- Email: [email protected]
The univent tube for airway management in combined ascending and descending thoracic aortic surgery
The Univent Tube for Airway Management in Combined Ascending and Descending Thoracic Aortic Surgery Shubjeet Kaur, MD, Stephen O. Heard, MD, and Robert LanceT, MD RAUMATIC disruption of both the ascending and
T descending aorta in the patient suffering from blunt multiple trauma is an uncommon clinical occurrence. 1-5The
combination of a median sternotomy and cardiopulmonary bypass to repair the tear in the ascending aorta and left thoracotomy to repair the descending aortic disruption can create problems in perloperative airway and ventilatory management, including the need for reintubation and one-lung ventdatlon. The authors report the use of the Univent bronchial blocker tube (Fuji Systems Corp.) T M in the airway management and provision of one-lung anesthesia for a patient in whom repairs of both ascending and descending aortic tears were performed at the same setting.
CASE REPORT A 33-year-old 54-kg unbelted male driver was involved in a motor vehicle accident. Emergency medical personnel noted that the steering wheel was markedly deformed. Initial work-up showed multiple facial lacerations, facial fractures, a right pneumothorax for which a chest tube was inserted, a left fifth phalangeal fracture, and a probable myocardial contusion (T-wave inversion m leads V2-V6 and ventricular arrhythmias). Cervical and thoracic spine x-rays failed to show any fractures, and CT scans of the head and abdomen were normal. Review of the chest x-ray by an attending radiologist the next day suggested an abnormal aortic knob (Fig 1). An aortogram (Fig 2) showed a tear at
the level of the distal ascending aorta just proxamal to its junction with the lnnommate artery and a second tear in the mid-descending thoracic aorta. The patient was brought to the operating room for emergent repair of both injuries. He was found to be extremely anxious and complaining of back pain. He was able to open his mouth about two finger breadths (secondary to pain caused by the facial fractures). The patient was instrumented with two large-bore peripheral catheters and right radial artery and pulmonary artery catheters. Because of concerns about his NPO (nothing by mouth) status, the authors decided to perform a modified rapidsequence induction using etomidate, 8 mg, sufentanil, 250 t~g, lidocaine, 100 mg, and vecuronium, 10 mg. Cricoid pressure was maintained during induction, although the patient was ventilated. Intubation of the trachea was
From the Departments of Anesthestology and Surgery, Dtvlston of Cardzothoractc Surgery, University of Massachusetts Medtcal Center, Worcester, MA 01655. Address repnnt requests to Shubjeet Kaur, MD, Department of Anesthestology, Untverstty of Massachusetts Medtcal Center, 55 Lake Ave, North, Worcester, MA 01655 Copyright © 1995 by W B Saunders Company 1053-0770/95/0902-001453 00/0 Key words Umvent tube, one-lung venttlatton, thoractc aorttc surgery
Fig 1. Admission chest x-ray showing a right pneumothorax, enlarged right paratracheal stripe suggesting a hematoma, and an indistinct descending aorta JournalofCardtothoractc and VascularAnesthesta, Vol 9, No 2 (April), 1995' pp 181-183
181
182
Fig 2. Aortogram showing tears (arrows) just proximal to the innominate artery and in the mid-descending aorta
accomplished with a 7.5-ram cuffed Univent bronchial blocker tube. The authors believed this would facilitate quick airway control and allow them to provide one-lung anesthesia without a tube change. General anesthesia was maintained with sufentanil, doxacurium, and enflurane. An arterial blood gas obtained while the patient was ventilated with 100% oxygen showed an A-a gradaent in excess of 400 mmHg, consistent with an underlying pulmonary contusion. After median sternotomy, cannulation of the right atrium and femoral artery, and anticoagulation, the patient was placed on cardiopulmonary bypass and cooled to 18°C. Repair of the ascending aortic tear was performed under conditions of total circulatory arrest (TCA). Before TCA,
KAUR, HEARD, AND LANCEY
the patient was given additional doxacurium, 5 mg, midazolam, 2 mg, and sufentanll, 100 Ixg, to ensure adequate anesthetic depth. The patient's head was packed in ice, and he was given a bolus of sodium thiopental, 500 mg, and mannitol, 25 mg, as additional cerebral protective measures. The patient was found to have a partial tear of the mtima and media of the distal ascending aorta just proximal to the junction with the innominate artery, encompassing 1Aof the circumference of the ascending aorta on the right anterolateral side. The ascending aorta was opened 2 cm proximal to the junction with the innomlnate artery. The tear was resected for a distance of 1 cm, and the aorta was closed with a running Prolene suture. The patient was rewarmed, and careful de-airing techniques were undertaken to prevent air embolism to the brain. The total duration of deep hypothermic circulatory arrest was 22 minutes. Normal sinus rhythm was regained spontaneously, and the paUent was weaned successfully from cardiopulmonary bypass without any inotropic support, after a total time of 69 minutes. After chest closure, the bronchial blocker was advanced into the left main bronchus, and its position was confirmed by fiberoptic bronchoscopy. The patient was then turned to the right lateral decubitus position. A left thoracotomy was performed, and a left atrial to descending aorta heparinized shunt was placed. During one-lung anesthesia, the descending thoracic aorta was clamped 6 cm above and 6 cm below its mldportion. Approximately 4 cm of the aorta were removed to resect the tear, and a 20-ram Hemashield 6-cm condmt was interposed. The clamps were removed after a total time of 57 minutes. While the left lung was deflated, the arterial oxygen tension dropped to 54 mmHg. Oxygenation improved when continuous positive airway pressure (CPAP, 5 cm H20) was provided to the left lung through the lumen of the bronchial blocker, 12and 5 cm H20 posmve end-expiratory pressure was provided to the right lung. This has been shown to be an effective sequence of maneuvers to deal with relative hypoxla during one-lung ventilation. 13 In addition, reexpansion of the left lung was required three times during the procedure because of arterial desaturatmon. The arterial oxygen tension improved to the low 200 mmHg range with these maneuvers. The duration of one-lung ventilation was 57 minutes. The mean arterial pressure during the period of partial left heart bypass was in the mid-80-mmHg range in the left upper extremity and in the mid-70-mmHg range as measured in the right femoral artery. The flow rate through the shunt was approximately 2 liters per minute. At the conclusion of surgery, the blocker was deflated and pulled back into the endotracheal tube. The patient was turned supine and transported to the intensive care unit in stable condition. He was extubated uneventfully about 30 hours later. The patient had no adverse neurologlc sequelae. He returned to the operating room 2 days later for repair of facial fractures under general anesthesia without problems. He was discharged from the hospltal about 2 weeks later in good health after resolution of a persistent air leak from his left chest tube.
UNIVENT TUBE THORACIC AORTIC SURGERY
183
DISCUSSION
The need for median sternotomy and left thoracotomy requiring one-lung ventilation m a patient during a staged operation is a rare event. This case was ideal for the use of a Univent tube. By carefully planning the airway management at the beginning, the authors were able to safely control the patient's airway yet provide one-lung ventilation without the need for a change of the endotracheal tube. Airway edema and fluid shifts after cardiopulmonary bypass may make reintubation (from a single-lumen to a double-lumen tube) hazardous. As a result of this technique of airway management, there was minimal delay between the conclusion of the first stage of the operation and the start of the second. On completion of the procedure the patient was safely and expeditiously transferred to the intensive care unit without submitting him to the risk of yet another endotracheal tube change (double lumen to single lumen). Lack of familiarity with appropriate placement of the bronchial blocker incorporated in the Univent tube can be a significant limitation in selecting the Univent tube for airway management in such a clinical situation An alternative to using a Univent tube was to use a double-lumen tube (DLT) throughout the procedure and replace it at the conclusmn of surgery with a standard
endotracheal tube for postoperative ventilatory support. Its disadvantage is having a tube with a large external diameter in place for a relatively long period of time in a patient at risk for significant airway edema, and an inability to provide good pulmonary toilet. 14 This would not be an issue if a DLT of size 37 F or smaller was used, as the external diameter of a 7.5 Univent tube is similar to that of a 37 F DLT. Instead of using either the Unwent tube or DLT, a regular endotracheal tube could have been advanced into the right main bronchus during the left thoracotomy to provide one-lung ventilation. However, this would have run the risk of collapsing the right upper lobe in a patient who had an underlying pulmonary contusion. Another option was to use a regular endotracheal tube and advance a separate bronchial blocker (eg, Fogarty catheter) by its side into the left mainstem bronchus. The disadvantage would have been the lack of ablhty to apply CPAP to the nondependent lung during one-lung ventilation. In conclusion, the authors were able to safely manage the airway of this patient and provide one-lung ventilation and acceptable operating conditions by using the Unlvent bronchial blocker endotracheal tube. This was accomplished with minimal delay between the two stages of the surgical repair.
REFERENCES
1 K~rshMM, Orrmger MB, Behrendt DM, et al' Management of unusual traumatic ruptures of the aorta Surg Gynecol Obstet 146 365-370. 1978 2 Lowery RC, Ergln A, Galla J, et al Successful treatment of multiple simultaneous great vessel disruptions. Ann Thorac Surg 41.672-674, 1986 3 Stothert JC, McBride L, TIdik S, et al. Multiple aortic tears treated by primary suture repam J Trauma 27 955-956, 1987 4 Asfaw I, Ramadan H, Talbert JG. et al Double traumatic rupture of the thoracic aorta J Trauma 25.1102-1104. 1985 5. Rablnsky I, Sldhu GS, Wagner RB Mid-descending aortic traumatic aneurysms. Ann Thorac Surg 50'155-160, 1990 6. Kamaya H, Krishna PR. New endotracheal tube (Univent Tube®) for selective blockade of one lung. Anesthesiology 63 342343, 1985 7 Hultgren BL, Krishna PR, Kamaya H' A new tube for onelung ventilation experience with the Unlvent Tube®. Anesthesiology 65'A481, 1986 8 Inoue H, Shohtsu A, Ogawa J, et al New device for one-lung
anesthesia endotracheal tube with movable blocker. J Thorac Cardlovasc Surg 83 940-941, 1982 9. Inoue H, Shohtsu A, Ogawa J, et al Endotracheal tube with moveable blocker to prevent aspiration of intratracheal bleeding. Ann Thorac Surg 37 497-499, 1984 10 Karwande SV: A new tube for single-lungventilation Chest 92'761-763, 1987 11 MacGllllvray RG' Evaluation of a new tracheal tube with a movable bronchus blocker. Anaesthesaa 43 687-689, 1988 12. Benumof JL, Gaughan S, Ozakl G: Operative lung CPAP with the UnIvent bronchial blocker tube Anesthesiology 75'A119, 1991 13. Obara H, Tamaka O, Hoshlno Y, et al The effect of positive end-expiratory pressure to the nondependent and dependent lung. Anaesthesia 41-1007-1010, 1986 14. Gayes JM The Univent tube as the best technique for providing one-lung anesthesia Pro One-lung anesthesia IS best accomplished w~th the Unlvent endotracheal tube J Cardlothorac Vasc Anesth 7"103-107, 1993
T descending aorta in the patient suffering from blunt multiple trauma is an uncommon clinical occurrence. 1-5The
combination of a median sternotomy and cardiopulmonary bypass to repair the tear in the ascending aorta and left thoracotomy to repair the descending aortic disruption can create problems in perloperative airway and ventilatory management, including the need for reintubation and one-lung ventdatlon. The authors report the use of the Univent bronchial blocker tube (Fuji Systems Corp.) T M in the airway management and provision of one-lung anesthesia for a patient in whom repairs of both ascending and descending aortic tears were performed at the same setting.
CASE REPORT A 33-year-old 54-kg unbelted male driver was involved in a motor vehicle accident. Emergency medical personnel noted that the steering wheel was markedly deformed. Initial work-up showed multiple facial lacerations, facial fractures, a right pneumothorax for which a chest tube was inserted, a left fifth phalangeal fracture, and a probable myocardial contusion (T-wave inversion m leads V2-V6 and ventricular arrhythmias). Cervical and thoracic spine x-rays failed to show any fractures, and CT scans of the head and abdomen were normal. Review of the chest x-ray by an attending radiologist the next day suggested an abnormal aortic knob (Fig 1). An aortogram (Fig 2) showed a tear at
the level of the distal ascending aorta just proxamal to its junction with the lnnommate artery and a second tear in the mid-descending thoracic aorta. The patient was brought to the operating room for emergent repair of both injuries. He was found to be extremely anxious and complaining of back pain. He was able to open his mouth about two finger breadths (secondary to pain caused by the facial fractures). The patient was instrumented with two large-bore peripheral catheters and right radial artery and pulmonary artery catheters. Because of concerns about his NPO (nothing by mouth) status, the authors decided to perform a modified rapidsequence induction using etomidate, 8 mg, sufentanil, 250 t~g, lidocaine, 100 mg, and vecuronium, 10 mg. Cricoid pressure was maintained during induction, although the patient was ventilated. Intubation of the trachea was
From the Departments of Anesthestology and Surgery, Dtvlston of Cardzothoractc Surgery, University of Massachusetts Medtcal Center, Worcester, MA 01655. Address repnnt requests to Shubjeet Kaur, MD, Department of Anesthestology, Untverstty of Massachusetts Medtcal Center, 55 Lake Ave, North, Worcester, MA 01655 Copyright © 1995 by W B Saunders Company 1053-0770/95/0902-001453 00/0 Key words Umvent tube, one-lung venttlatton, thoractc aorttc surgery
Fig 1. Admission chest x-ray showing a right pneumothorax, enlarged right paratracheal stripe suggesting a hematoma, and an indistinct descending aorta JournalofCardtothoractc and VascularAnesthesta, Vol 9, No 2 (April), 1995' pp 181-183
181
182
Fig 2. Aortogram showing tears (arrows) just proximal to the innominate artery and in the mid-descending aorta
accomplished with a 7.5-ram cuffed Univent bronchial blocker tube. The authors believed this would facilitate quick airway control and allow them to provide one-lung anesthesia without a tube change. General anesthesia was maintained with sufentanil, doxacurium, and enflurane. An arterial blood gas obtained while the patient was ventilated with 100% oxygen showed an A-a gradaent in excess of 400 mmHg, consistent with an underlying pulmonary contusion. After median sternotomy, cannulation of the right atrium and femoral artery, and anticoagulation, the patient was placed on cardiopulmonary bypass and cooled to 18°C. Repair of the ascending aortic tear was performed under conditions of total circulatory arrest (TCA). Before TCA,
KAUR, HEARD, AND LANCEY
the patient was given additional doxacurium, 5 mg, midazolam, 2 mg, and sufentanll, 100 Ixg, to ensure adequate anesthetic depth. The patient's head was packed in ice, and he was given a bolus of sodium thiopental, 500 mg, and mannitol, 25 mg, as additional cerebral protective measures. The patient was found to have a partial tear of the mtima and media of the distal ascending aorta just proximal to the junction with the innominate artery, encompassing 1Aof the circumference of the ascending aorta on the right anterolateral side. The ascending aorta was opened 2 cm proximal to the junction with the innomlnate artery. The tear was resected for a distance of 1 cm, and the aorta was closed with a running Prolene suture. The patient was rewarmed, and careful de-airing techniques were undertaken to prevent air embolism to the brain. The total duration of deep hypothermic circulatory arrest was 22 minutes. Normal sinus rhythm was regained spontaneously, and the paUent was weaned successfully from cardiopulmonary bypass without any inotropic support, after a total time of 69 minutes. After chest closure, the bronchial blocker was advanced into the left main bronchus, and its position was confirmed by fiberoptic bronchoscopy. The patient was then turned to the right lateral decubitus position. A left thoracotomy was performed, and a left atrial to descending aorta heparinized shunt was placed. During one-lung anesthesia, the descending thoracic aorta was clamped 6 cm above and 6 cm below its mldportion. Approximately 4 cm of the aorta were removed to resect the tear, and a 20-ram Hemashield 6-cm condmt was interposed. The clamps were removed after a total time of 57 minutes. While the left lung was deflated, the arterial oxygen tension dropped to 54 mmHg. Oxygenation improved when continuous positive airway pressure (CPAP, 5 cm H20) was provided to the left lung through the lumen of the bronchial blocker, 12and 5 cm H20 posmve end-expiratory pressure was provided to the right lung. This has been shown to be an effective sequence of maneuvers to deal with relative hypoxla during one-lung ventilation. 13 In addition, reexpansion of the left lung was required three times during the procedure because of arterial desaturatmon. The arterial oxygen tension improved to the low 200 mmHg range with these maneuvers. The duration of one-lung ventilation was 57 minutes. The mean arterial pressure during the period of partial left heart bypass was in the mid-80-mmHg range in the left upper extremity and in the mid-70-mmHg range as measured in the right femoral artery. The flow rate through the shunt was approximately 2 liters per minute. At the conclusion of surgery, the blocker was deflated and pulled back into the endotracheal tube. The patient was turned supine and transported to the intensive care unit in stable condition. He was extubated uneventfully about 30 hours later. The patient had no adverse neurologlc sequelae. He returned to the operating room 2 days later for repair of facial fractures under general anesthesia without problems. He was discharged from the hospltal about 2 weeks later in good health after resolution of a persistent air leak from his left chest tube.
UNIVENT TUBE THORACIC AORTIC SURGERY
183
DISCUSSION
The need for median sternotomy and left thoracotomy requiring one-lung ventilation m a patient during a staged operation is a rare event. This case was ideal for the use of a Univent tube. By carefully planning the airway management at the beginning, the authors were able to safely control the patient's airway yet provide one-lung ventilation without the need for a change of the endotracheal tube. Airway edema and fluid shifts after cardiopulmonary bypass may make reintubation (from a single-lumen to a double-lumen tube) hazardous. As a result of this technique of airway management, there was minimal delay between the conclusion of the first stage of the operation and the start of the second. On completion of the procedure the patient was safely and expeditiously transferred to the intensive care unit without submitting him to the risk of yet another endotracheal tube change (double lumen to single lumen). Lack of familiarity with appropriate placement of the bronchial blocker incorporated in the Univent tube can be a significant limitation in selecting the Univent tube for airway management in such a clinical situation An alternative to using a Univent tube was to use a double-lumen tube (DLT) throughout the procedure and replace it at the conclusmn of surgery with a standard
endotracheal tube for postoperative ventilatory support. Its disadvantage is having a tube with a large external diameter in place for a relatively long period of time in a patient at risk for significant airway edema, and an inability to provide good pulmonary toilet. 14 This would not be an issue if a DLT of size 37 F or smaller was used, as the external diameter of a 7.5 Univent tube is similar to that of a 37 F DLT. Instead of using either the Unwent tube or DLT, a regular endotracheal tube could have been advanced into the right main bronchus during the left thoracotomy to provide one-lung ventilation. However, this would have run the risk of collapsing the right upper lobe in a patient who had an underlying pulmonary contusion. Another option was to use a regular endotracheal tube and advance a separate bronchial blocker (eg, Fogarty catheter) by its side into the left mainstem bronchus. The disadvantage would have been the lack of ablhty to apply CPAP to the nondependent lung during one-lung ventilation. In conclusion, the authors were able to safely manage the airway of this patient and provide one-lung ventilation and acceptable operating conditions by using the Unlvent bronchial blocker endotracheal tube. This was accomplished with minimal delay between the two stages of the surgical repair.
REFERENCES
1 K~rshMM, Orrmger MB, Behrendt DM, et al' Management of unusual traumatic ruptures of the aorta Surg Gynecol Obstet 146 365-370. 1978 2 Lowery RC, Ergln A, Galla J, et al Successful treatment of multiple simultaneous great vessel disruptions. Ann Thorac Surg 41.672-674, 1986 3 Stothert JC, McBride L, TIdik S, et al. Multiple aortic tears treated by primary suture repam J Trauma 27 955-956, 1987 4 Asfaw I, Ramadan H, Talbert JG. et al Double traumatic rupture of the thoracic aorta J Trauma 25.1102-1104. 1985 5. Rablnsky I, Sldhu GS, Wagner RB Mid-descending aortic traumatic aneurysms. Ann Thorac Surg 50'155-160, 1990 6. Kamaya H, Krishna PR. New endotracheal tube (Univent Tube®) for selective blockade of one lung. Anesthesiology 63 342343, 1985 7 Hultgren BL, Krishna PR, Kamaya H' A new tube for onelung ventilation experience with the Unlvent Tube®. Anesthesiology 65'A481, 1986 8 Inoue H, Shohtsu A, Ogawa J, et al New device for one-lung
anesthesia endotracheal tube with movable blocker. J Thorac Cardlovasc Surg 83 940-941, 1982 9. Inoue H, Shohtsu A, Ogawa J, et al Endotracheal tube with moveable blocker to prevent aspiration of intratracheal bleeding. Ann Thorac Surg 37 497-499, 1984 10 Karwande SV: A new tube for single-lungventilation Chest 92'761-763, 1987 11 MacGllllvray RG' Evaluation of a new tracheal tube with a movable bronchus blocker. Anaesthesaa 43 687-689, 1988 12. Benumof JL, Gaughan S, Ozakl G: Operative lung CPAP with the UnIvent bronchial blocker tube Anesthesiology 75'A119, 1991 13. Obara H, Tamaka O, Hoshlno Y, et al The effect of positive end-expiratory pressure to the nondependent and dependent lung. Anaesthesia 41-1007-1010, 1986 14. Gayes JM The Univent tube as the best technique for providing one-lung anesthesia Pro One-lung anesthesia IS best accomplished w~th the Unlvent endotracheal tube J Cardlothorac Vasc Anesth 7"103-107, 1993