BRONCHIAL BLOCKERS & ENDOBRONCHIAL TUBES

DR. SIDDHARTHA SHARMAModerator : DR. REEMA MEENA

INTRODUCTION

Bronchial blockers are inflatable devices that are placed along side or through a single lumen tracheal tube to selectively occlude a bronchial orifice.

Separation of two lungs is essential for a variety of thoracic surgical procedures and can be life-saving in certain clinical situations.

A variety of methods have been described and used to isolate one lung.

These methods includsDouble-lumen ETT (DLT)

Bronchial blockers.Single lumen bronchial tube

Indications For Separation Of Two Lungs and/or OLV

ABSOLUTE

1. To avoid contamination of a non-diseased lung A. Infection (e.g. unilateral pulmonary abscess) B. Massive pulmonary hemorrhage C. Unilateral pulmonary lavage (e.g. for

pulmonary alveolar proteinosis)

2. Control of distribution of ventilation

A. Bronchopleural fistula B. Bronchopleural cutaneous fistula C. Surgical opening of a major conducting airway D. Giant unilateral lung cyst or bulla E. Tracheobronchial tree disruption F. Life-threatening hypoxemia due to unilateral lung disease

3. Video assisted thoracoscopy (VATS)

Relative indications

Thoracic aortic aneurysm repair Pneumonectomy Pulmonary resection via median sternotomy Upper lobectomy Lung transplantation Unilateral lung disease causing severe

hypoxemia

Indication for bronchial blockers Bronchial blockers are indicated where DLT insertion is not

possible or advisable as in patients withDifficult airwayLesions with in the trachea Severely distorted tracheobronchial anatomy Cervical spine injuriesWho cannot tolerate period of apnoeaon anticoagulants Endotracheal tube insituWhen only a lobe is needed to be blocked rather than entire lungWhen sequential blockage of both lungs is neededPatients requiring Mechanical ventilation postoperativelyTo apply CPAP

LIMITATIONSSlow collapse of the desired lung. Small lumen of bronchial blockers can be

connected to suction to facilitate more rapid deflation of the lung.

Small lumen of bronchial blockers allow suctioning of air but secretions, blood, and pus cannot be eliminated through them and cause obstruction of the lumen preventing the application of CPAP.

This is remedied by injecting saline or by placing suction and/or an appropriate sized wire down the lumen.

LIMITATIONS..Bronchial blockers are more easily dislodged

during patient positioning and surgical manipulation of the lung.

Elliptical-shaped balloons, versus spherical, help to prevent dislodgment.

Whenever, patient position is changed, correct bronchial blocker placement needs to be confirmed with bronchoscopy.

Bronchial blockers present the potential risk of perforating a bronchus or lung parenchyma causing a pneumothorax.

Types of bronchial blockers Univent bronchial blocker systemArndt endobronchial blockerCohen Flexitip Endobronchial Blocker Fogarty embolectomy catheters Foley catheters, Balloon-tipped pulmonary artery

catheters,

Univent TubeDeveloped in 1982 by Dr. InoueIt is a single-lumen silicone tube with a small

separate lumen along the anterior concave wall.

This separate lumen contains the small hollow nonlatex bronchial blocker that can extend about 8-10 cm beyond the tip and it has a blue colored high pressure and low volume cuff.

The lumen of the bronchial blocker is 2 mm in internal diameter. The Univent is supplied in sizes 6.0-9.0 mm internal diameter

Univent Tube… After inserting the univent tube the blocker is visualized by using a flexible fiberoptic

bronchoscope through an airway adapter having a port for bronchoscope.

The blocker is placed in the desired bronchus under vision.

When the bronchus needs to be blocked the lung is deflated with the blocker open to

atmosphere.

Cuff should be inflated with minimum amount of ait that would provide seal. This can be

achived by attaching by sample line from Co2 analysizer to the proximal end of the blocker and

noting when the waveform disappears

Typical cuff inflation volume is 5-6cc.

Univent blocker can also be used with normal tracheal tubes and placed coaxially or in

parallel.

Univent Tube…Univent Tube

Univent Tube…AdvantageDifficult airways requiring OLV• Selective lobar blockade• Tracheostomized patients requiring OLV• Rapid sequence induction that requires

OLV• Robotic (cardiac, thoracic, or esophageal

surgery)

Univent Tube…Disadvantage#8.5–9.0 tied fit to pass through vocal cords• Enclosed channel of 2.0 mm (not enough

lumento aspirate secretions)• More expensive ($137.00)• Potential for inclusion in the stapling line

The Cohen Bronchial Blocker• It has 9F external diameter, 1.4mm inner lumen and length of 65cm with angle tip

• High volume low pressure blue spherical balloon at the tip

• Murphy eyes in the distal tip

• A proximal control wheel to adjust the tip deflection . An arrow on the wheel indicates the direction to which the tip deflects

The Cohen Bronchial Blocker

Fogarty Embolectomy CatheterSingle-lumen balloon tipped catheter with a

removable styletIn the parallel fashion, the Fogarty catheter is

inserted prior to intubationIn the co-axial fashion, the Fogarty catheter is

placed through the endotracheal tubeBoth techniques require fiberoptic bronchoscopy

to direct the Fogarty catheter into the correct pulmonary segment

Once the catheter is in place, the balloon is inflated, sealing the airway

Clinical limitations of the Fogarty catheterNo accessory lumen

So Suction , Oxygen insuffulation or applying CPAP to the blocked lung is not possible not possible

Latex allergyLow volume high pressure cuff

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Arndt Endobronchial Blocker setInvented by Dr. Arndt, an anesthesiologistIs available as a 7 or 9 French, wire-guided,

yellow catheter, 65 and 78cm lengths, with centimeter markings from 10-60.

Ideal for diff intubation, pre-existing ETT and when postop ventilation needed or in pediatric patients

It consists of blocking catheter airway adaptor

Arndt Endobronchial Blocker set..Blocking catheter: it has a blue colored high-volume,

low-pressure balloon, which is elliptical or spherical in shape.

A flexible nylon wire passes through the proximal end of catheter and extends to the distal end then exits as a small loop

Air way adapter: have 4 ports 1 15 mm port that attaches to the ETT2 ventilation port that connects to the breathing

circuit3 port for a flexible fiberoptic scope4 port angled approximately 30º for the blocker

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Arndt Endobronchial Blocker set..The fiberoptic scope (a pediatric scope is most easily used) and

the blocker are placed through their specific ports in the adapter. Use an adequate amount of lubricant on the scope and the

blocker. The scope is threaded through the wire loop at the end of the

blocker and the wire loop should remain loose. The entire unit is placed on the ETT and the circuit connected to

the ventilation port, allowing continuous ventilation during placement.

The fiberoptic scope is “driven” into the left mainstem bronchus and the blocker is gently passed down over the scope until resistance is encountered.

The scope is then gently withdrawn until the carina and the blocker are in view.

Single lumen bronchial tubeRarely used now Gordon Green tube is a right sided Single lumen

bronchial tube that can be used for left thoracotomies

It has both tracheal and bronchial cuffsUsed in pediatric patients or patients with massive

hemoptysisElastic bougie can be inserted into the chosen

bronchus by using a bronchoscope and bronchial tube can be railroaded over the bougie

Neither suctioning nor application of CPAP to the nonventilated lung is possible