Atemwegsmanagement in der Thoraxanästhesie mit dem Bronchusblocker

Zusammenfassung

Bronchusblocker stellen für die Ein-Lungen-Ventilation eine Alternative zum Doppellumentubus dar – bei spezifischen Patientengruppen können sie sogar die einzige Option für die Lungenisolation sein. In diesem Beitrag werden Indikationen für Bronchusblocker gezeigt und die verfügbaren Modelle mit praktischen Hinweisen vorgestellt. Im Anschluss wird die klinische Anwendbarkeit der Bronchusblocker mit der des Doppellumentubus verglichen.

Abstract

Traditionally the double-lumen-tube (DLT) is considered the gold standard for lung separation. Despite being equally feasible for standard situations, there are special populations and circumstances requiring the use of a bronchial blocker (BB) to establish one-lung ventilation. Children under 8 years of age and patients without a patent orotracheal airway necessitate the use of a bronchial blocker in most cases, as well as those requiring selective lobar blockade or a rapid sequence induction. Surgery with predicted postoperative mechanical ventilation or in tracheotomized patients at least favors their use by avoiding the complications of a tube exchange. Bronchial blocker models currently in clinical use include the wire-guided Arndt-Blocker, the Flexitip Cohen-Blocker, the Fuji Uniblocker, the Y-shaped EZ-Blocker and the tracheoscopy-guided VivaSight-EB. Their common concept is the occlusion of the operative lung by the inflation of their distal balloon, with the deflation of that lung occurring through their inner lumen. They mainly differ in their mode of placement. Bronchial blockers offer a clinical performance comparable to the DLT. Placement times for lung isolation devices and surgical exposure may depend more on the experience of the anaesthetist than the device itself. Bronchial blockers wonʼt replace the DLT as gold standard at least due to their cost of acquisition, but provided adequate training outside of the emergency situation, their utilisation offers equal operative conditions at comparable placement times, dislocation rates and ease of use. A modern bronchial blocker should be available in institutions managing complex thoracic cases.

Kernaussagen

• Für die Ein-Lungen-Ventilation im Rahmen der modernen Thoraxchirurgie können bei den meisten Patienten Doppellumentuben und Bronchusblocker gleichwertig angewendet werden – auch wenn Bronchusblocker wegen der höheren Kosten im Vergleich zu DLT nicht regelhaft zum Einsatz kommen.

• Unterschiede zwischen DLT und Bronchusblockern hinsichtlich Platzierungszeiten, Dislokationsraten, Qualität der chirurgischen Exposition und Raten an Atemwegsverletzungen sind weniger durch die verwendeten Modelle als durch die Erfahrung des Anwenders bedingt.

• Klare Indikationen für DLT wie Manschettenresektionen bei zentralen Bronchialtumoren oder die Sekretkontrolle bei Bronchiektasien, Lungenabszessen oder Tuberkulose werden seltener.

• Gleichzeitig nehmen Ein-Lungen-Ventilationen zu bei Patienten, bei denen aufgrund von Voroperationen, multimodaler Therapie oder sehr jungem Lebensalter die Intubation mit einem DLT erschwert oder unmöglich ist.

• Zusätzlich sind die Rapid Sequence Induction und der erwartet schwierige Atemweg Domänen des SLT mit anschließender Verwendung eines Bronchusblockers [29].

• Kliniken, die regelhaft Ein-Lungen-Ventilationen durchführen, sollten einen dedizierten Bronchusblocker vorhalten. Seine indikationsgerechte Anwendung durch erfahrene Anästhesisten verbessert die Patientensicherheit, ohne dass Nachteile hinsichtlich verlängerter Anlagedauer, erhöhter Dislokationsraten oder verschlechterter chirurgischer Exposition zu befürchten sind [30].

Schlüsselwörter

Bronchusblocker - Doppellumentubus - Lungenisolation - Ein-Lungen-Ventilation

Key words

bronchial blocker - double lumen tube - lung isolation - one-lung ventilation

• Literatur

• 1 Cohen E. Recommendations for airway control and difficult airway management in thoracic anesthesia and lung separation procedures. Are we ready for the challenge?. Minerva Anestesiol 2009; 75: 3-5
• 2 Arndt GA, DeLessio ST, Kranner PW. et al. One-lung ventilation when intubation is difficult – presentation of a new endobronchial blocker. Acta Anaesthesiol Scand 1999; 43: 356-358 doi:10.1034/j.1399-6576.1999.430320.x
• 3 Cohen E. The Cohen flexitip endobronchial blocker: an alternative to a double lumen tube. Anesth Analg 2005; 101: 1877-1879 doi:10.1213/01.ANE.0000184116.86888.D9
• 4 Tanabe S, Tanaka A, Nishino T. [Experience using an improved bronchial blocker (Phycon TCB bronchial blocker)]. Masui 2004; 53: 1317-1319
• 5 Mungroop HE, Wai PT, Morei MN. et al. Lung isolation with a new Y-shaped endobronchial blocking device, the EZ-Blocker. Br J Anaesth 2010; 104: 119-120 doi:10.1093/bja/aep353
• 6 Huitink JM, Koopman EM, Bouwman RA. et al. Tracheal intubation with a camera embedded in the tube tip (Vivasight(^™)). Anaesthesia 2013; 68: 74-78 doi:10.1111/anae.12065
• 7 Clayton-Smith A, Bennett K, Alston RP. 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: 955-966 doi:10.1053/j.jvca.2014.11.017
• 8 Narayanaswamy M, McRae K, Slinger P. et al. Choosing a lung isolation device for thoracic surgery: a randomized trial of three bronchial blockers versus double-lumen tubes. Anesth Analg 2009; 108: 1097-1101 doi:10.1213/ane.0b013e3181999339
• 9 Campos JH, Hallam EA, Van Natta T. et al. Devices for lung isolation used by anesthesiologists with limited thoracic experience: comparison of double-lumen endotracheal tube, Univent torque control blocker, and Arndt wire-guided endobronchial blocker. Anesthesiology 2006; 104: 261-266
• 10 Ruetzler K, Grubhofer G, Schmid W. et al. Randomized clinical trial comparing double-lumen tube and EZ-Blocker for single-lung ventilation. Br J Anaesth 2011; 106: 896-902 doi:10.1093/bja/aer086
• 11 Bauer C, Winter C, Hentz JG. et al. Bronchial blocker compared to double-lumen tube for one-lung ventilation during thoracoscopy. Acta Anaesthesiol Scand 2001; 45: 250-254 doi:10.1111/j.1399-6576.2001.450218.x
• 12 Vila E, Ibáñez C, Gomes A. et al. A comparison of double-lumen endotracheal tube and Arndt bronchial blocker in right and left thoracic surgery. Eur J Anaesthesiol 2006; 23: 73-74 doi:10.1097/00003643-200606001-00262
• 13 Vilà E, García Guasch R, Ibáñez C. et al. [Comparison of the double-lumen endotracheal tube and the Arndt bronchial blocker used by inexperienced anesthesiologists in right- and left-sided thoracic surgery]. Rev Esp Anestesiol Reanim 2007; 54: 602-607
• 14 Dumans-Nizard V, Liu N, Laloë PA. et al. A comparison of the deflecting-tip bronchial blocker with a wire-guided blocker or left-sided double-lumen tube. J Cardiothorac Vasc Anesth 2009; 23: 501-505 doi:10.1053/j.jvca.2009.02.002
• 15 Grocott HP, Darrow TR, Whiteheart DL. et al. Lung isolation during port-access cardiac surgery: double-lumen endotracheal tube versus single-lumen endotracheal tube with a bronchial blocker. J Cardiothorac Vasc Anesth 2003; 17: 725-727 doi:10.1053/j.jvca.2003.09.012
• 16 Lehmann A, Zeitler C, Lang J. et al. [A comparison of the Arndt endobronchial blocker with a double lumen tube in robotic cardiac surgery]. Anasthesiol Intensivmed Notfallmed Schmerzther 2004; 39: 353-359 doi:10.1055/s-2004-814514
• 17 Mourisse J, Liesveld J, Verhagen A. et al. Efficiency, efficacy, and safety of EZ-blocker compared with left-sided double-lumen tube for one-lung ventilation. Anesthesiology 2013; 118: 550-561 doi:10.1097/ALN.0b013e3182834f2d
• 18 Zhong T, Wang W, Chen J. et al. Sore throat or hoarse voice with bronchial blockers or double-lumen tubes for lung isolation: a randomised, prospective trial. Anaesth Intensive Care 2009; 37: 441-446
• 19 Campos JH, Hallam EA, Ueda K. Lung isolation in the morbidly obese patient: a comparison of a left-sided double-lumen tracheal tube with the Arndt^® wire-guided blocker. Br J Anaesth 2012; 109: 630-635 doi:10.1093/bja/aes206
• 20 Campos JH, Kernstine KH. A comparison of a left-sided Broncho-Cath with the torque control blocker univent and the wire-guided blocker. Anesth Analg 2003; 96: 283-289 doi:10.1213/00000539-200301000-00056
• 21 Zheng H, Duan Y, Geng W. et al. [A comparison of double-lumen endotracheal tube with univent blocker and bronchial blocker during thoracic surgical anesthesia]. Zhonghua Yi Xue Za Zhi 2012; 92: 2481-2484
• 22 Cohen E. Back to blockers?. Anesthesiology 2013; 118: 490-493 doi:10.1097/ALN.0b013e3182839981
• 23 Campos JH, Massa FC. Is there a better right-sided tube for one-lung ventilation? A comparison of the right-sided double-lumen tube with the single-lumen tube with right-sided enclosed bronchial blocker. Anesth Analg 1998; 86: 696-700
• 24 Knoll H, Ziegeler S, Schreiber JU. et al. Airway injuries after one-lung ventilation: a comparison between double-lumen tube and endobronchial blocker: a randomized, prospective, controlled trial. Anesthesiology 2006; 105: 471-477
• 25 Slinger P. Con: the new bronchial blockers are not preferable to double-lumen tubes for lung isolation. J Cardiothorac Vasc Anesth 2008; 22: 925-929 doi:10.1053/j.jvca.2008.09.001
• 26 Aïssou M, Coroir M, Debes C. et al. [Cost analysis comparing single-use (Ambu^® aScopeTM) and conventional reusable fiberoptic flexible scopes for difficult tracheal intubation]. Ann Fr Anesth Reanim 2013; 32: 291-295 doi:10.1016/j.annfar.2013.01.014
• 27 Tvede MF, Kristensen MS, Nyhus-Andreasen M. A cost analysis of reusable and disposable flexible optical scopes for intubation. Acta Anaesthesiol Scand 2012; 56: 577-584 doi:10.1111/j.1399-6576.2012.02653.x
• 28 Koopman EM, Barak M, Weber E. et al. Evaluation of a new double-lumen endobronchial tube with an integrated camera (VivaSight-DL(^™)): a prospective multicentre observational study. Anaesthesia 2015; 70: 962-968 doi:10.1111/anae.13068
• 29 Campos JH. Lung isolation techniques. Anesthesiol Clin North America 2001; 19: 455-474 doi:10.1016/S0889-8537(05)70243-1
• 30 Neustein SM. Pro: bronchial blockers should be used routinely for providing one-lung ventilation. J Cardiothorac Vasc Anesth 2015; 29: 234-236 doi:10.1053/j.jvca.2014.07.028