Question 24.1

College Answer

a) Indications- (any 3 of these)

• To avoid contamination of a non-diseased lung 
• Infection (e.g. unilateral pulmonary abscess)
• Massive pulmonary haemorrhage
• Unilateral pulmonary lavage (pulmonary alveolar proteinosis)
• Control of distribution of ventilation 
• Bronchopleural fistula 
• Giant unilateral lung cyst or bulla 
• Tracheobronchial tree disruption /Major airway trauma
• Severe hypoxaemia due to unilateral lung disease
• During surgical procedures
  • Pneumonectomy, lobectomy
  • Oesophageal resection
  • Lung transplant
  • Thoracic aneurysm surgery
  • Thoracic spine surgery

• Advantages - (any 2)

• • Can be used in patients through existing endotracheal tube (oral or nasal) without requirement to change to a double-lumen tube or back to a single lumen tube after. Therefore useful in patients with difficult airway, cervical spine injury, etc.

• • Can be used in patients with major airway trauma or distorted trachoebronchial anatomy more safely than DLT

• • Can provide selective lobar blockade of a specific lobe- in cases of haemorrhage, air leak, infection in one lobe, thereby allowing ventilation of more lung units.

Limitations - (any 2)

• Do not allow suctioning of deflated lung due to small lumen
• Requires ETT >7.5mm diameter.
• Collapse of desired lung may be slow
• Easily dislodged
• Risk of perforation of bronchus or lung parenchyma
• Difficult to block R upper lobe bronchus due to variable take-off.

Discussion

The image above is a picture of a PRO-Breathe endobronchial blocker, from PROACT Medical. The image was used without any permission from the manufacturer. We can also be grateful to PROACT for this detailed user manual, with diagrams and technical information.

So; what is the indication for its use?

Well.

It is essentially any situation when a double-lumen tube would be ideal, but for some reason you can't (or don't want to) insert it.

For instance:

• nasal intubation
• small patient
• difficult intubation
• patient with a tracheostomy
• subglottic stenosis
• thick and excessive secretions

All the other indications resemble the indications for the insertion of a dual-lumen tube:

• Prevention of cross-contamination of one lung by the other, eg. in the following cases:
  • Infection (e.g. unilateral pulmonary abscess)
  • Massive pulmonary haemorrhage

• Enable the ventilation of each lung with a different ventilation setting in settings where the each hemithorax is wildly different from the other, for example:
  • Severe chest injury
  • Bronchopleural fistula
  • Open chest (eg. mid thoracic surgery)
  • Giant unilateral lung cyst or bulla
• Bypass a damaged section of the airway
  • Tracheobronchial tree disruption /Major airway trauma
• Permit the lavage of each lung independently - pulmonary alveolar proteinosis is frequently mentioned as an indication, and I suppose if one finds oneself bringing it up during a viva, one should then be prepared to discuss what it is.

Advantages for its use:

• Can use the current normal ETT- no need to insert a DLT
• Safer than the DLT in patients with a traumatic airway injury
• Can provide selective lobar blockade of a specific lobe, rather than of the entire lung

• Technically, simpler than DLT isnertion

Disadvantages to its use:

The college suggest the following:

• Do not allow suctioning of deflated lung due to small lumen
• Requires ETT >7.5mm diameter.
• Collapse of desired lung may be slow
• Easily dislodged
• Risk of perforation of bronchus or lung parenchyma
• Difficult to block R upper lobe bronchus due to variable take-off.

To this I would add:

• Surgery on a mainstem bronchus is impossible if the bronchus is blocked
• Bronchoscopy of the blocked lung is impossible

Neustein, Steven M. "The use of bronchial blockers for providing one-lung ventilation." Journal of cardiothoracic and vascular anesthesia 23.6 (2009): 860-868.

Campos, Javier H. "An update on bronchial blockers during lung separation techniques in adults." Anesthesia & Analgesia 97.5 (2003): 1266-1274. This excellent article discusses several different styles of EBBs, with commends on the merits and demerits of each.

This article was found at the amazing www.onelung.org.uk, a site dedicated to a thoracic anaesthesia course which teaches anaesthetists to perform lung isolation.