Usefulness of the Airtraq DL™ videolaryngoscope for placing a double-lumen tube.

BACKGROUND: Endotracheal insertion of a double-lumen tube (DLT) may be difficult because of its size and shape. The Airtraq™ is a new videolaryngoscope that allows supraglottis exposure without needing to align the oro-pharyngo-laryngeal axis. A specific model (Airtraq DL™), with a large diameter, has been specifically designed to insert a DLT. We have tested the efficiency of this device on the quality of supraglottis exposure and the endotracheal position of the DLT. STUDY DESIGN: This was a prospective and observational study. METHODS: This study included 37 consecutive patients with no risk for difficult intubation and who required insertion of a DLT for one-lung ventilation. The main outcomes were the success rate of endotracheal intubation within 120 s, the quality of glottis exposure, the position of the tube within the trachea and the occurrence of any complications. RESULTS: All patients were safely intubated, but only 33 (89%) were successfully intubated within 120 s (mean time: 44±27 s). Using the Airtraq DL™ videolaryngoscope, significantly more patients were graded Cormack and Lehane I as compared to the Macintosh laryngoscope (97% vs. 73%, P<0.05). Overall, fiberoptic bronchoscopy detected 62% of incorrectly positioned DLTs. Blood was noted on the blade of the videolaryngoscope in seven patients, desaturation occurred in two patients and labial trauma in one patient. CONCLUSION: The use of the Airtraq DL™ improves exposure of the supraglottis during insertion of a DLT. However, previous removal of the stylet could increase the risk of incorrectly positioning the tube.

Cardiopulmonary bypass during a second-lung implantation improves postoperative oxygenation after sequential double-lung transplantation.

OBJECTIVES: During sequential double-lung transplantation (DLT), the newly implanted first lung receives the entire cardiac output during the implantation of the second one. This may be responsible for the increased hydrostatic pressure that causes severe interstitial and alveolar edema that can lead to allograft dysfunction. The authors tested the hypothesis that CPB started after first graft implantation and before second recipient lung removal should improve post-transplantation oxygenation and clinical outcomes. DESIGN: Observational during 2 consecutive 1-year periods. SETTING: University hospital. PARTICIPANTS: Nine consecutive patients undergoing sequential DLT with CPB started after first graft implantation and before second recipient lung removal were compared to controls, who were 10 consecutive patients who underwent sequential DLT but without CPB the year before. MEASUREMENTS AND MAIN RESULTS: Oxygenation after transplantation was assessed. The use of CPB during the implantation of the second lung was associated with an increased mean postoperative ratio of PaO2 to the fraction of inspired oxygen at 1 hour (363±51 v 240±113, p = 0.01) and 6 hours (430±111 v 280±103, p = 0.03). The mean duration of CPB was 111±19 min. The occurrence of primary graft dysfunction and the need for extracorporeal membrane oxygenation tended to be lower, but did not reach significance. Similarly, mortality rate was comparable between both groups, as was the rate of blood transfusions. CONCLUSIONS: The authors' results suggest that the use of CPB started after first graft implantation and before second recipient lung removal appears to benefit oxygenation and reduces the occurrence of severe pulmonary edema in the first transplanted lung.

Daily titration of neurally adjusted ventilatory assist using the diaphragm electrical activity.

PURPOSE: To determine the feasibility of daily titration of the neurally adjusted ventilatory assist (NAVA) level in relation to the maximal diaphragmatic electrical activity (EAdi(maxSBT)) measured during a spontaneous breathing trial (SBT) during pressure support ventilation (PSV). METHODS: The study included 15 consecutive patients in whom mechanical ventilation weaning was initiated with the NAVA mode. EAdi(maxSBT) was determined daily during an SBT using PSV with 7 cmH2O of inspiratory pressure and no positive end-expiratory pressure (PEEP). If the SBT was unsuccessful, NAVA was used and the level was then adjusted to obtain an EAdi of ~60% of the EAdi(maxSBT). Arterial blood gas analyses were performed 20 min after each change in NAVA level. RESULTS: Three patients were dropped from the study at day 4 because of worsening of their sickness. The median duration of NAVA ventilation was 4.5 days (IQR 3-6.5). From day 1 to extubation, EAdi(maxSBT) and EAdi increased significantly from 16.6 (9.6) to 21.7 (10.3) µV (P = 0.013) and from 10.0 (5.5) to 15.1 (9.2) µV (P = 0.026), respectively. The pressure delivered significantly decreased from 20 (8) to 10 (5) cmH2O (P = 0.003). Conversely, tidal volume, carbon dioxide tension, and pH values remained unchanged during the same period. CONCLUSION: These results suggest that daily titration of NAVA level with an electrical goal of ~60% EAdi(maxSBT) is feasible and well tolerated. The respiratory mechanics improvement and increase in respiratory drive allowed for a daily reduction of the NAVA level while preserving breathing, oxygenation, and alveolar ventilation until extubation.