Saudi Journal of Anaesthesia

LETTERS TO EDITOR
Year
: 2020  |  Volume : 14  |  Issue : 3  |  Page : 409--410

A comment on – “Lung isolation for lobectomy in elderly, post-radiation fibrosis of a difficult airway – pediatric double-lumen tube and pediatric ureteroscope as rescue devices”


Swapnil Y Parab 
 Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India

Correspondence Address:
Dr. Swapnil Y Parab
13, Periyar, Anushakti Nagar, Mumbai - 400 094, Maharashtra
India




How to cite this article:
Parab SY. A comment on – “Lung isolation for lobectomy in elderly, post-radiation fibrosis of a difficult airway – pediatric double-lumen tube and pediatric ureteroscope as rescue devices”.Saudi J Anaesth 2020;14:409-410


How to cite this URL:
Parab SY. A comment on – “Lung isolation for lobectomy in elderly, post-radiation fibrosis of a difficult airway – pediatric double-lumen tube and pediatric ureteroscope as rescue devices”. Saudi J Anaesth [serial online] 2020 [cited 2020 Oct 22 ];14:409-410
Available from: https://www.saudija.org/text.asp?2020/14/3/409/285435


Full Text



Sir,

I read with great interest, the article by Gupta et al. on “Lung isolation for lobectomy in elderly, post-radiation fibrosis of a difficult airway – pediatric double-lumen tube and pediatric ureteroscope as rescue devices.”[1] I, hereby, congratulate the authors for the innovative use of ureteroscope for the confirmation of the position of 28 F double-lumen tube (DLT). However, I wish to share a concern regarding the management of the case. The patient was a known case of hypopharyngeal cancer and had received irradiation to the neck. Radiation results in extensive fibrosis in the neck, losing the suppleness of the tissues in submandibular and submental space, thus making visualization of larynx difficult. Moreover, lymphatic drainage of the larynx was affected resulting in glottic edema and reduction in the glottic opening. Besides, this patient had restricted mouth opening and limited neck extension. By all means, the patient was a case of an anticipated difficult airway, which was also confirmed upon direct laryngoscopy. The insertion of a single lumen tube followed by the use of bronchial blocker (BB) would have been ideal for this patient. DLT is difficult to insert due to its large external diameter and fixed curvatures. In this case, where the airway was difficult, repeated attempts were made to insert DLT. Repeated attempts can worsen the glottic edema by trauma to the tissues. Reluctance to use BB is common worldwide. Surveys on the practice of thoracic anesthesia have shown that the use of BBs is negligible as compared to the use of DLTs.[2],[3] DLT carries certain advantages such as lesser time for insertion, better access to both lungs, and lesser incidence of intraoperative displacement. However, a meta-analysis comparing the use of DLT and BBs in thoracic surgeries has shown that the quality of lung collapse had been comparable with the use of both devices. Further, DLTs were associated with a significantly higher risk of airway injuries as compared to BBs.[4] Better designs and materials have made the BBs as reliable as DLTs. Still, it is a matter of concern that many thoracic anesthesiologists are biased in their preference for lung isolation devices.

Lung isolation in a patient with anticipated difficult airway is a classical indication for the use of BB.[5] In this case, after inserting a single lumen tube, a bronchial blocker could have been inserted into the left mainstem bronchus. An advantage with the blocker is that it can be passed extra-luminally i.e. outside the tube. This method is particularly useful when a pediatric bronchoscope is not available. An adult bronchoscope can be passed through the endotracheal tube to confirm the location of BB passed extra-luminally.

In conclusion, judicious selection of lung isolation devices is a key to success for safe and effective thoracic anesthesia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Gupta B, Khan A, Ghosh D. Lung isolation for lobectomy in an elderly, post radiation fibrosis of a difficult airway-pediatric double lumen tube and pediatric ureteroscope as rescue devices. Saudi J Anaesth 2020;14:281-3.
2Eldawlatly A, Turkistani A, Shelley B, El-Tahan M, Macfie A, Kinsella J. Thoracic-anaesthesia group collaborators. Anesthesia for thoracic surgery: A survey of middle eastern practice. Saudi J Anaesth 2012;6:192-6.
3Shelley B, Macfie A, Kinsella J. Anesthesia for thoracic surgery: A survey of UK practice. J Cardiothorac Vasc Anesth 2011;25:1014-7.
4Clayton-Smith A, Bennett K, Alston RP, Adams G, Brown G, Hawthorne T, et al. A comparison of the efficacy and adverse effects of double-lumen endobronchial tubes and bronchial blockers in thoracic surgery: A systematic review and meta-analysis of randomized controlled trials. J Cardiothorac Vasc Anesth 2015;29:955-66.
5Collins SR, Titus BJ, Campos JH, Blank RS. Lung isolation in the patient with a difficult airway. Anesth Analg 2018;126:1968-78.