Changes in the Bronchial Cuff Pressure of Left-Sided Double-Lumen Endotracheal Tube by Lateral Positioning: A Prospective Observational Study.
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SUBMITTER: Kim JH
PROVIDER: S-EPMC8070095 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:INTRODUCTION:Correct pressure is important when using a double-lumen endotracheal tube (DLT), especially in thoracic surgery. An inadequate bronchial cuff pressure (BCP) can cause air leak and interfere with visualisation of the surgical field, whereas an excessive pressure BCP can lead to cuff-related complications. Based on several reports that cuff pressure could alter after a positional change when using an endotracheal tube, we hypothesise that a change from the supine position to the lateral decubitus position, which is essential for thoracic surgery, would affect the BCP of the DLT. METHODS AND ANALYSIS:This prospective, single-centre, observational study will enrol 74 patients aged 18-70 years undergoing elective lung surgery from September 2018 to April 2019. The primary outcome will be the change in the 'initially established BCP' (maximum BCP not exceeding 40 cm H2O with no air leak in the supine position) after lateral decubitus positioning. BCP and air leak will be assessed in each patient position during inflation of the cuff with air in 0.5?mL increments from 0 to 3?mL. Secondary outcomes will include the incidence of BCP exceeding 40 cm H2O after the initial established value and that of a change in the smallest bronchial cuff volume without air leak after a change to the lateral position. The relationship between the change in BCP and airway pressure, compliance and body mass index after lateral positioning will be investigated. ETHICS AND DISSEMINATION:The study will be conducted in accordance with the Declaration of Helsinki and supervised by the Daegu Catholic University Medical Center institutional review board (study approval number CR-18-111). All patients will receive information about the study and will need to provide written informed consent before enrolment. The results will be presented at an international meeting and published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER:NCT03656406; Pre-results.
| S-EPMC6475141 | biostudies-literature
Project description:The minimum bronchial cuff volume (BCVmin) of a double-lumen tube (DLT) without air leaks during lung isolation may vary among individuals, and lateral positioning could increase the bronchial cuff pressure (BCP). We investigated the effect of initially established BCVmin (BCVi) on the change in BCP by lateral positioning. Seventy patients who underwent elective lung surgery were recruited and divided into two groups according to the BCVi obtained during anesthetic induction in each patient. Outcome analysis was conducted using data from 39 patients with a BCVi greater than 0 (BCVi > 0 group) and 27 with a BCVi of 0 (BCVi = 0 group). The primary outcome was a change in the value measured in the supine and lateral positions of the initially established BCP (BCPi; BCP at the time of BCVi injection), which was significantly larger in the BCVi > 0 group than in the BCVi = 0 group (1.5 (0.5-6.0) cmH2O vs. 0.0 (0.0-1.0) cmH2O; p < 0.001). BCVi was related to the left main bronchus (LMB) diameter (Spearman's rho = 0.676, p < 0.001) and the gap between the LMB diameter and the outer diameter of the bronchial cuff (Spearman's rho = 0.553, p < 0.001). Therefore, selecting a DLT size with a bronchial cuff that fits each patient's LMB may be useful in minimizing the change in BCP when performing lateral positioning during thoracic surgery. If the bronchial cuff requires unavoidable initial inflation, it is necessary to be aware that BCP may increase during lateral positioning and to monitor the BCP regularly if possible.
| S-EPMC10095022 | biostudies-literature
Project description:BackgroundDouble-lumen endobronchial tube (DLT) displacement, defined as migration of the DLT > 15 mm from optimal position, may threaten patient safety. Lateral decubitus positioning (LDP) of the patient can induce DLT displacement; however, little is known regarding the predictors for DLT displacement after this maneuver. Obesity may further aggravate DLT displacement by distorting mediastinal anatomy, but no comprehensive data exist concerning the impact of obesity on DLT displacement after LDP. Therefore, we evaluated the predictive value of preoperative risk factors, including obesity, for DLT displacement after LDP in patients who underwent pulmonary resection.MethodsData of patients who underwent pulmonary resection between July 2020 and July 2021 were retrospectively reviewed. Age, sex, height, weight, body mass index, left main bronchus diameter, DLT size, lateral decubitus direction, DLT depth, patient height divided by the DLT depths in supine and lateral decubitus positions (H/Dsupine and H/Dlateral, respectively), and extent of DLT dislocation were assessed. Logistic regression analysis identified risk factors, and the optimal cutoff values for continuous variables were determined using receiver operating characteristic curve analysis.ResultsData from 428 patients were analyzed. DLT displacement was observed in 52 patients (12.1%). Obesity and H/Dsupine were independent predictors for DLT displacement after LDP (odds ratio [OR]: 5.69, 95% CI [2.89, 11.23], P < 0.001 and OR: 8.28, 95% CI [2.92, 23.48], P < 0.001, respectively).ConclusionsObesity was significantly associated with DLT displacement after LDP. Pre-emptively advancing the DLT from its optimal position before LDP may be advantageous in patients with obesity.
| S-EPMC10244602 | biostudies-literature
Project description:ObjectiveInflation of the endotracheal tube cuff is needed for providing ventilation. Cuff pressure should be maintained inside the appropriate range to prevent critical airway complications. The purpose of this study is to evaluate the pressure changes in the endotracheal tube cuff during otorhinolaryngologic surgery.Design and methodThis single-center observational study was conducted at Severance Hospital in Korea between April 2020 and November 2020. Patients aged >20 years scheduled to undergo otorhinolaryngological surgical procedures were enrolled. Patients undergoing planned tracheostomy and those who were slated for uncuffed endotracheal tube use were excluded. Intubation was performed after the induction of general anesthesia. A pressure transducer was connected to the pilot balloon of the endotracheal tube, and cuff pressure was continuously monitored until extubation. If the cuff pressure was not appropriate for more than 5 min, it was adjusted to the appropriate range by injecting or removing air. The percentage of time for which the cuff pressure remained within the appropriate range was calculated and defined as the time in the therapeutic range (TTR). The presumed cause for the rise or fall in cuff pressure was identified.ResultsIn total 199 patients, alterations in cuff pressure outside the appropriate range occurred in 191 patients (96.0%). The mean TTR was 79.7% (SD 25.0%), and head and neck surgery had the lowest mean TTR of 69.0% compared to ear and nose surgeries (94.2 and 82.1%, respectively). Sixty-eight patients (34.2%) demonstrated inadequate endotracheal tube cuff pressure for more than 20% of the total anesthesia time. Twenty-six patients (13.1%) demonstrated optimal endotracheal tube cuff pressure for less than 50% of the total anesthesia time. The causative factors inducing inappropriate cuff pressure were found to vary, including positional changes, surgical procedure, anatomical manipulation, and anesthetic procedure.ConclusionIn otorhinolaryngologic surgery, cuff pressure increased or decreased outside the appropriate range due to various factors. Therefore, we suggest close continuous monitoring of cuff pressure during anesthesia for otorhinolaryngologic surgery.Clinical trial registrationclinicaltrials.gov, identifier NCT03938493.
| S-EPMC10277466 | biostudies-literature
Project description:The use of a video-assisted laryngoscope (VL) has been shown to reduce the time to achieve intubation with a double-lumen endobronchial tube (DLT). As the blade of the VL is curved differently to a standard laryngoscope, the DLT must be angled into a hockey stick shape to fit properly. We conducted a study to establish which direction of angulation was best to facilitate correct positioning of the DLT when using a VL.We enrolled patients scheduled for thoracic surgery who required intubation with a DLT. They were prospectively randomized into one of two groups: those intubated with a DLT angled to conceal the tracheal orifice (the tracheal orifice-covered, TOC) group or the tracheal orifice-exposed (TOE) group. The composite primary outcome measures were time taken to intubate and the frequency of first-time success. The time taken to intubate was divided into: T1, the time from mouth opening to visualization of the vocal cords with the VL; and T2, the time taken to advance the DLT through the cords until its tip lay within the trachea and three carbon dioxide waveforms had been detected by capnography. The hemodynamic responses to intubation and intubation-related adverse events were also recorded.Sixty-six patients completed the study, with 33 in each group. Total intubation time was significantly shorter in the TOC group (mean 30.6?±?standard deviation 2.7 seconds versus 38.7?±?3.3 seconds, p <0.0001). T2 was also significantly shorter in the TOC group than the TOE group (27.2?±?2.5 seconds versus 34.9?±?3.0 seconds, p <0.0001). The severity of hoarseness on the first postoperative day and sore throat on the fourth postoperative day were significantly lower in the TOC group than the TOE group (p?=?0.02 and <0.0001, respectively). The hemodynamic responses to intubation were broadly similar between the groups.When placing a left-sided DLT using a VL, angling the bronchial lumen to a hockey stick shape that conceals the tracheal lumen saves time and ameliorates the severity of post-intubation complications.ClinicalTrials.gov Identifier: NCT01605591.
| S-EPMC4158352 | biostudies-literature
Project description:BackgroundAppropriate placement of left-sided double-lumen endotracheal tubes (LDLTs) is paramount for optimal visualization of the operative field during thoracic surgeries that require single lung ventilation. Appropriate placement of LDLTs is therefore confirmed with fiberoptic bronchoscopy (FOB) rather than clinical assessment alone. Recent studies have demonstrated lung ultrasound (US) is superior to clinical assessment alone for confirming placement of LDLT, but no large trials have compared US to the gold standard of FOB. This noninferiority trial was devised to compare lung US with FOB for LDLT positioning and achievement of lung collapse for operative exposure.MethodsThis randomized, controlled, double-blind, noninferiority trial was conducted at the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand from October 2017 to July 2019. The study enrolled 200 ASA classification 1-3 patients that were scheduled for elective thoracic surgery requiring placement of LDLT. Study patients were randomized into either the FOB group or the lung US group after initial blind placement of LDLT. Five patients were excluded due to protocol deviation. In the FOB group (n = 98), fiberoptic bronchoscopy was used to confirm lung collapse due to proper positioning of the LDLT, and to adjust the tube if necessary. In the US group (n = 97), lung ultrasonography of four pre-specified zones (upper and lower posterior and mid-axillary) was used to assess lung collapse and guide adjustment of the tube if necessary. The primary outcome was presence of adequate lung collapse as determined by visual grading by the attending surgeon on scale from 1 to 4. Secondary outcomes included the time needed to adjust and confirm lung collapse, the time from finishing LDLT positioning to the grading of lung collapse, and intraoperative parameters such has hypotension or hypertension, hypoxia, and hypercarbia. The patient, attending anesthesiologist, and attending thoracic surgeon were all blinded to the intervention arm.ResultsThe primary outcome of lung collapse by visual grading was similar between the intervention and the control groups, with 89 patients (91.8%) in the US group compared to 83 patients (84.1%) in the FOB group (p = 0.18) experiencing adequate collapse. This met criteria for noninferiority per protocol analysis. The median time needed to confirm and adjust LDLT position in the US group was 3 min (IQR 2-5), which was significantly shorter than the median time needed to perform the task in the FOB group (6 min, IQR 4-10) (p = 0.002).ConclusionsIn selected patients undergoing thoracic surgery requiring LDLT, lung ultrasonography was noninferior to fiberoptic bronchoscopy in achieving adequate lung collapse and reaches the desired outcome in less time.Trial registrationThis study was registered at clinicaltrials.gov, NCT03314519 , Principal investigator: Kasana Raksamani, Date of registration: 19/10/2017.
| S-EPMC9150310 | biostudies-literature
Project description:BackgroundSubglottic secretion had been proven as one of the causes of microaspiration and increased risk of ventilator-associated pneumonia (VAP). The role of ultrasound to detect subglottic secretion has not yet been established.PurposeThe purpose of this study is to determine the sensitivity and specificity of upper airway ultrasound (US) in the detection of subglottic secretions as compared to computed tomography (CT) scanning.Material and methodsA prospective observational study was carried out in adult trauma patients requiring mechanical ventilation and cervical CT scan. All patients had an endotracheal tube cuff-pressure maintained between 20 and 30 cm H2O. Airway US was performed at the bedside immediately before the patient was transferred to the CT scan suite. The sensitivity, specificity, and positive/negative predictive values (PPV, NPV) of the upper airway US detection of subglottic secretions were then calculated and compared with CT findings.ResultsFifty participants were consecutively included. Subglottic secretions were detected in 31 patients using upper airway US. The sensitivity and specificity of upper airway US in detecting subglottic secretion were 96.7% and 90%, respectively (PPV 93.5%, NPV 94.7%). 18 (58%) patients with subglottic secretions developed VAP during their ICU stay (p = 0.01). The area under the receiver operating curve (AUROC) was 0.977 (95% CI 0.936-1.00).ConclusionsUpper airway US is a useful tool for detecting subglottic secretions with high sensitivity and specificity.Clinical implicationsThis study shows: 1. Upper airway US may aid in detecting subglottic secretions, which are linked to VAP. 2. Detecting subglottic secretions at the bedside aids in determining the best frequency of subglottic aspiration to clean the subglottic trachea. 3. Upper airway US may also aid in detecting the correct ETT position. Trial registration Clinicaltrials.gov.Clinicaltrialsgov identifier NCT04739878 Date of registration 2nd May 2021 URL of trial registry record https://clinicaltrials.gov/ct2/show/NCT04739878 .
| S-EPMC10164205 | biostudies-literature
Project description:BACKGROUND:During intubation with a blind technique, a left-sided double-lumen tube (DLT) can be misdirected into the right bronchus even though its curved tip of the bronchial lumen turns to the left. This right bronchial misplacement may be associated with the tip angle of DLTs. We thus performed a randomized trial to test the hypothesis that the DLT with an acute tip angle enters the right bronchus less frequently than the tube with an obtuse tip angle. METHODS:We randomized surgical patients (n = 1427) receiving a polyvinyl chloride left-sided DLT. Before intubation, the curved tip was further bent to an angle of 135° and kept with a stylet inside in the curved-tip group, but not in the control group. After the tip was inserted into the glottis under direct or video laryngoscopy, the stylet was removed and the DLT was advanced into the bronchus with its tip turning to the left. We checked which bronchus was intubated, and the time and number of attempts for intubation. After surgery, we assessed airway injury, sore throat, and hoarseness. The primary outcome was the incidence of right bronchial misplacement of the DLT. RESULTS:DLTs were misdirected into the right bronchus more frequently in the control group than in the curved-tip group: 57/715 (8.0%) vs 17/712 (2.4%), risk ratio (95% CI) 3.3 (2.0-5.7), P < 0.001. The difference was significant in the use of 32 (P = 0.003), 35 (P = 0.007), and 37 (P = 0.012) Fr DLTs. Intubation required longer time (P < 0.001) and more attempts (P = 0.002) in the control group. No differences were found in postoperative airway injury, sore throat and hoarseness. CONCLUSIONS:Before intubation of left-sided DLTs, augmentation of the curved DLT tip reduced the right bronchial misplacement and facilitated intubation without aggravating airway injury.
| S-EPMC6333363 | biostudies-literature
Project description:BackgroundPositional change affects the cuff pressure of an endotracheal tube (ETT) in treacheally intubated patients. We compared the cuff pressure of a TaperGuard ETT and a cylindrical ETT after lateral rotation of head during middle ear surgery.MethodsFifty-two patients aged 18-70 years underwent a tympanomastoidectomy under general anesthesia were randomly allocated to receive endotracheal intubation with cylindrical (group C, n = 26) or TaperGuard ETTs (group T, n = 26). After endotracheal intubation, the ETT cuff pressure was set at 22 cmH2O in the neutral position of head. After lateral rotation of head, the cuff pressure was measured again and readjusted to 22 cmH2O. In addition, the change of distance from the carina to the tip of the ETT was measured before and after the positional change. The incidence of cough, sore throat, and hoarseness was assessed at 30 minutes, 6 hours, and 24 hours after surgery.ResultsThere was no difference in demographic data between groups. After lateral rotation of head, the cuff pressure significantly increased in group T (11.9 ± 2.3 cmH2O) compared with group C (6.0 ± 1.9 cmH2O) (P < 0.001). The incidence of a cuff pressure >30 cmH2O was higher in group T (96.2%) than in group C (30.8%) (P < 0.001). In addition, the degree of displacement of an ETT was greater in group T (11.0 ± 1.7 mm) than in group C (7.2 ± 2.6 mm) (P < 0.001). The overall incidences of postoperative sore throat, hoarseness, and cough at 30 minutes, 6 hours, and 24 hours after surgery were comparable between two groups.ConclusionThe cuff pressure was higher in the TaperGuard ETT than in the cylindrical ETT after positional change of head from neutral to lateral rotation. In addition, after a positional change, the extent of displacement of ETT was greater in the TaperGuard ETT than in the cylindrical ETT.
| S-EPMC5348178 | biostudies-literature
Project description:Laboratory studies demonstrated that the lateral Trendelenburg position (LTP) is superior to the semirecumbent position (SRP) in the prevention of ventilator-associated pulmonary infections. We assessed whether the LTP could also prevent pulmonary colonization and infections caused by an endotracheal tube (ETT) biofilm.Eighteen pigs were intubated with ETTs colonized by Pseudomonas aeruginosa biofilm. Pigs were positioned in LTP and randomized to be on mechanical ventilatin (MV) up to 24 hour, 48 hour, 48 hour with acute lung injury (ALI) by oleic acid and 72 hour. Bacteriologic and microscopy studies confirmed presence of biofilm within the ETT. Upon autopsy, samples from the proximal and distal airways were excised for P.aeruginosa quantification. Ventilator-associated tracheobronchitis (VAT) was confirmed by bronchial tissue culture ?3 log colony forming units per gram (cfu/g). In pulmonary lobes with gross findings of pneumonia, ventilator-associated pneumonia (VAP) was confirmed by lung tissue culture ?3 log cfu/g.P.aeruginosa colonized the internal lumen of 16 out of 18 ETTs (88.89%), and a mature biofilm was consistently present. P.aeruginosa colonization did not differ among groups, and was found in 23.6% of samples from the proximal airways, and in 7.1% from the distal bronchi (P?=?0.001). Animals of the 24 hour group never developed respiratory infections, whereas 20%, 60% and 25% of the animals in group 48 hour, 48 hour-ALI and 72 hour developed P.aeruginosa VAT, respectively (P?=?0.327). Nevertheless, VAP never developed.Our findings imply that during the course of invasive MV up to 72 hour, an ETT P.aeruginosa biofilm hastily colonizes the respiratory tract. Yet, the LTP compartmentalizes colonization and infection within the proximal airways and VAP never develops.
| S-EPMC4355496 | biostudies-literature