Salih TOPÇU, Tülay HOŞTEN

Anestezistler için bronkoskopik anatominin önemi

Tek akciğer ventilasyonu göğüs cerrahisinin olmazsa olmazlarındandır; bilgi ve beceri gerektirir. Başarılı tek akciğer ventilasyonu için tek akciğer ventilasyonunda kullanılan ekipmanlar, bronkoskopi ve solunum yollarının anatomisinin bilinmesi önemlidir. Biz bu derlemede anestezistler ve göğüs cerrahları için, trakeobronşiyal ağacın bronkoskopik anatomisi ve tek akciğer ventilasyonu ekipmanını anlatmayı amaçladık. Göğüs cerrahisi kliniğimizde tanı ve tedavi için yatırılan hastaların kaydedilen preoperatif ve intraoperatif bronkoskopi uygulamaları anestezist perspektifi ile değerlendirildi. Bronkoskopik değerlendirmede anatomik işaretler belirlendi. Tek akciğer ventilasyonu için kliniğimizde kullanılan çift lümenli tüpler ve bronşiyal blokerlerin, fiberoptik bronkoskopi eşliğinde optimal ve yanlış yerleştirilme görüntüleri alındı. Bulgular sol akciğer izolasyonu, sol ana bronşun yapısı nedeniyle daha güvenle yapılırken, hem çift lümenli tüpler, hem de bronşiyal blokerlerin sağ ana bronşa yerleştirilmesi daha fazla özen gerektirmektedir. Tek akciğer ventilasyonu uygulamalarında başarı, anestezistlerin trakeobronşiyal ağacın fiberoptik bronkoskopik anatomisini iyi bilmeleri ve cerrahi ekiple iş birliği içinde olmalarıyla artacaktır.

The importance of bronchoscopic anatomy for anesthesiologists

One-lung ventilation (OLV) is a sine qua non of thoracic surgery and requires knowledge and talent. Close familiarity with equipments used for OLV as well as bronchoscopy and respiratory tract anatomy is important for successful OLV. We aim to outline the bronchoscopic anatomy of the tracheobronchial tree and OLV equipment for anesthetists and thoracic surgeons in this review. The recorded preoperative and intraoperative bronchoscopic applications of the patients hospitalized in our Thoracic Surgery clinic for diagnosis and treatment have been evaluated from an anesthetist's perspective. Anatomic landmarks were identified in the bronchoscopic evaluation. Optimal and misplacement images of double-lumen tubes (DLT) and bronchial blockers (BB) used for OLV in our clinic were obtained via fiber optic bronchoscopy. While left lung isolation can be made more safely due to the anatomy of the left main bronchus, placement of both DLTs and BBs to the right main bronchus requires greater care. Success in OLV procedures would increase with anesthetists being well informed about the fiber optic bronchoscopic anatomy of the tracheobronchial tree and in close cooperation with the surgical team.

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1. Fischer GW, Cohen E. An update on anesthesia for thoracoscopic surgery. Curr Opin Anaesthesiol 2010; 23: 7-11.
2. Campos JH. Update on selective lobar blockade during pulmonary resections. Curr Opin Anaesthesiol 2009; 22: 18-22.
3. Slinger PD, Campos JH. Anesthesia for thoracic surgery. In: Miller RD (ed). Miller’s Anesthesia. 7th ed. Philadelphia: Churchill Livingstone, 2009: 1819-89.
4. Neustein SM, Eisenkraft JB. Anesthesia for thoracic surgery. In: Barash PG, Cullen BF, Stoelting RK, Cahalan M (eds). Handbook of Clinical Anesthesia. 6th ed. Lippincott Williams and Wilkins, 2006; 1032-73.
5. Brodsky JB, Macario A, Mark JB. Tracheal diameter predicts double-lumen tube size: a method for selecting left double-lumen tubes. Anesth Analg 1996; 82: 861-4.
6. Bardoczky G, d’Hollander A, Yernault JC, Van Meuylem A, Moures JM, Rocmans P. On-line expiratory flow-volume curves during thoracic surgery: occurrence of auto-PEEP. Br J Anaesth 1994; 72: 25-8.
7. Hannallah MS, Benumof JL, Ruttimann UE. The relationship between left mainstem bronchial diameter and patient size. J Cardiothorac Vasc Anesth 1995; 9: 119-21.
8. Hampton T, Armstrong S, Russell WJ. Estimating the diameter of the left main bronchus. Anaesth Intensive Care 2000; 28:540-2.
9. Hannallah M, Benumof JL, Silverman PM, Kelly LC, Lea D. Evaluation of an approach to choosing a left double-lumen tube size based on chest computed tomographic scan measurement of left mainstem bronchial diameter. J Cardiothorac Vasc Anesth 1997; 11: 168-71.
10. Stout DM, Bishop MJ, Dwersteg JF, Cullen BF. Correlation of endotracheal tube size with sore throat and hoarseness following general anesthesia. Anesthesiology 1987; 67: 419-21.
11. Brodsky JB, Benumof JL, Ehrenwerth J, Ozaki GT. Depth of placement of left double-lumen endobronchial eubes. Anesth Analg 1991; 73: 570-2.
12. Yasumoto M, Higa K, Nitahara K, Shono S, Hamada T. Optimal depth of insertion of left-sided double-lumen endobronchial tubes cannot be predicted from body height in below averagesized adult patients. Eur J Anaesthesiol 2006; 23: 42-4.
13. Sakuragi T, Kumano K, Yasumoto M, Dan K. Rupture of the left main-stem bronchus by the tracheal portion of a double-lumen endobronchial tube. Acta Anaesthesiol Scand 1997; 41:1218-20.
14. Klein U, Karzai W, Bloos F, Wohlfarth M, Gottschall R, Fritz H, et al. Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia: a prospective study. Anesthesiology 1998; 88: 346-50.
15. Inoue S, Nishimine N, Kitaguchi K, Furuya H, Taniguchi S. Double lumen tube location predicts tube malposition and hypoxaemia during one lung ventilation. Br J Anaesth 2004; 92:195-201.
16. Benumof JL. The position of a double-lumen tube should be routinely determined by fiberoptic bronchoscopy. J Cardiothorac Vasc Anesth 1993; 7: 513-4.
17. Benumof JL, Partridge BL, Salvatierra C, Keating J. Margin of safety in positioning modern double-lumen endotracheal tube. Anesthesiology 1985; 67: 729-38.
18. Hammer GB, Harrison TK, Vricella LA, Black MD, Krane EJ. Single lung ventilation in children using a new paediatric bronchial blocker. Paediatr Anaesth 2002; 12: 69-72.
19. Hammer GB, Brodsky JB, Redpath JH, Cannon WB. The Univent tube for single-lung ventilation in paediatric patients. Paediatr Anaesth 1998; 8: 55-7.
20. Hoşten T, Gürkan Y, Sahillioğlu E, Topçu S, Solak M, Toker K. Our bronchial blocker experiences in one lung ventilation. Tuberk Toraks 2009; 57: 155-62.
21. Boerner T, Ramathan S. Functional anatomy of the airway. In: Benumof JL (ed). Airway Management. St Louis: Mosby, 1996: 3-21.
22. Soto RG, Oleszak SP. Resection of the Arndt bronchial blocker during stapler resection of the left lower lobe. J Cardiothorac Vasc Anesth 2006; 20: 131-2.
23. Patane PS, Sell BA, Mahla ME. Awake fiberoptic endobronchial intubation. J Cardiothorac Anesth 1990; 4: 229-31.
24. Tsai KM. Lung isolation update. Seminars in Anesthesia, Perioperative Medicine and Pain 2003; 22: 88-105.
25. Narayanaswamy M, McRae K, Slinger P, Dugas G, Kanellakos GW, Roscoe A, 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: 1097-101.