On Monday, I had a surgery for esophageal cancer, and I routinely went to see a patient the day before, this is a male patient in his fifties, 171 cm tall, 72 kg in weight, usually pay attention to exercise, and is a patient with a very standard figure. But in my years of anesthesia experience, seeing this patient always feels that it does not conform to the aesthetics of our anesthesiologist. The lower jaw is a little small, and the chin distance is a bit short, so that he can only see the hard palate when he opens his mouth. I had a glimpse of alarm in my heart, and I had to be a little more prepared with the tools when I inserted the double-lumen tube tomorrow.
After the patient is admitted to the room, the vital signs are monitored and the veins are opened. First, radial artery puncture arterial manometry was performed under local anesthesia, deep venous access was established, and mida** 3mg, sufentanil 30ug, etomibe 20mg, and rocuronamide 50mg were given. After induction, the first time I tried to insert a double-lumen tube with an ordinary laryngoscope, and an anesthesiologist who had worked for 20 years said that he couldn't see the epiglottis, but fortunately he was prepared in advance and immediately switched to **laryngoscope.
It was very difficult to insert it, but due to repeated shaping during the insertion process, especially the poor alignment of the front end of the double-lumen tube after being inserted in the shape of a fishhook, the sealing effect of the left lung was not good after repeated auditions, which was unexpected. At this time, some people said that it was necessary to change the occluder, but because there was no fiber scope occluder, it was never used.
At this time, I flashed in my mind that 20 years ago, there were very few general anesthesia done, and only the method used during major surgery, at that time, the double-lumen tube was very thick, and sometimes if it could not be inserted, a single-lumen tube would be used for single-lung ventilation, and sometimes some extended endotracheal tubes would be customized to be inserted into the single lung. For example, if the left lung needs to collapse, a single-lumen tube is inserted into the right lung. If the right lung collapses, insert a single-lumen tube into the left lung. However, due to anatomical reasons, the angle between the inferior border of the left main bronchus and the longitudinal axis of the trachea is about 375 degrees, the angle between the lower edge of the right main bronchus and the longitudinal axis of the trachea is about 23 degrees, so the probability of insertion into the right main bronchus will be relatively large.
Today's patient happens to have left chest insertion and can choose to insert a single-lumen tube into the right main bronchus. Decisively replaced 7No. 0 strengthened endotracheal tube, the intubation process is about the same as that of inserting a double-lumen tube, after the catheter passes the glottis, rotate 90 degrees to the right and enter the right main bronchus, the depth is 30cm cuff inflation, the upper and lower lobes of the right lung are well ventilated by auscultation, the catheter is fixed in the lateral decubitus position, and the upper and lower lung ventilation conditions are confirmed by auscultation again.
The surgery began, and the left lung collapsed well during the operation. Respiratory parameter setting: VT360ml, F14 times, I:E=1:2. Fluid replacement at a uniform rate and urine output monitored. The oxygen saturation was maintained at 99% during the operation, and the catheter was pushed to 23cm after the operation to suction sputum to expand the lungs, and the catheter was withdrawn to the main bronchus and then auscultated again, and the breath sound of both lungs was good, and the surgeon was quite satisfied with the exposure of the surgical field. After the operation, the respiratory secretions are aspirated and the endotracheal tube is removed after the patient is awake. Breathe well. There were no adverse reactions such as postoperative sore throat and hoarseness in postoperative follow-up. In addition, relevant studies have shown that the application of single-lumen endotracheal intubation in obese patients can shorten the intubation time and reduce the occurrence of postoperative vocal cord injury and hoarseness.
Professor Chai Huiping of the Department of Thoracic Surgery of the Affiliated Hospital of Anhui Medical University carried out the full laparoscopic orvil surgery for esophageal cancer, which has high requirements for lung collapse, and it is often seen that he mentioned in his surgical summary that it takes half an hour or even 40 minutes to adjust the double lumen tube. If this method is used, the collapse of the lungs will not be bad, and as long as it is inserted into the position, the collapse of the lungs in the surgical field can be maintained to a satisfactory extent.
However, this method also has many disadvantages, such as the small chance of inserting it into the left lung by hand is not easy to succeed in surgery that requires the right lung to collapse. In addition, it should be noted in the application of lung tumors, firstly, it is inconvenient to suction sputum, and secondly, it is difficult to switch between single-lung ventilation and double-lung ventilation. Re-entry to the main bronchus is required. It is not recommended for patients with increased bronchiectasis sputum volume, unilateral massive pulmonary hemoptysis, and isolated lung infection.
Regardless of whether a single-lumen tube or a double-lumen tube is used for single-lung ventilation, the upper lung is not ventilated but there is still hemoperfusion, which is easy to cause intrapulmonary shunt, and due to the influence of lateral decubitus position, the ventilation of the lower lung is less than perfusion, which further leads to an increase in intrapulmonary shunt, which is prone to hypoxemia and carbon dioxide retention. Intraoperative respiratory management must be strengthened. Maintain the patency of the respiratory tract, attract respiratory secretions in time, ensure sufficient muscle relaxation during the operation, strengthen the protection of the lungs, maintain a certain colloidal osmotic pressure, and reduce pulmonary interstitial edema. Overall, good intraoperative ventilation management is also important.
Single-lung ventilation can be achieved through double-lumen bronchial intubation and bronchial occluder, which requires good obstruction of both lungs and adequate ventilation and oxygenation. Double-lumen bronchial tubes are commonly used in clinical practice, but they also have their shortcomings, one is that it is expensive, the effective lumen is small, the airway resistance is large, it is easy to be blocked by secretions, and the outer diameter is thick, and the coronal and sagittal planes have fixed angles, which is easy to cause postoperative sore throat and hoarseness. Patients with poor glottal exposure are difficult to intubate. Mechanical ventilation is when the airway pressure is too high, which can lead to airway pressure injury to the lung tissue. Airway resistance is inversely proportional to the 4th power of airway diameter. However, the outer diameter of the single-lumen tube is smaller, the intubation is relatively easy, and the incidence of postoperative sore throat and hoarseness is low. There are advantages to using it in the right case.
Feng Yan, Department of Anesthesiology, Jimin Cancer Hospital, Anhui Medical University.
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