Bahk J H, Lim Y J, Kim C S
Department of Anesthesiology and Clinical Research Institute, Seoul National University Hospital, Korea.
J Trauma. 2000 Nov;49(5):899-902. doi: 10.1097/00005373-200011000-00018.
Lung isolation and preservation of normal lung are the first lines of therapy in life-threatening massive hemoptysis. If bleeding continues but the side of origin is uncertain, use of a double-lumen tube (DLT) is reasonable. Utilizing a blind method to locate the bronchial cuff of a left-sided DLT without using any instrument, a DLT (Broncho-Cath, Mallinckrodt Medical Ltd., Athlone, Ireland) was successfully positioned without delay in a patient with massive hemoptysis, where auscultation could be misleading or useless and fiberoptic bronchoscope (FOB) was inapplicable. This study was performed to discern whether this blind method could substitute for FOB verification or auscultation in most circumstances where these two methods are unavailable or inapplicable.
After receiving informed consent and hospital ethics board approval, 58 elective thoracic surgical patients, aged 17 to 67 years, were enrolled in the study and divided into two groups. A conventional method using an FOB was used to locate the left-sided DLT in 29 patients (group 1). In the other 29 patients (group 2), the blind manual method was used. The left-sided DLT was inserted until some resistance was felt, at which time the bronchial cuff was inflated with approximately 2.0 mL of air. While gently holding the pilot with thumb and index finger of the nondominant hand, the DLT was slowly withdrawn until an abrupt decrease of pilot pressure was sensed. At that moment, the bronchial cuff was deflated, and the DLT was advanced approximately 1.5 cm; using an FOB, its position was checked by an independent observer not involved in positioning the DLT. Success was defined as the point when the proximal margin of the carina was within the margin of safety for the DLT, which is defined as the difference between the length of the left main bronchus and the length of the tube between the proximal margin of the left bronchial cuff and the left lumen tip. Postoperative FOB was performed to evaluate bronchial injury.
In 26 of 29 patients (group 2), the position of the DLT was bronchoscopically confirmed to be a success. The other three cases were deemed to be too shallow; specifically, the bronchial cuffs were slightly herniated onto the carina (acceptable position). This method was more traumatic than FOB-guided DLT intubation (conventional method) (p = 0.001); however, the most severe damage was erosion.
This method, which requires no specific instrument and no time-consuming technique, can be taught easily and may be used in a situation where the rapidity of lung isolation or collapse is the key to saving life. We conclude that this blind method can be an alternative to the FOB and/or auscultation for the positioning of DLT in an emergency situation.
肺隔离和正常肺组织的保护是危及生命的大量咯血的一线治疗方法。如果出血持续但出血部位不明，使用双腔支气管导管（DLT）是合理的。在一名大量咯血患者中，未使用任何仪器，采用盲法定位左侧DLT的支气管套囊，成功迅速地放置了一个DLT（支气管导管，Mallinckrodt Medical Ltd.，阿斯隆，爱尔兰），在此患者中听诊可能会产生误导或毫无用处，且纤维支气管镜（FOB）无法使用。本研究旨在探讨在这两种方法不可用或不适用的大多数情况下，这种盲法是否可以替代FOB验证或听诊。
在获得知情同意并经医院伦理委员会批准后，纳入58例年龄在17至67岁之间的择期胸外科手术患者，并将其分为两组。29例患者（第1组）采用传统的FOB方法定位左侧DLT。另外29例患者（第2组）采用盲法手动操作。插入左侧DLT直至感觉到一定阻力，此时向支气管套囊内注入约2.0 mL空气。用非优势手的拇指和示指轻轻握住导管的控制柄，缓慢拔出DLT，直到感觉到控制柄压力突然下降。此时，将支气管套囊放气，将DLT向前推进约1.5 cm；由一名未参与DLT定位的独立观察者使用FOB检查其位置。成功的定义为隆突近端边缘位于DLT的安全范围内，安全范围定义为左主支气管长度与左支气管套囊近端边缘与左腔尖端之间的导管长度之差。术后进行FOB检查以评估支气管损伤。
29例患者（第2组）中有26例经支气管镜检查确认DLT位置成功。另外3例被认为位置过浅；具体而言，支气管套囊稍有疝入隆突（可接受位置）。该方法比FOB引导的DLT插管（传统方法）创伤更大（p = 0.001）；然而，最严重的损伤是糜烂。
这种方法不需要特殊仪器，也不需要耗时的技术，易于传授，可用于肺隔离或萎陷的速度是挽救生命关键的情况。我们得出结论，在紧急情况下，这种盲法可作为FOB和/或听诊定位DLT的替代方法。
