An Update on Bronchial Blockers During Lung Separation Techniques in Adults

摘要

Techniques for one-lung ventilation (OLV) can be accomplished in two different ways. The first involves the use of a double-lumen endotracheal tube (DLT). The second method involves blockade of a mainstem bronchus to allow lung collapse distal to the occlusion (bronchial blockers) (1–3). In 1936, Magill (4) achieved bronchial blockade using a long tube with an inflatable cuff at its distal end that was advanced alongside a single-lumen endotracheal tube. Since then, more devices have been introduced including: 1) the Fogarty vascular embolectomy catheter (5) [Edwards Lifesciences, Irvine, CA]; 2) a Wiruthan bronchial blocker (6) [Willy Rusch AG, Kernen, Germany]; 3) a single-lumen endotracheal tube with an enclosed bronchial blocker (Torque Control Blocker Univent®) [Vitaid Lewinston, NY](7); and 4) the wire-guided endobronchial blocker [Arndt blocker; Cook® Critical Care, Bloomington, IN](8). Although DLTs are still the most common device used during lung separation techniques (9), bronchial blockade technology is on the increase, and in some specific clinical situations it can offer more advantages over the DLTs. This review addresses current concepts on the use of bronchial blockers as an alternative to achieve lung separation in adults. Use of the Fogarty Embolectomy Catheter as a Bronchial Blocker The Fogarty occlusion embolectomy catheter (5) is a device designed specifically to be used as a vascular tool; however, there are well documented reports of its use in successful bronchial blockade to achieve lung isolation. Common sizes of the Fogarty occlusion catheter used in adults for bronchial blockade include: number 6.0, 8/14, or 8/22 French (F) catheter, which has a length of 80 cm. The number 8 refers to the catheter size and the numbers 14 and 22 correspond to the inflated balloon diameter in millimeters. The occlusion balloon of the Fogarty catheter is considered a high-pressure, low-volume cuff, that requires between 0.5 to 10 mL of air to achieve occlusion of a bronchus. The Fogarty catheter has an incorporated stylet that can be preshaped at the distal end to facilitate its guidance into the left mainstem bronchus. The Fogarty occlusion catheter has the following advantages: 1) it can be advanced through the lumen of an existing single-lumen endotracheal tube; 2) it can be used as a rescue device when difficulties to position a right- or left-sided DLT are encountered in patients who are already intubated with a DLT and are in the lateral decubitus position. By advancing the Fogarty catheter inside the endobronchial or endotracheal lumen of a DLT, lung isolation can be obtained (10,11). 3) Fogarty catheters have been used as a selective lobar bronchial blocker in patients with bronchopleural fistula where placement of this device along with a DLT reduced the amount of leakage and led to improvement of gas exchange (12). 4) Fogarty catheters also have been used as a double endobronchial blocker to collapse the right lung with two independent Fogarty catheters to facilitate a right-sided lung isolation during selective lobar blockade (13). 5) Fogarty catheters have been used in patients with tracheostomies requiring OLV. 6) Finally, they can be used nasotracheally if oral airway anatomy is distorted and OLV is required. The disadvantages of the Fogarty occlusion catheter for use as a bronchial blocker are: 1) the Fogarty catheter is a vascular device, and not designed as a bronchial blocker; 2) the Fogarty catheter is made of natural rubber latex, which is contraindicated in patients with latex allergy; 3) there is a lack of a communicating channel in the center, therefore suction or oxygen insufflation is not possible; 4) there is a lack of guidewire device. Although its stylet facilitates insertion into a bronchus, it cannot be coupled with a fiberoptic bronchoscope; 5) an air leak from the breathing circuit can be a common problem, specifically when the Fogarty catheter is placed inside the single-lumen endotrac