ventilation; Pneumothorax
3.  The use of VivaSight™ single lumen endotracheal tube in morbidly obese patients undergoing laparoscopic sleeve gastrectomy 
BMC Anesthesiology  2014;14:31.
Background
The population of obese patients is progressively growing and bariatric operations are becoming increasingly common. Morbidly obese patients require special anesthetic care and are often considered to be difficult to ventilate and intubate. The VivaSight™ Single Lumen tube is an endotracheal tube with a camera embedded in its tip. The view from the tip appears continuously on a monitor in the anesthesiologist's vicinity. The aim of this study was to assess the VivaSight™ in comparison with conventional endotracheal tube as an aid in the intubation and surveillance of tube position during surgery of obese patients.
Methods
This is a prospective study of 72 adult obese patients who underwent laparoscopic sleeve gastrectomy. The patients were randomly assigned to be intubated by either the VivaSight™ (40 patients, test group) or a conventional endotracheal tube (32 patients, control group). Data on the patients, the pre-operative airway evaluation, the endotracheal intubation and the post-operative outcome were collected and compared.
Results
The Mallampati scores were significantly higher in the test group than in the control group. Endotracheal intubation took 29 ± 10 and 24 ± 8 seconds using the VivaSight™ and a conventional tube respectively (p = 0.02). Three of the patients in the control group, while none of those in the test group, had soft tissue injury (p < 0.05).
Conclusion
We found the VivaSight™ SL to be helpful in the endotracheal intubation and continuous surveillance of tube position in morbidly obese patients undergoing laparoscopic sleeve gastrectomy.
doi:10.1186/1471-2253-14-31
PMCID: PMC4016667  PMID: 24817827
Equipment; Airway; Anesthetic techniques; Fiber-optic; Ventilation; Mechanical; Morbid obesity; Surgery; Bariatric complications
4.  ProSeal laryngeal mask airway improves oxygenation when used as a conduit prior to laryngoscope guided intubation in bariatric patients 
Indian Journal of Anaesthesia  2013;57(1):25-30.
Background:
The primary objective of this study was to compare the effect of ventilation using the ProSeal™ laryngeal mask airway (PLMA) with facemask and oropharyngeal airway (FM), prior to laryngoscopy, on arterial oxygenation in morbidly obese patients undergoing bariatric surgery.
Methods:
Forty morbidly obese patients were randomly recruited to either PLMA or FM. After pre-oxygenation (FiO2 1.0) in the ramp position with continuous positive airway pressure of 10 cm H2O for 5 min, anaesthesia was induced. Following loss of jaw thrust oropharyngeal airway, the FM and PLMA were inserted. On achieving paralysis, volume control ventilation with PEEP (5 cm H2O) was initiated. The difficulty in mask ventilation (DMV) in FM, number of attempts at PLMA and laryngoscopy were graded (Cormack and Lehane) in all patients. Time from onset of laryngoscopy to endotracheal tube confirmation was recorded. Hypoxia was defined as mild (SpO2 ≤95%), moderate (SpO2 ≤90%) and severe (SpO2 ≤85%).
Results:
Significant rise in pO2 was observed within both groups (P=0.001), and this was significantly higher in the PLMA (P=0.0001) when compared between the groups. SpO2 ≥ 90% (P=0.018) was seen in 19/20 (95%) patients in PLMA and 13/20 (65%) in FM at confirmation of tracheal tube. A strong association was found between DMV and Cormack Lehane in the FM group and with number of attempts in the PLMA group. No adverse events were observed.
Conclusion:
ProSeal™ laryngeal mask airway as conduit prior to laryngoscopy in morbidly obese patients seems effective in increasing oxygen reserves, and can be suggested as a routine airway management technique when managing the airway in the morbidly obese.
doi:10.4103/0019-5049.108557
PMCID: PMC3658330  PMID: 23716762
Bariatric; morbidly obese; oxygenation; ProSeal™
5.  One lung ventilation in a patient with an upper and lower airway abnormality 
Indian Journal of Anaesthesia  2012;56(6):567-569.
One-lung ventilation for a thoracotomy procedure was achieved with the help of a endobronchial blocker in a young girl with limited mouth opening, minimal neck extension, and a distorted tracheo-bronchial anatomy. As the patient would not cooperate for an awake nasotracheal intubation despite adequate preperation, an inhalational anesthetic was used to make the patient unconscious, taking care that spontaneous breathing was maintained. Nasotracheal intubation was done with the help of a fiberoptic bronchoscope. A wire-guided Arndt endobronchial blocker was placed coaxially through the endotracheal tube using a fiberoptic bronchoscope. This case report highlights that in a scenario of both upper and lower airway distortion, a bronchial blocker positioned through a nasotracheal tube under fiberoptic guidance might be the best option when one-lung ventilation is required.
doi:10.4103/0019-5049.104578
PMCID: PMC3546245  PMID: 23325943
Bronchoscopy; fiberoptic; Intratracheal intubation; nasotracheal; thoracic surgical procedures
6.  Successful nasal intubation with a laryngeal nerve monitoring tube using bronchoscopy in a patient with plunging goiter: a case report 
BMC Research Notes  2013;6:467.
Background
The appropriate positioning of nerve integrity monitoring during thyroid surgery is of relevance. In this case report we describe our experience with accurate placement of a nerve integrity monitoring endotracheal tube, obtained by fiberoptic control, in a patient with expected difficult airway management.
Case presentation
We report the case of a 70-year-old obese woman scheduled for elective total thyroidectomy due to plunging intrathoracic goiter. The preoperative indirect laryngoscopy pointed out a massive bombè of the hypopharyngeal wall to the right and right vocal cord paralysis. The epiglottis was oedematous and the glottis could not be identified. On physical examination, the tongue was large and a Mallampati’s score of 3 was determined. Hence, due to an expected difficult airway management, a nasal intubation with an electromyographic nerve integrity monitoring endotracheal tube trough fiberoptic bronchoscopy was successfully performed.
Conclusion
Our experience suggests that nasal intubation can be safely performed by using a nerve integrity monitoring tube with the help of fiberoptic bronchoscopy.
doi:10.1186/1756-0500-6-467
PMCID: PMC4225601  PMID: 24229430
Difficult airway; Recurrent laryngeal nerve monitoring; Fiberoptic bronchoscopy; Thyroid surgery
7.  Use of two Endotracheal Tubes to Perform Lung Isolation and One-Lung Ventilation in a Patient With Tracheostomy Stenosis: A Case Report 
Introduction:
Lung isolation is a common technique used in thoracic surgery to prevent spillage to unaffected lung and to provide a better view for the surgeon.
Case Presentation:
A 41-year-old woman with a history of pharyngo-laryngo-oesophagectomy (PLO) and tracheostomy was a candidate for thoracic duct ligation because of chylothorax. Since the patient had tracheostmy stomal stenosis, two cuffed tracheal tubes (internal diameter = 4.5 mm) were used; one tube was placed in the right bronchus and the other tube in the left one by fiberoptic laryngoscopy in 10 minutes. Right lung was collapsed during the surgery for 3.5 hours with a slight decrease in oxygenation (SpO2 = 91%–93%) and with no evident hemodynamic change. Potential trauma from a double-lumen tube and a bronchial blocker as well as inaccessibility to a univent tube prevented us to use these standard methods in this case.
Conclusions:
This report presents a new method for lung isolation in specific cases and in the absence of certain equipment.
doi:10.5812/aap.18280
PMCID: PMC4286801  PMID: 25599024
Lung Isolation; Tracheostomy; Endotracheal Tube; One-Lung Ventilation
8.  Real-time ultrasound-guided percutaneous dilatational tracheostomy: a feasibility study 
Critical Care  2011;15(1):R67.
Introduction
Ultrasound (US) performed prior to percutaneous tracheostomy (PT) may be useful in avoiding injury to pretracheal vascular structures and in avoiding high placement of the tube. Bedside real-time US guidance with visualization of needle path is routinely utilized for other procedures such as central venous catheterization, and may enhance the safety and accuracy of PT without causing airway occlusion or hypercarbia. Our objective was to demonstrate that PT performed under real-time US guidance with visualization of needle path during tracheal puncture is feasible, including in patients with features that increase the technical difficulty of PT.
Methods
Mechanically ventilated patients with acute brain injury requiring tracheostomy underwent US guided PT. The orotracheal tube was withdrawn using direct laryngoscopy. The trachea was punctured under real-time US guidance (with visualization of the needle path) while using the acoustic shadows of the cricoid and the tracheal rings to identify the level of puncture. After guidewire passage the site and level of entry was verified using the bronchoscope, which was then withdrawn. Following dilatation and tube placement, placement in the airway was confirmed using auscultation and the "lung sliding" sign on US. Bronchoscopy and chest X-ray were then performed to identify any complications.
Results
Thirteen patients successfully underwent US guided PT. Three patients were morbidly obese, two were in cervical spine precautions and one had a previous tracheostomy. In all 13 patients bronchoscopy confirmed that guidewire entry was through the anterior wall and between the first and fifth tracheal rings. There was no case of tube misplacement, pneumothorax, posterior wall injury, significant bleeding or other complication during the procedure.
Conclusions
Percutaneous tracheostomy performed under real-time ultrasound guidance is feasible and appears accurate and safe, including in patients with morbid obesity and cervical spine precautions. Larger studies are required to further define the safety and relative benefits of this technique.
Trial registration
UMIN Clinical Trials Registry, UMIN000005023.
doi:10.1186/cc10047
PMCID: PMC3222000  PMID: 21342494
9.  Bonfils assisted double lumen endobronchial tube placement in an anticipated difficult airway 
The role of various airway adjuncts in the management of difficult airway has been described in the literature. Bonfils rigid fiberscope is one of the airway assist devices widely used for endotracheal intubation in the individuals with cervical instability warranting limited neck movements. With our experience in the utilization of Bonfils for single lumen endotracheal tube placement, we are increasingly using for double lumen endobronchial (DLT) intubation as well. We would like to describe our experience in the use of Bonfils for DLT placement and outline the merits and limitations of the other suitable airway assist devices in this report. The double lumen tube has to be modified by decreasing the length of DLT to accommodate the Bonfils fiberscope and this is applicable only in certain type of double lumen tubes for e.g. Bronchocath.
doi:10.4103/0970-9185.142867
PMCID: PMC4234799  PMID: 25425788
Bonfils; bronchocath; difficult airway; double lumen
10.  Bronchial obstruction by tumor embolus of contralateral lung during pneumonectomy: report of a case 
Bronchial obstruction due to a tumor embolus of the contralateral lung during pneumonectomy is an uncommon and fatal complication. According to previous cases, a bronchial balloon of double-lumen endotracheal tube (DLT) could prevent a dislodged tumor from traveling to the contralateral lung. We experienced a tumor embolism from the bronchus with cancer to the other bronchus despite applying DLT. A 59-year-old male with endobronchial lung cancer underwent a left pneumonectomy. One-lung ventilation was established by the right-sided DLT. After a left bronchial division, a sudden increase of peak airway pressure and reduction of the expired tidal volume to 50 ml was observed. Intraoperative fiberoptic bronchoscopy showed a near total obstruction of the right main bronchus due to tumor emboli. It was not possible to remove the tumor embolus through bronchoscopic suction and forceps. Therefore, we reopened the left bronchial stump and successfully extracted tumor embolus under bronchoscopic guidance.
doi:10.1186/1749-8090-8-26
PMCID: PMC3598947  PMID: 23421935
Airway obstruction; Bronchial neoplasm; Pneumonectomy; Double-lumen endotracheal tube
11.  Thoracic ultrasound confirmation of correct lung exclusion before one-lung ventilation during thoracic surgery 
Journal of Ultrasound  2013;16(4):195-199.
Introduction
Fiberoptic bronchoscopy is the standard method for verifying the correct position of a double-lumen endotracheal tube (DLET) prior to one-lung ventilation. However, it must be performed by a specially trained anesthesiologist and is often resource consuming. The aim of this study was to compare this approach with thoracic ultrasound done by a nurse anesthetist in terms of sensitivity, specificity, and cost-effectiveness.
Methods
We conducted a prospective cross-over case–control study involving 51 adult patients consecutively undergoing thoracic surgery with one-lung ventilation. After orotracheal intubation with a DLET, correct exclusion of the lung being operated on exclusion was assessed first by a certified anesthesiologist using standard fiberoptic bronchoscopy and then by a trained nurse anesthetist using thoracic ultrasound. The nurse was blinded as to the findings of the anesthesiologist’s examination.
Results
The two approaches proved to be equally sensitive and specific, but the ultrasound examination was more rapid. This factor, together with the fact that ultrasound was performed by a nurse instead of a physician, and the costs of materials and sterilization, had a significant economic impact amounting to a net saving of €37.20 ± 5.40 per case.
Conclusions
Although fiberoptic bronchoscopy is still the gold standard for checking the position of a DLET, thoracic ultrasound is a specific, sensitive, cost-effective alternative, which can be used to rapidly verify the proper function of the tube based on the demonstration of correct lung exclusion.
doi:10.1007/s40477-013-0050-9
PMCID: PMC3846950  PMID: 24432174
Thoracic ultrasound; Anesthesia; Thoracic surgery
12.  Anæsthesia in Chest Surgery, with Special Reference to Controlled Respiration and Cyclopropane 
Problems in chest surgery: Cases with prolonged toxæmia or amyloid disease require an anæsthetic agent of low toxicity. When sputum or blood are present in the tracheobronchial tree the anæsthesia should abolish reflex distrubances and excessive sputum be removed by suction. The technique should permit the use of a high oxygen atmosphere; controlled respiration with cyclopropane or ether fulfil these requirements. Open pneumothorax is present when a wound of the chest wall allows air to pass in and out of the pleural cavity. The lung on the affected side collapses and the mediastinum moves over and partly compresses the other lung.
The dangers of an open pneumothorax: (1) Paradoxical respiration—the lung on the affected side partially inflates on expiration and collapses on inspiration. Part of the air entering the good lung has been shuttled back from the lung on the affected side and is therefore vitiated. Full expansion of the sound lung is handicapped by the initial displacement of the mediastinum which increases on inspiration. The circulation becomes embarrassed.
(2) Vicious circle coughing. During a paroxysm of coughing dyspnœa will occur. This accentuates paradoxical respiration and starts a vicious circle. Death from asphyxia may result.
Special duties of the anæsthetist: (1) To carry out or supervise continuous circulatory resuscitation. During a thoracotomy a drip blood transfusion maintains normal blood-pressure and pulse-rate.
(2) To maintain effcient respiration.
Positive pressure anæsthesia: Risk of impacting secretions in smaller bronchi with subsequent atelectasis; eventual risk of CO2 poisoning without premonitory signs.
Controlled respiration: (1) How it is produced. (2) Its uses in chest surgery.
Controlled respiration means that the anæsthetist, having abolished the active respiratory efforts of the patient, maintains an efficient tidal exchange by rhythmic squeezing of the breathing bag. This may be done mechanically by Crafoord's modification of Frenkner's spiropulsator or by hand.
Active respiration will cease (i) if the patient's CO2 is lowered sufficiently by hyperventilation, (ii) if the patient's respiratory centre is depressed sufficiently by sedative and anæsthetic drugs, and (iii) by a combination of (i) and (ii) of less degree.
The author uses the second method, depressing the respiratory centre with omnoponscopolamine, pentothal sodium, and then cycloprȯpane. The CO2 absorption method is essential for this technique, and this and controlled respiration should be mastered by the anæsthetist with a familiar agent and used at first only in uncomplicated cases.
The significance of cardiac arrhythmias occuring with cyclopropane is discussed.
The place of the other available anæsthetic agents is discussed particularly on the advisability of using local anæsthesia for the drainage of empyema or lung abscess.
Pharyngeal airway or endotracheal tube? Anæsthesia may be maintained with a pharyngeal airway in many cases but intubation must be used when tracheobronchial suction may be necessary and when there may be difficulty in maintaining an unobstructed airway.
A one-lung anæsthesia is ideal for pneumonectomy. This may be obtained by endotracheal anæsthesia after bronchial tamponage of the affected side (Crafoord, v. fig. 6b) or by an endobronchial intubation of the sound side (v. figs. 9b and 9c). Endobronchial placing of the breathing tube may be performed “blind”. Before deciding on blind bronchial intubation, the anæsthetist must examine X-ray films for any abnormality deviating the trachea or bronchi. Though the right bronchus may be easily intubated blindly as a rule, there is the risk of occluding the orifice of the upper lobe bronchus (fig. 9d) when the patient will become cyanosed. If the tube bevel is facing its orifice the risk of occlusion will be decreased (fig. 9c).
Greater accuracy in placing the tube can be effected by inserting it under direct vision. Instruments for performing this manœuvre are described.
In lobectomy for bronchiectasis the anæsthetist must try to prevent the spread of infection to other parts. Ideally, the bronchus of the affected lobe should be plugged with ribbon gauze (Crafoord, v. fig. 6c) or a suction catheter with a baby balloon on it placed in the affected bronchus. In the presence of a large bronchopleural fistula controlled respiration cannot be established during operation. As the surgeon is rarely able to plug the fistula, if pneumonectomy is to be performed intubation for a one-lung anæsthesia is the best method. During other procedures it is essential to maintain quiet respiration.
In war casualties it is almost always possible, with the technique described, to leave the lung on the affected side fully expanded and thus frequently to restore normal respiratory physiology. Co-operation between surgeon and anæsthetist is essential.
PMCID: PMC1998132  PMID: 19992357
13.  Anaesthesia for serial whole-lung lavage in a patient with severe pulmonary alveolar proteinosis: a case report 
Introduction
Pulmonary alveolar proteinosis is a rare condition that requires treatment by whole-lung lavage. We report a case of severe pulmonary alveolar proteinosis and discuss a safe and effective strategy for the anaesthetic management of patients undergoing this complex procedure.
Case presentation
A 34-year-old Caucasian man was diagnosed with severe pulmonary alveolar proteinosis. He developed severe respiratory failure and subsequently underwent serial whole-lung lavage. Our anaesthetic technique included the use of pre-oxygenation, complete lung separation with a left-sided double-lumen endotracheal tube, one-lung ventilation with positive end-expiratory pressure, appropriate ventilatory monitoring, cautious use of positional manoeuvres and single-lumen endotracheal tube exchange for short-term postoperative ventilation.
Conclusion
Patients with pulmonary alveolar proteinosis may present with severe respiratory failure and require urgent whole-lung lavage. We have described a safe and effective strategy for anaesthesia for whole-lung lavage. We recommend our anaesthetic technique for patients undergoing this complex and uncommon procedure.
doi:10.1186/1752-1947-2-360
PMCID: PMC2607303  PMID: 19038019
14.  Severe lingual tonsillar hypertrophy and the rationale supporting early use of wire-guided retrograde intubation 
Saudi Journal of Anaesthesia  2010;4(2):102-104.
An expanding body of literature exists which describes the airway challenges and management options for lingual tonsillar hypertrophy (LTH). The use of retrograde intubation to secure a patient‘s airway in the setting of LTH has been previously unreported and should be considered early in the event of a cannot intubate, cannot ventilate scenario. A 55-year-old man, who had previously been described as an easy intubation, presented an unexpected cannot intubate, cannot ventilate scenario secondary to LTH. Various noninvasive airway maneuvers were attempted to restore ventilation without success. We describe the advantages of early use of wire-guided retrograde intubation as an alternative to a surgical airway for obtaining a secure airway in a patient with LTH, in whom noninvasive airway management maneuvers have failed. Multiple different noninvasive approaches to management of LTH have been previously described including the laryngeal tube, laryngeal mask airway, and fiberoptic bronchoscopy. Unfortunately, none of these noninvasive airway maneuvers successfully ventilated this patient and an invasive airway became necessary. Retrograde intubation is a less invasive alternative to the surgical airway with potentially less risk for complications. Retrograde intubation may be particularly effective in the setting of LTH as it may stent open an otherwise occluded airway and allow passage of an endotracheal tube. Skillful use of this technique should be considered early as a viable option in any case of unexpected difficult intubation due to LTH.
doi:10.4103/1658-354X.65120
PMCID: PMC2945505  PMID: 20927270
Lingual tonsillar hypertrophy; retrograde intubation; difficult intubation
15.  Endobronchial hemorrhage after intubation with double-lumen endotracheal tube in a patient with idiopathic thrombocytopenic purpura for minimally invasive cardiac surgery: a case report 
Minimally invasive cardiac surgery (MICS) requires lung isolation. Lung isolation is usually achieved with double-lumen endotracheal tube (DLT). Patients with idiopathic thrombocytopenic purpura (ITP) have an increased risk of bleeding events. We suspected endobronchial hemorrhage after exchange of DLT during induction of anesthesia for replacement of mitral valve in a 62-year-old man with a known ITP. The MICS was stopped and bronchial artery embolization was performed in the angiographic room. In the present case, in order to reduce the risk of bronchial arterial injury in ITP patient we intubated with single lumen endotracheal tube. Lung isolation led to achievement of intermittent total lung deflation. Based on the results, we recommend a high-dose intravenous immunoglobulin therapy and platelet transfusion prior to cardiac surgery in patients with ITP to increase platelet count. Moreover, it is proposed that in order to clear the vision during the operation, ventilation can be held or made intermittent both prior to cardiopulmonary bypass or at its conclusion to permit exposure.
doi:10.4097/kjae.2014.66.1.59
PMCID: PMC3927003  PMID: 24567815
Cardiac surgery; Double-lumen endotracheal tube; Endobronchial hemorrhage; Idiopathic thrombocytopenic purpura; Minimally invasive surgical procedures
16.  Fiberoptic intubation through laryngeal mask airway for management of difficult airway in a child with Klippel–Feil syndrome 
Saudi Journal of Anaesthesia  2014;8(3):412-414.
The ideal airway management modality in pediatric patients with syndromes like Klippel-Feil syndrome is a great challenge and is technically difficult for an anesthesiologist. Half of the patients present with the classic triad of short neck, low hairline, and fusion of cervical vertebra. Numerous associated anomalies like scoliosis or kyphosis, cleft palate, respiratory problems, deafness, genitourinary abnormalities, Sprengel's deformity (wherein the scapulae ride high on the back), synkinesia, cervical ribs, and congenital heart diseases may further add to the difficulty. Fiberoptic bronchoscopy alone can be technically difficult and patient cooperation also becomes very important, which is difficult in pediatric patients. Fiberoptic bronchoscopy with the aid of supraglottic airway devices is a viable alternative in the management of difficult airway in children. We report a case of Klippel-Feil syndrome in an 18-month-old girl posted for cleft palate surgery. Imaging of spine revealed complete fusion of the cervical vertebrae with hypoplastic C3 and C6 vertebrae and thoracic kyphosis. We successfully managed airway in this patient by fiberoptic intubation through classic laryngeal mask airway (LMA). After intubation, we used second smaller endotracheal tube (ETT) to stabilize and elongate the first ETT while removing the LMA.
doi:10.4103/1658-354X.136637
PMCID: PMC4141399  PMID: 25191201
Fiberoptic intubation; Klippel-Feil syndrome; laryngeal mask airway; The ideal airway management modality in pediatric patients with syndromes like Klippel-Feil syndrome is a great challenge and is technically difficult for an anesthesiologist. Fiberoptic bronchoscopy alone can be technically difficult and patient cooperation also becomes very important, which is difficult in pediatric patients. Fiberoptic bronchoscopy with the aid of supraglottic airway devices is a viable alternative in the management of difficult airway in children
17.  A novel technique of differential lung ventilation in the critical care setting 
BMC Research Notes  2011;4:134.
Background
Differential lung ventilation (DLV) is used to salvage ventilatory support in severe unilateral lung disease in the critical care setting. However, DLV with a double-lumen tube is associated with serious complications such as tube displacement during ventilatory management. Thus, long-term ventilatory management with this method may be associated with high risk of respiratory incidents in the critical care setting.
Findings
We devised a novel DLV technique using two single-lumen tubes and applied it to five patients, two with severe unilateral pneumonia and three with thoracic trauma, in a critical care setting. In this novel technique, we perform the usual tracheotomy and insert two single-lumen tubes under bronchoscopic guidance into the main bronchus of each lung. We tie the two single-lumen tubes together and suture them directly to the skin. The described technique was successfully performed in all five patients. Pulmonary oxygenation improved rapidly after DLV induction in all cases, and the three patients with thoracic trauma were managed by DLV without undergoing surgery. Tube displacement was not observed during DLV management. No airway complications occured in either the acute or late phase regardless of the length of DLV management (range 2-23 days).
Conclusions
This novel DLV technique appears to be efficacious and safe in the critical care setting.
doi:10.1186/1756-0500-4-134
PMCID: PMC3101656  PMID: 21545715
18.  An awake double lumen endotracheal tube intubation using the Clarus Video System in a patient with an epiglottic cyst: a case report 
Korean Journal of Anesthesiology  2014;66(2):157-159.
A 54-year-old male patient was scheduled for an elective pylorus-preserving pancreaticoduodenectomy combined with video-assisted thoracic surgery at our hospital. This patient had a history of intubation failure in other institutions due to an epiglottic cyst. An airway assessment of the patient was normal. A preoperative laryngoscopy revealed a bulging epiglottic mass covering most of the epiglottis and occupying most of the pharyngeal space. The patient was administered intravenous midazolam 1 mg, fentanyl 50 µg, and glycopyrrolate 0.2 mg. A bilateral superior laryngeal nerve block was then performed with 2% lidocaine 2 ml on each side. A 10% lidocaine spray was applied on to the oropharynx. After preoxygenation with 100% oxygen over 10 minutes, a rigid fiberscope with an optical stylet loaded with a 37 Fr double lumen endotracheal tube was inserted orally and passed into the glottic aperture. The patient was fully awakened after surgical procedure and was transferred to the recovery room after extubation.
doi:10.4097/kjae.2014.66.2.157
PMCID: PMC3948444  PMID: 24624275
Airway obstruction; Difficult intubation; Laryngeal mass
19.  Maintaining endotracheal tube cuff pressure at 20 mm Hg to prevent dysphagia after anterior cervical spine surgery; protocol of a double-blind randomised controlled trial 
Background
In anterior cervical spine surgery a retractor is obligatory to approach the spine. Previous studies showed an increase of endotracheal tube cuff pressure after placement of a retractor. It is known that high endotracheal tube cuff pressure increases the incidence of postoperative dysphagia, hoarseness, and sore throat. However, until now no evidence supports the fact whether adjusting the endotracheal tube cuff pressure during anterior cervical spine surgery will prevent this comorbidity. We present the design of a randomized controlled trial to determine whether adjusting endotracheal tube cuff pressure after placement of a retractor during anterior cervical spine surgery will prevent postoperative dysphagia.
Methods/design
177 patients (aged 18–90 years) scheduled for anterior cervical spine surgery on 1 or more levels will be included. After intubation, endotracheal tube cuff pressure is manually inflated to 20 mm Hg in all patients. Patients will be randomized into two groups. In the control group endotracheal tube cuff pressure is not adjusted after retractor placement. In the intervention group endotracheal tube cuff pressure after retractor placement is maintained at 20 mm Hg and air is withdrawn when cuff pressure exceeds 20 mm Hg. Endotracheal tube cuff pressure is measured after intubation, before and after placement and removal of the retractor. Again air is inflated if cuff pressure sets below 20 mmHg after removal of the retractor. The primary outcome measure is postoperative dysphagia. Other outcome measures are postoperative hoarseness, postoperative sore throat, degree of dysphagia, length of hospital stay, and pneumonia. The study is a single centre double blind randomized trial in which patients and research nurses will be kept blinded for the allocated treatment during the follow-up period of 2 months.
Discussion
Postoperative dysphagia occurs frequently after anterior cervical spine surgery. This may be related to high endotracheal tube cuff pressure. Whether adaptation and maintaining the pressure after placement of the retractor will decrease the incidence of dysphagia, has to be determined by this trial.
Trial registration
Netherlands Trial Register (NTR) 3542: http://www.trialregister.nl.
doi:10.1186/1471-2474-14-280
PMCID: PMC3848991  PMID: 24067111
Anterior cervical spine surgery; Surgical retractor; Endotracheal tube cuff pressure; Sore throat; Hoarseness; Dysphagia
20.  Iatrogenic Left Main Bronchus Injury following Atraumatic Double Lumen Endotracheal Tube Placement 
Case Reports in Anesthesiology  2013;2013:524348.
Tracheobronchial disruption is an uncommon but severe complication of double lumen endotracheal tube placement. The physical properties of a double lumen tube (large external diameter and length) make tracheobronchial injury more common than that associated with smaller single lumen endotracheal tubes. Here we present the case of an iatrogenic left main bronchus injury caused by placement of a double lumen tube in an otherwise unremarkable airway.
doi:10.1155/2013/524348
PMCID: PMC3833405  PMID: 24288629
21.  Assessment of airway length of Korean adults and children for otolaryngology and ophthalmic surgery using a fiberoptic bronchoscope 
Korean Journal of Anesthesiology  2010;59(4):249-255.
Background
Knowledge regarding normal upper airway anatomy is essential for airway management and is required to prevent malpositioning of endotracheal tubes. We evaluated the length of the upper airway in Korean children and adults who had no abnormality of the upper airway using a fiberoptic bronchoscope.
Methods
Eighty seven patients aged 5 to 81 years undergoing noninvasive elective surgery were included in this study. After induction of anesthesia was complete, we measured the distance from the upper incisor to various components of the upper airway by fiberoptic bronchoscopy.
Results
In adults, the mean length between the upper incisor and midtrachea was found to be 21.8 ± 1.8 cm in males and 19.9 ± 1.3 cm in females, while the mean length of the trachea was 10.1 ± 1.3 cm in males and 10.3 ± 1.6 cm in females. The length between the upper incisor and midtrachea (IT) were correlated with height both in children (IT [cm] = 2.531 + 0.109 × height [cm]) and adults (IT [cm] = 0.167 + 0.127 × height [cm]), which shows that they differ from the western standard (length of tube [cm] = 5 + 0.1 × height [cm]).
Conclusions
In adults and children, the length from the incisor to the midtrachea was significantly different when compared with western standards. Therefore, re-evaluation of the proper and precise depth of endotracheal tube in Koreans should be considered.
doi:10.4097/kjae.2010.59.4.249
PMCID: PMC2966705  PMID: 21057614
Bronchoscopy; Intratracheal; Intubation
22.  Endotracheal intubation with a video-assisted semi-rigid fiberoptic stylet by prehospital providers 
Background
Emergency medical technicians intubate patients in unfamiliar surroundings and with less than ideal positioning. This study was designed to evaluate advanced life support (ALS) emergency medical technicians' (EMTs) ability to successfully intubate a simulated airway using a video-assisted semi-rigid fiberoptic stylet, the Clarus Video System (CVS).
Methods
ALS EMTs were first shown a brief slideshow and three example videos and then given 20 min to practice intubating a mannequin using both the CVS and standard direct laryngoscopy (DL). The mannequin was then placed on the floor to simulate field intubation at the scene. Each participant was given up to three timed attempts with each technique. Endotracheal tube position was confirmed with visualization by one of the study authors. Comparisons and statistical analysis were conducted using SPSS® Statistics 21 (IBM®). Demographics and survey results were also collected and analyzed.
Results
The median total time for intubation was 15.00 s for DL and 15.50 s for CVS revealing no significant difference between the two techniques (p = 0.425), and there was no significant difference in the number of attempts required to successfully place the endotracheal tube (ETT) (p = 0.997). Demographic factors including handedness and eye dominance did not seem to affect outcomes. Participants reported a relatively high level of satisfaction with the CVS.
Conclusions
ALS EMTs were able to obtain intubation results similar to those of their usual direct laryngoscopy technique when utilizing a video-assisted semi-rigid fiberoptic stylet with very limited instruction and experience with the device. The CVS technique warrants further study for use as an alternative to DL and video laryngoscopy in the prehospital difficult airway scenario.
doi:10.1186/s12245-014-0045-0
PMCID: PMC4269860  PMID: 25593618
Airway; Clarus Video System; Emergency; EMS; EMT; Fiber optic; Fiberoptic; Laryngoscopy; Levitan; Optical; Prehospital; Shikani; Stylet; Video
23.  Tracheal laceration during intubation of a double-lumen tube and intraoperative fiberoptic bronchoscopic evaluation through an LMA in the lateral position -A case report- 
Korean Journal of Anesthesiology  2011;60(4):285-289.
A 76-year-old, 148-cm woman was scheduled for right upper lobectomy. A 32 Fr left-sided double lumen tube was placed using a conventional technique. Despite several attempts under fiberoptic bronchoscope-guidance, we could not locate the double lumen tube properly. We thus decided to proceed with the bronchial tube in the right mainstem bronchus. During surgery, 8-cm-long laceration was noted on the posterolateral side of the trachea. To check the possibility of laceration of the proximal trachea, the double lumen tube was changed to an LMA for use as a conduit for fiberoptic bronchoscopic evaluation in the lateral position. A plain endotracheal tube with the cuff modified and collapsed was re-intubated after evaluation. And then she was transferred to SICU.
doi:10.4097/kjae.2011.60.4.285
PMCID: PMC3092965  PMID: 21602980
Fiberoptic bronchoscope; Intubation; Laceration; LMA; Trachea
24.  Esophageal misplacement of a single-lumen tube after its exchange for a double-lumen tube despite the use of an airway-exchange catheter 
Saudi Journal of Anaesthesia  2013;7(2):194-196.
An airway-exchange catheter (AEC) can increase the safety of exchanges of endotracheal tubes (ETTs); however, the procedure is associated with potential risks. We describe a case of esophageal misplacement of a single-lumen ETT after switching from a double-lumen tube, despite the use of an AEC as a guidewire. To avoid this, physicians should consider the insertion depth and maintenance depth of the AEC and should verify its position before changing ETTs and should perform, if possible, with simultaneous visualization of the glottis with direct or video laryngoscopy during the exchange. Additionally, the new ETT position should be confirmed by auscultation, end-tidal carbon dioxide, and portable chest X-ray.
doi:10.4103/1658-354X.114050
PMCID: PMC3737699  PMID: 23956723
Airway extubation; esophagus; intratracheal; intubation
25.  A comparison of Bonfils intubation fiberscopy and fiberoptic bronchoscopy in difficult airways assisted with direct laryngoscopy 
Korean Journal of Anesthesiology  2010;58(3):249-255.
Background
To evaluate the usefulness of Bonfils intubation fiberscope assisted by direct laryngoscopy (BIF-DL) and flexible fiberoptic bronchoscope assisted by direct laryngoscopy (FOB-DL) using video recording in cases of unanticipated difficult intubation with respect to the time required to visualize the vocal cords and place the endotracheal tube. We compared two fiberscopes in patients with authentic difficult airways.
Methods
In this randomized, controlled clinical trial, 40 patients (grade 3 according to grades of difficulty in laryngoscopy), scheduled for surgery under general anesthesia were randomly allocated to BIF-DL group or FOB-DL group. Number of attempts, time required for visualization of the vocal cord (T1) and placement of the endotracheal tube (T2) from insertion of instrument during the last successful attempt, and duration of scope manipulation during all attempts (Ttotal) were recorded. If intubation failed with one method, the other method was tried; these cases were then excluded. The incidence of sore throat and hoarseness was assessed.
Results
T1, T2, and Ttotal were significantly shorter in BIF-DL group (T1: 21.9 ± 8.2 sec vs. 80.4 ± 29.9 sec, P < 0.001, Ttotal: 77.9 ± 41.2 sec vs. 145.5 ± 83.9 sec, P = 0.003). In two cases, it was impossible to intubate with BIF-DL, but the procedure was subsequently successful using fibreoptic bronchoscope.
Conclusions
Intubation of difficult airways can be performed more rapidly with BIF-DL, but sometimes it may not be possible to intubate with the scope.
doi:10.4097/kjae.2010.58.3.249
PMCID: PMC2872830  PMID: 20498773
Bronchoscopes; Fiberoptics; Intubation; Laryngoscopy; Video recording

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