Advantages of a New Polyvinyl Chloride Double-Lumen Tube in Thoracic Surgery

Transcription

1 Advantages of a New Polyvinyl Chloride Double-Lumen Tube in Thoracic Surgery Nelson A. Burton, M.D., Donald C. Watson, M.D., Jay B. Brodsky, M.D., and James B. D. Mark, M.D. ABSTRACT Double-lumen endobronchial tubes offer many advantages during thoracic operations. However, technical problems with tube placement and potentially life-threatening complications have discouraged widespread use of standard doublelumen tubes. Some of these problems may be reduced with a new polyvinyl chloride (PVC) doublelumen tube. A total of 214 intubations were undertaken in 204 patients using one of three endobronchial tubes. The cases of these patients were reviewed to determine differences in the complications associated with the Carlens, Robertshaw, and PVC tubes. Complications included unsuccessful or difficult intubation, tube dislodgment, unsatisfactory lung deflation, tube malposition, and hypoxemia. In 8 of 16 intubations with the Carlens tube and in 14 of 62 intubations with the Robertshaw tube, there were complications. In all, 22 of 78 intubations (28% 1 using conventional double-lumen tubes were complicated compared with 5 of 136 (4%) using the PVC tube. The technical problems and risks of endobronchial intubation were reduced significantly with the PVC double-lumen tube. The use of the double-lumen endobronchial tube for selective bronchospirometry was described by Carlens [l] in The following year, Bjork and Carlens [2] reported use of a double-lumen tube for thoracic surgical operations. While their indications for this tube were to prevent infected secretions from flooding the unaffected or "down" lung with the patient in the lateral decubitus position, they suggested that the tube might have wider application. From the Department of Surgery, Division of Thoracic Surgery, and the Department of Anesthesia, Stanford University Medical Center, Stanford, CA. Presented in part at the 47th Annual Scientific Assembly of the American College of Che!jt Physicians, San Francisco, CA, Oct 27, Address reprint requests to Dr. Mark, Department of Surgery, A-242, Stanford Medical Center, Stanford, CA Over the next decade, several groups including Bjork and colleagues j;3], Jenkins and Clarke [4], and Newman and associates [5] advocated more extensive use of the Carlens catheter in pulmonary operations. Numerous advantages were cited. However, several concerns, including difficulty in intubation and tube placement as well as increased airway resistance, precluded the widespread use of the Carlens tube. The Robertshaw double-i umen tube, introduced in 1962 [6], was intended to alleviate some of these problems and has had enthusiastic advocates of its routine use [7-91. The tube was designed without the carinal hook and with wider lumens and a more molded curvature to reduce kinking (Fig 1). In spite of these changes and numerous reports on the favorable physiological affects of endobronchial anesthesia [lo-141, the use of double-lumen tubes is still not common in thoracic surgical operations. Recently we have been using a new polyvinyl chloride (PVC) double-lumen endobronchial tube for single-lung ventilation (Figs 2, 3). This tube has features of construction that allow greater ease and safety in intubation and in the maintenance of one-lung anesthesia. The purpose of this review is to examine a consecutive series of patients undergoing thoracic surgical procedures in which one of three double-lumen tubes was used in order to document any differences in the type and incidence of difficulties and complications associated with the use of double-lumen endobronchial tubes. Clinical Material and Methods Between July 1, 1977, and June 30, 1981, 214 intubations with a double-lumen endobronchial tube were undertaken in 204 patients. Patients ranged in age from 10 to 80 years, with a mean age of 48 years. There were 112 male and 92 female patients. The 214 intubations done involved a variety of operations. There were 137 pulmonary resections: pneumonectomy, 17; 78

2 79 Burton et al: Polyvinyl Chloride Double-Lumen Tube A B Fig 1. (A) Left- and right-sided Robertshaw tubes. Asymmetrical expansion of cuffs is illustrated. This is a disadvantage of latex tubes that are resterilized. (B) Left-sided Carlens tube with balloons inflated. Carinal hook is visible. lobectomy or bilobectomy, 67; unilateral wedge resection, 36; and median sternotomy for bilateral wedge resection, 17. The remaining 77 operations were as follows: thoracoscopy, 32; esophageal operation, 12; resection of medias- tinal tumor, 11; exploratory thoracotomy, 8; bilateral pleurodesis (sternotomy), 4; decortication, 3; chest wall and wedge resection, 2; transaxillary dorsal sympathectomy, 2; hiatal hernia repair, 1; repair of diaphragm, 1; and pleural biopsy, 1. Following induction of general anesthesia, intubation with one of the endobronchial tubes was attempted. In all patients intubation was performed by residents under the supervision

3 80 The Annals of Thoracic Surgery Vol 36 No 1 July 1983 Fig 2. Disposable double-lumen endotracheal tube with cuffs deflated. Metal adapter at proximal end is reusable. of staff anesthesiologists. After successful intubation, the position of the tube was carefully checked by auscultation with the patient in the supine position and then in the lateral position to establish satisfactory inflation of each lung. While patients were on single-lung ventilation they were maintained with an inspired oxygen concentration of 100%. Arterial blood gas determinations from a radial artery catheter were made prior to, during, and following one-lung anesthesia in 157 patients. In general, patients undergoing less extensive procedures, such as thoracoscopy, did not have placement of radial artery catheters. The Carlens and Robertshaw tubes have been described previously [l, 3, 4, 61. The disposable PVC tube* we have been using is available in sizes 35, 37, 39, and 41F. The tube is designed for left-sided bronchial intubations. The bronchial portion of the tube is a continuation of the double-lumen body of the main tube at an angle of approximately 30 degrees and reaches approximately 4.5 cm beyond the tracheal orifice. The separate balloon cuffs are low-pressure, high-volume PVC. Cross-sectional areas of both tracheal and bronchial lumens range from 29 mm2 in a 35F tube to 42 mm2 in the 41F tube *Broncho-Cath Endobronclid Tube, Nntioncil Catheter Company, Argyle, NY (Table 1). The maximal circumference of the tube is from 38 to 45 mm (Table 2). Results There were no significant differences in the three groups regarding age, sex, operative procedures, or arterial blood gas determinations prior to single-lung ventilation. Lung deflation times ranged from El to 165 minutes, with a mean of 61 minutes. Difficulties and complications included unsuccessful intubation after at least three attempts, hypoxemia (defined as a partial pressure of arterial oxygen less than 60 mm Hg with an inspired oxygen fraction of loo%), unsatisfactory deflation of the lung in the operative field, md tube dislodgment or malposition. There were no operative deaths and no severe postoperative complications that could be attributed to the use of any doublelumen tube. A Carlens tube was used in 16 intubations, and difficulties were iencountered in 8 of these. On three occasions intubation was unsuccessful and necessitated placement of a standard endotracheal tube in 1 patient and a Robertshaw double-lumen tube in 2 patients. In addition, 3 patients had difficult intubations requiring multiple attempts to place the tube for satisfactory single-lung ventilation. In two instdnces the tube became dislodged while the patient was

4 81 Burton et al: Polyvinyl Chloride Double-Lumen Tube A B Fig 3. (A) Close-up of distal end of tube uiifh cuffs inflated. (B) Close-up of proximal end of tube.

5 82 The Annals of Thoracic Surgery Vol 36 No 1 July 1983 Table 1. Cross-sectional Areas of Three Double-Lumen Tubes Tube Polyvinyl Carlensb Robertshawb Sizea Chlorideb Right Left Average Tracheal Bronchial Average 35F F F F "The 37, 39, and 41F correspond to small, medium, and large, respectively, in the Robertshaw tube. bdata shown as square millimeters each lumen Table 2. Maximal Circumference of Three Double-Lumen Tubes Polyvinyl Tube Chloride Carlens Robertshaw Sizea (mm) Imm) (mm) 35F F F F 45,55 55 "The 37, 39, and 41F correspond to small, medium, and large, respectively, in the Robertshaw tube. being positioned. There were complications in 14 of 62 intubations with the Robertshaw tube. Hypoxemia, noted in 6 patients, was the primary complication. Unsatisfactory lung deflation occurred in 2 patients and undoubtedly was related to improper placement of the tube. In 1 patient intubation using the Robertshaw tube was unsuccessful, and a standard endotracheal tube had to be used. Finally, there were 5 patients in whom intubation was unsuccessful during the first three attempts. In all, 22 (28%) of the 78 intubations using conventional double-lumen tubes were marked by difficulties or complications. While lifethreatening complications, including tracheal and bronchial rupture, have been reported by others using these double-lumen tubes, no such complications were encountered in the present series. The PVC double-lumen tube was used in 136 patients, and complications occurred in 5 of them. In the single instance in which multiple attempts were required for intubation, the patient was noted to have a severely deviated trachea that would have made intubation with a standard endotracheal tube difficult. Another patient had severe hypoxemia at the time of intubation, and efforts to use a double-lumen tube were abandoned. In 2 patients, intraoperative hypoxemia was encountered. The final complication in this group was an unsuspected malposition of the tube. The rate of difficulties or complications with the PVC tube (4%) compared with the rate of complications encountered with conventional double-lumen tubes (28%) was statistically significant (p < 0.001). While the rate of complications with the Robertshaw tube was substantially lower than that with the Carlens tube, the difference was not significant (p = 0.06). The difference in complication rate between the Robertshaw tube and the PVC tube was significant (p < 0.001). Comment Although the concept of selective endobronchial anesthesia was suggested in 1931 [15], nearly twenty years passed lbefore it found application in thoracic surgical operations [16]. Initially the double-lumen tube was used as a means of preventing contamination of the noninvolved lung, but the indications for its use were rapidly expanded by Bjork and associates [3]. Since then, selective ventilation with the double-lumen tube has been advocated not only for pulmonary resections [3] but for a wide variety of thoracic procedures, including thoracoplasty, decortication, and esophageal operations [4, 5, 14, 171 as well as mediastinal operations [9]. It also has been reported to he iisefiil in 1-a~diovascular operations [17, 181. Tl~oracuscopy is facilitated if the lung can be selectively deflated [17, 191, and

6 83 Burton et al: Polyvinyl Chloride Double-Lumen Tube in median sternotomy we and others [20] have found that the double-lumen tube is beneficial for bilateral pulmonary operations. It also has been used for transthoracic gastric stapling in patients with morbid obesity [21]. During a thoracic surgical operation, a lung can be collapsed selectively using a bronchial blocker [22]. However, this technique does not allow for intermittent reexpansion or suctioning of the lung during operation. The advantages of selective ventilation with a double-lumen endobronchial tube have been documented numerous times [3-5, 7-9, 17, 181. Most obvious are the much improved exposure with a totally atelectatic lung and the lack of the need to retract the lung vigorously while maintaining adequate ventilation. Additional benefits in pulmonary operations include easier hilar dissection; more precise management of the bronchial stump, including open inspection of the bronchus; and selective deflation and inflation of the lung intraoperatively, as needed. Finally, the benefits for patients with purulent secretions [23], active hemorrhage, bronchopleural fistula, or the need for bronchoplasty remain the most compelling indications for the use of double-lumen tubes. Despite these advantages, there is still widespread reluctance to use double-lumen tubes routinely in thoracic surgical operations [7]. One major objection to their use is a fear of lifethreatening hypoxemia secondary to a ventilation/perfusion mismatch. Other potentially lifethreatening complications include tracheal and bronchial rupture [24, 251, esophageal injury, circulatory collapse [26], and difficulty with the intubation and the correct placement of the tubes. The physiological effects of one-lung ventilation with the Carlens or the Robertshaw tubes have been studied extensively [lo-14,27,28]. In general, it is agreed that while perfusion is greater in the ventilated lung, as much as a third of the cardiac output may go through the nonventilated lung [14]. It is recommended, therefore, that all patients be maintained on 100% oxygen during one-lung anesthesia; also, periods of lung reexpansion may be necessary during the procedure [2, 7, 111. While partial pressure of oxygen may remain very low in a few patients, overall oxygenation is usually satisfactory and is even improved in some instances [8], and minute ventilation is unchanged [lo] for patients being ventilated in one lung if the tube position is satisfactory. Clearance of carbon dioxide and cardiac output usually remain unchanged [lo, 121. Some cases of hypoxemia may be related to tube malposition. Insufflation of 100% oxygen with a catheter or high-frequency ventilation [29] through the appropriate lumen to the collapsed lung minimizes the incidence of hypoxia. While frequent use of the conventional double-lumen tubes will probably decrease the possibility of major and minor complications, we have found that problems with the tubes themselves may be limiting. In the hands of our anesthesia residents, under the supervision of staff anesthesiologists, the technique of insertion was much easier to master with the PVC tube than with the older tubes. While there is no advantage in the airway size, the overall construction of the PVC tube lends itself to easier intubation and positioning, and appears to be less likely to produce the hazardous complications reported with the stiffer red-rubber latex tubes. These changes in design include the softer, more flexible structure of PVC, very soft, lowpressure, high-volume bronchial and tracheal balloons, a more gentle distal curve, and a greater inside to outside diameter (i.e., smaller outside circumference for a roughly equivalent inner cross-sectional area) than either the Robertshaw or the Carlens tube (see Table 2). Only a left PVC tube is available. We use it for both right and left intrathoracic operations, including left pneumonectomy. The potential hazard of obstruction of the right upper lobe bronchus negates any benefit from a right-sided double-lumen tube except for patients with leftsided bronchial lesions. During left pneumonectomy immediately before the left main bronchus is clamped, we merely pull the left-sided PVC tube out of the bronchus and continue to ventilate just the right lung through the tube s tracheal lumen. We think that the PVC doublelumen tube greatly facilitates the clinical applications of selective ventilation for thoracic surgical operations and encourage greater adoption of its use.

7 84 The Annals of Thoracic Surgery Vol 36 No 1 July 1983 References 1. Carlens E: A new flexible double-lumen catheter for bronchospirometry. J Thorac Surg 18:742, Bjork VO, Carlens E: The prevention of spread during pulmonary resection by use of a doublelumen catheter. J Thorac Surg 20:151, Bjork VO, Carlens E, Friberg 0: Endobronchial anesthesia. Anesthesiology 14:60, Jenkins AV, Clarke G: Endobronchial anaesthesia with the Carlens catheter. Br J Anaesth 30:13, Newman RW, Finer GE, Downs JE: Routine use of the Carlens double-lumen endobronchial catheter. J Thorac Cardiovasc Surg 42:327, Robertshaw FL: Low resistance double-lumen endobronchial tubes. Br J Anaesth 34:576, Read RC, Friday CD, Eason CN: Prospective study of the Robertshaw endobronchial catheter in thoracic surgery. Ann Thorac Surg 24:156, Wood RE, Campbell D, Razzuk MA, et al: Surgical advantages of selective unilateral ventilation. Ann Thorac Surg 14:173, Zeitlin GL, Short DH, Ryder GH: An assessment of the Robertshaw double-lumen tube. Br J Anaesth 37:858, Aalto-Setala M, Heinonen J, Salorinne Y: Cardiorespiratory function during thoracic anesthesia: a comparison of two-lung ventilation and one-lung ventilation with and without PEEP. Acta Anaesthesiol Scand 19:287, Kerr JH, Crampton-Smith A, Prys-Roberts C, et al: Observations during endobronchial anaesthesia: 11. Oxygenation. Br J Anaesth 46:84, Kerr JH, Crampton-Smith A, Prys-Roberts C, et al: Observations during endobronchial anaesthesia: I. Ventilation and carbon dioxide clearance. Br J Anaesth 45:159, Khanam T, Branthwaite MA: Arterial oxygenation during one-lung anesthesia. Anesthesiology 28:280, Thomson DF, Campbell D: Changes in arterial oxygen tension during one-lung anaesthesia. Br J Anaesth 45:611, Gale JW, Waters RM: Closed endobronchial anesthesia in thoracic surgery. J Thorac Surg 1:432, Moody JD: Endobronchial occlusion during pulmonary resection. J Thorac Surg 18:82, Mendus-Edwards E, Hatch DJ: Experiences with double-lumen tubes. Anesthesiology 20:461, Das BB, Fenstermacher JM, Keats AS: Endobronchial anesthesia for resection of aneurysms of the descending aorta. Anesthesiology 32:152, Baumgartner WA, Mark JBD: The use of thoracoscopy in the diagnosis of pleural disease. Arch Surg 115:420, Meng RL, Jensik RJ, Kittle CF, et al: Median sternotomy for synchronous bilateral pulmonary operations. J Thorac Cardiovasc Surg 80:1, Oakes DD, Cohn R13, Brodsky JB, et al: Lateral thoracotomy and one-lung anesthesia in patients with morbid obesity. Ann Thorac Surg, 33:572, Ginsberg RJ: New technique for one-lung anesthesia using an endobronchial blocker. J Thorac Cardiovasc Surg 82:542, Brodsky JB, Abramowitz MD, Mehrez MP: Endobronchial intubation for intraoperative protection of a single functioning lung: a case report. Anesth Analg (Clevth) 55:340, Guernelli N, Bragaglia RB, Briccoli A, et al: Tracheobronchial ruptures due to cuffed Carlens tubes. Ann Thorac Surg 28:66, Heiser M, Steinberg JJ, MacVaugh H, et al: Bronchial rupture, a complication of the use of the Robertshaw double-llumen tube. Anesthesiology 51238, Dryden GD: Circulatory collapse after pneumonectomy (an unusual complication from the use of a Carlens catheter): case report. Anesth Analg (Cleve) 56:451, Tarhan S, Lundborg RO: Effects of increased expiratory pressure on blood gas tensions and pulmonary shunting during thoracotomy with the use of the Carlens catheter. Can Anaesth SOC J 17:4, Tarhan S, Lundborg RO: Carlens endobronchial catheter versus regular endotracheal tube during thoracic surgery: a comparison of blood gas tensions and pulmonary shunting. Can Anaesth SOC J 18:594, El-Baz N, Kittle CF, Faber LP, et al: Highfrequency ventilation with an uncuffed endobronchial tube: a new technique for one-lung anesthesia. J Thorac Cardiovasc Surg 84:823, 1982