Lung Isolation in Patients with Difficult Airways

  • Daniel Tran
  • Wanda M. PopescuEmail author


Recognition of a difficult airway prior to the use of lung isolation devices is essential. Radiological studies must be reviewed, including a posterior–anterior chest radiograph and computer tomography scan of the chest. Securing the airway first is a must in patients with difficult airways requiring lung isolation. The use of an independent bronchial blocker is the first-line choice in patients with difficult airways who require lung isolation. The use of the airway exchange catheter is recommended during placement of double-lumen endotracheal tubes in patients with difficult airways.


Difficult airway One-lung ventilation Lung isolation Tracheostomy 

Supplementary material

Video 18.1

A patient with a non-cuffed Shiley tracheostomy presents for thoracic surgery requiring lung isolation. A Cook airway catheter is placed through the Shiley tracheostomy. The Shiley is removed, and a single-lumen 8.0-mm tube is placed over the exchange catheter. A 9.0 F Fuji Uniblocker is placed in the desired mainstem bronchus under flexible bronchoscopic guidance. Suction is attached to the end of the bronchial blocker to facilitate lung deflation (MP4 145537 kb)

Video 18.2

The bronchial blocker cuff is inflated under direct bronchoscopic view to confirm complete bronchial occlusion (MP4 258730 kb)


  1. 1.
    Campos JH. Progress in lung separation. Thorac Surg Clin. 2005;15:71–83.CrossRefGoogle Scholar
  2. 2.
    Hagihira S, Takashina M, Mori T, Yoshiya I. One-lung ventilation in patients with difficult airways. J Cardiothorac Vasc Anesth. 1998;12:186–8.CrossRefGoogle Scholar
  3. 3.
    Campos JH. Update on tracheobronchial anatomy and flexible fiberoptic bronchoscopy in thoracic anesthesia. Curr Opin Anaesthesiol. 2009;22:4–10.CrossRefGoogle Scholar
  4. 4.
    American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management ofthe difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003;98:1269–77.CrossRefGoogle Scholar
  5. 5.
    Campos JH. Difficult airway and one-lung ventilation. Curr Rev Clin Anesth. 2002;22:199–205.Google Scholar
  6. 6.
    Campos JH. Lung isolation techniques for patients with difficult airways. Curr Opin Anaesthesiol. 2010;23:12–7.CrossRefGoogle Scholar
  7. 7.
    Poon KH, Liu EH. The airway scope for difficult double-lumen tube intubation. J Clin Anesth. 2008;20:319.CrossRefGoogle Scholar
  8. 8.
    Davis L, Cook-Sather SD, Schreiner MS. Lighted stylet tracheal intubation: a review. Anesth Analg. 2000;90:745–6.CrossRefGoogle Scholar
  9. 9.
    Campos JH. Fiberoptic bronchoscopy in anesthesia. Curr Rev Clin Anesth. 2008;29:61–72.Google Scholar
  10. 10.
    Arndt GA, Buchika S, Kranner PW, DeLessio ST. Wire-guided endobronchial blockade in a patient with a limited mouth opening. Can J Anaesth. 1999;46:87–9.CrossRefGoogle Scholar
  11. 11.
    Cohen E. The Cohen flexitip endobronchial blocker: an alternative to a double lumen tube. Anesth Analg. 2005;101:1877–9.CrossRefGoogle Scholar
  12. 12.
    Campos JH. Which device should be considered the best for lung isolation: double-lumen endotracheal tube versus bronchial blockers. Curr Opin Anaesthesiol. 2007;20:27–31.CrossRefGoogle Scholar
  13. 13.
    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;108:1097–101.CrossRefGoogle Scholar
  14. 14.
    Kus A, et al. A comparison of the EZ-Blocker with a Cohen Flex-Tip blocker for one-lung ventilation. J Cardiothorac Vasc Anesth. 2014 Aug;28(4):896–9.CrossRefGoogle Scholar
  15. 15.
    Mourisse J, et al. Efficiency, efficacy, and safety of EZ-blocker compared with left-sided double-lumen tube for one-lung ventilation. Anesthesiology. 2013;118(3):550–61.CrossRefGoogle Scholar
  16. 16.
    Ruetzler K, et al. Randomized clinical trial comparing double-lumen tube and EZ-Blocker for single-lung ventilation. Br J Anaesth. 2011;106(6):896–902.CrossRefGoogle Scholar
  17. 17.
    Campos JH. Use of the wire-guided endobronchial blocker for one-lung anesthesia in patients with airway abnormalities. J Cardiothorac Vasc Anesth. 2003;17:352–4.CrossRefGoogle Scholar
  18. 18.
    Angie Ho CY, Chen CY, Yang MW, Liu HP. Use of the Arndt wire-guided endobronchial blocker via nasal for one-lung ventilation in patient with anticipated restricted mouth opening for esophagectomy. Eur J Cardiothorac Surg. 2005;28:174–5.CrossRefGoogle Scholar
  19. 19.
    Cohen E. Pro: the new bronchial blockers are preferable to double-lumen tubes for lung isolation. J Cardiothorac Vasc Anesth. 2008;22:920–4.CrossRefGoogle Scholar
  20. 20.
    Carney A, Dickinson M. Anesthesia for esophagectomy. Anesthesiol Clin. 2015;33(1):143–63.CrossRefGoogle Scholar
  21. 21.
    Robinson AR III, Gravenstein N, Alomar-Melero E, Peng YG. Lung isolation using a laryngeal mask airway and a bronchial blocker in a patient with a recent tracheostomy. J Cardiothorac Vasc Anesth. 2008;22:883–6.CrossRefGoogle Scholar
  22. 22.
    Ozaki M, Murashima K, Fukutome T. One-lung ventilation using the ProSeal laryngeal mask airway. Anaesthesia. 2004;59:726.CrossRefGoogle Scholar
  23. 23.
    Tsuchihashi T, Ide S, Nakagawa H, Hishinuma N, et al. Differential lung ventilation using laryngeal mask airway and a bronchial blocker tube for a patient with unanticipated difficult intubation. Masui. 2007;56:1075–7.PubMedGoogle Scholar
  24. 24.
    Patane PS, Sell BA, Mahla ME. Awake fiberoptic endobronchial intubation. J Cardiothorac Anesth. 1990;4:229–31.CrossRefGoogle Scholar
  25. 25.
    O’Connor CJ, O’Connor TA. Use of lighted stylets to facilitate insertion of double-lumen endobronchial tubes in patients with difficult airway anatomy. J Clin Anesth. 2006;18:616–9.CrossRefGoogle Scholar
  26. 26.
    Smith CE, Kareti M. Fiberoptic laryngoscopy (WuScope) for double-lumen endobronchial tube placement in two difficult intubation patients. Anesthesiology. 2000;93:906–7.CrossRefGoogle Scholar
  27. 27.
    Huitink JM, et al. Tracheal intubation with a camera embedded in the tube tip (Vivasight™). Anaesthesia. 2013;68(1):74–8.CrossRefGoogle Scholar
  28. 28.
    Koopman EM, et al. Evaluation of a new double-lumen endobronchial tube with an integrated camera (VivaSight-DL™): a prospective multicentre observational study. Anaesthesia. 2015;70(8):962–8.CrossRefGoogle Scholar
  29. 29.
    Hernandez AA, Wong DH. Using a Glidescope for intubation with a double lumen endotracheal tube. Can J Anaesth. 2005;52:658–9.CrossRefGoogle Scholar
  30. 30.
    Bussières JS. A customized stylet for GlideScope® insertion of double lumen tubes. Can J Anaesth. 2012;59(4):424–5.CrossRefGoogle Scholar
  31. 31.
    Gamez R, Slinger P. A simulator study of tube exchange with 3 different designs of double-lumen tube. Anesth Analg. 2014;119:449–53.CrossRefGoogle Scholar
  32. 32.
    Benumof JL. Difficult tubes and difficult airways. J Cardiothorac Vasc Anesth. 1998;12:131–2.CrossRefGoogle Scholar
  33. 33.
    Thomas V, Neustein SM. Tracheal laceration after the use ofan airway exchange catheter for double-lumen tube placement. J Cardiothorac Vasc Anesth. 2007;21:718–9.CrossRefGoogle Scholar
  34. 34.
    deLima LG, Bishop MJ. Lung laceration after tracheal extubation over a plastic tube changer. Anesth Analg. 1991;73:350–1.CrossRefGoogle Scholar
  35. 35.
    Chen A, Lai HY, Lin PC, Chen TY, Shyr MH. GlideScope-assisted double-lumen endobronchial tube placement in a patient with an unanticipated difficult airway. J Cardiothorac Vasc Anesth. 2008;22:170–2.CrossRefGoogle Scholar
  36. 36.
    Suzuki A, Uraoka M, Kimura K, Sato S. Effects of using two airway exchange catheters on laryngeal passage during change from a double-lumen tracheal tube to a single-lumen tracheal tube. Br J Anaesth. 2007;99:440–3.CrossRefGoogle Scholar
  37. 37.
    Saito T, Naruke T, Carney E, et al. New double intrabronchial tube (Naruke tube) for tracheostomized patients. Anesthesiology. 1998;89:1038–9.CrossRefGoogle Scholar
  38. 38.
    Tobias JD. Variations on one-lung ventilation. J Clin Anesth. 2001;13:35–9.CrossRefGoogle Scholar
  39. 39.
    Campos JH, Ajax TJ, Knutson R, et al. Case conference 5–1990. A 76-year-old man undergoing an emergency descending thoracicaortic aneurysm repair has multiple intraoperative and postoperative complications. J Cardiothorac Anesth. 1990;4:631–45.CrossRefGoogle Scholar
  40. 40.
    Ehrenfeld JM, et al. Performance comparison of right- and left-sided double-lumen tubes among infrequent users. J Cardiothorac Vasc Anesth. 2010;24:598–601.CrossRefGoogle Scholar
  41. 41.
    Campos JH. Update on selective lobar blockade during pulmonary resections. Curr Opin Anaesthesiol. 2009;22:18–22.CrossRefGoogle Scholar
  42. 42.
    Tercan E, Sungun MB, Boyaci A, Kucukaydin M. One lung ventilation of a preterm newborn during esophageal atresia and tracheoesophageal fistula repair. Acta Anaesthesiol Scand. 2002;46:332–3.CrossRefGoogle Scholar
  43. 43.
    Taneja B, Saxenaet KN. Endotracheal intubation in a neonate with esophageal atresia and Trachea-Esophageal Fistula: pitfalls and techniques. J Neonatal Surg. 2014;3(2):18.PubMedPubMedCentralGoogle Scholar
  44. 44.
    Ghaye B, Szapiro D, Fanchamps JM, Dondelinger RF. Congenital bronchial abnormalities revisited. Radiographics. 2001;21:105–19.CrossRefGoogle Scholar
  45. 45.
    McLaughlin FJ, Strieder DJ, Harris GBC, et al. Tracheal bronchus: association with respiratory morbidity in childhood. J Pediatr. 1985;106:751–5.CrossRefGoogle Scholar
  46. 46.
    Hoffman JR, Schriger DL, Mower WR, et al. Low-risk criteria for cervical-spine radiography in blunt trauma: a prospective study. Ann Emerg Med. 1992;21:1454–60.CrossRefGoogle Scholar
  47. 47.
    Roberge RJ, Wears RC, Kelly M, et al. Selective application of cervical spine radiography in alert victims of blunt trauma: a prospective study. J Trauma. 1988;28:784–8.CrossRefGoogle Scholar
  48. 48.
    Goldberg W, Mueller C, Panacek E, et al. Distribution and patterns of blunt traumatic cervical spine injury. Ann Emerg Med. 2001;38:17–21.CrossRefGoogle Scholar
  49. 49.
    Crosby ET. Airway management in adults after cervical spine trauma. Anesthesiology. 2006;104:1293–318.CrossRefGoogle Scholar
  50. 50.
    Surgical treatment of thoracic trauma: lung. In: DiSaverio S, Tugnoli G, Catena F, et al., editors. Trauma surgery, thoracic and abdominal trauma. Vol. 2. New York: Springer; 2014. p. 77–90.Google Scholar
  51. 51.
    Nolan JP, Wilson ME. Orotracheal intubation in patients with potential cervical spine injuries. An indication for the gum elastic bougie. Anaesthesia. 1993;48:630–3.CrossRefGoogle Scholar
  52. 52.
    Mort TC. Continuous airway access for the difficult extubation:the efficacy of the airway exchange catheter. Anesth Analg. 2007;105:1357–62.CrossRefGoogle Scholar
  53. 53.
    Merlone SC, Shulman MS, Allen MD, Mark JB. Prolonged intubation with a polyvinylchloride double-lumen endobronchial tube. J Cardiothorac Anesth. 1987;1:563–4.CrossRefGoogle Scholar
  54. 54.
    Benumof JL. Airway exchange catheters: simple concept, potentially great danger. Anesthesiology. 1999;91:342–4.CrossRefGoogle Scholar
  55. 55.
    Merli G, Guarino A, Della Rocca G, et al. Recommendations for airway control and difficult airway management in thoracic anesthesia and lung separation procedures. Minerva Anestesiol. 2009;75:59–78.PubMedGoogle Scholar
  56. 56.
    Pott LM, Murray WB. Review of video laryngoscopy and rigid fiberoptic laryngoscopy. Curr Opin Anaesthesiol. 2008;21:750–8.CrossRefGoogle Scholar
  57. 57.
    Thong SY, Lim Y. Video and optic laryngoscopy assisted tracheal intubation–the new era. Anaesth Intensive Care. 2009;37:219–33.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of AnesthesiologyYale School of MedicineNew HavenUSA

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