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DOI 10.1007/s10877-014-9583-5
ORIGINAL RESEARCH
1 Introduction
Intubation of a main bronchus, more frequently on the
right, is a common incident during tracheal intubation for
general anesthesia and/or prolonged mechanical ventilation
[17].
The pathological consequences of one lung intubation
are mainly reduction of blood oxygenation, appearance of
tension pneumothorax (because of hyperinflation of the
intubated lung), and an increase in the post-intubation
pulmonary complications, including atelectasis and
pneumonia.
A report by the Australian Incident Monitoring Study
(AIMS) on 2000 patients found endobronchial intubation
(EBI) to be the most common incident involving tracheal
intubation [1]. A second AIMS study [2], on 2,947 patients,
found that accidental EBI accounted for 3.7 % of all
incidents reported. The relatively high incidence is mainly
due to the incertitude of the anatomical distance between
the teeth and the carina. That is why relying on fixed
measurement does not guarantee proper positioning in all
patients, as Owen and Cheney proposed in their study [3],
does not cover those patients who do not belong to the
normal range of height. Moreover, physical examination, including auscultation of the chest wall, is a nonobjective measure highly dependent on the physicians
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2 Methods
The study included six healthy goats at the age of 2 years.
The goats were not pregnant or lactating, and had a mean
weight of 50 kg. The experiment was conducted in the
Research and Development Unit of Assaf Harofeh Medical
Center, Israel. All the animals included in the study were
maintained according to the guidelines of the Local Ethics
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Committee for Animal Experimentation, and the experimental protocol was approved by the latter.
Before anesthesia, the physiological parameters of each
animal were measured and found to be within normal
range: heart rate around 50/min, body temperature 38.0 C,
and respiratory rate around 20/min.
Each goat was anesthetized using i.v. ketamine
1011 mg/kg, midazolam 0.2 mg/kg, Lidocaine 0.2 mg/kg,
and atropine 0.5 mg i.v. After tracheal intubation with an
extended tube of 50 cm, especially prepared for this study,
the animal was kept anesthetized with Isoflurane 12 % in
oxygen, the head up 20 degrees and mechanically ventilated with a tidal volume of 7 ml/kg.
2.1 Endotracheal tubes and device used for above cuff
CO2 reading
A modified version of the AnapnoGuard system ETT
(Hospitech Respiration Ltd., Petah Tikva, Israel) was used.
As illustrated in Fig. 1, in order to enable successive CO2
readings (air samples taken from the space above the cuff
and below the vocal cords to the AnapnoGuard system CO2
analyzer), the ETT has 2 additional lumens: one for CO2
readings (ventral lumen) while the other (dorsal lumen) is
split into two at the distal end, used for suctioning of
secretions. The lumens on both sides also serve as venting
lumens, meaning that when the system is used for suctioning secretions, the ventral (CO2) lumen serves for
venting while suctioning with the dorsal suction lumen and
vice versa. The CO2 samples are pumped into the CO2
analyzer via the CO2/vent lumen or the suction lumen.
3 Results
Fig. 2 Tracheal tube positioning and origin of CO2 during endobronchial intubation
4 Discussion
The AnapnoGuard system has already been clinically tried
during general anesthesia and proven to be a reliable
method of assuring the optimal cuff pressure that will avoid
Table 1 Sequence of procedures, average cuff pressure, and CO2
level above the ETT cuff
CO2 level
above
cuff
(mmHg)
Average
cuff
pressure
(mmHg)
Location of
ETT distal
tip
Procedure
Time
(min)
Induction of
general
anesthesia
15 (Range
1317)
Above
carina
Tracheal intubation
6a
13.5
(Range
1115)
Main
bronchus
(4 times
Rt, 2 times
Lt)
6a
27 (Range
2229.5)
Main
bronchus
Automatic inflation
of the cuff to a
preset maximal
pressure
10
0 (in max.
3 min)
13.6
(Range
1116)
Above
carina
ETT repositioning
14
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air leak around the tube when its distal tip is located
between the vocal cords and the carina [13]. In this
experimental setup the only difference in comparison to
any other anesthesia technique was the use of a special
ETT, with side ports connected to a system that continuously measured the CO2 level above the cuff and automatically adjusted the cuff pressure to a level that avoided
air leak. In addition, the length of the ETT used was greater
than that in use for humans because of the anatomic conformation of goats.
Our hypothesis for the present study was that once the
ETT distal tip accidentally slips into one of the main
bronchi, the AnapnoGuard system would react by identifying CO2 above the cuff. The origin of the CO2 in this
case is expected to be the unventilated lung, which at least
for the initial period of time is still perfused. Suggett et al.
[14] have demonstrated, in their dog model, that even at the
plateau phase, when the perfusion to the unventilated lung
is significantly decreased, CO2 is still being diffused. Since
during EBI, the malpositioned cuff cannot achieve complete sealing of the non-intubated lung, above cuff CO2
leak can be detected.
The proposed method of early detection of accidental
EBI has the advantage of being simple to use, noninvasive,
and suitable for any intubated patient. It displays on-line
the CO2 level above the cuff tube and thus can identify the
endobronchial position of the distal tip after only a very
short delay.
Each of the already proposed techniques to be used for
the purpose of identification of EBI has flaws and limitations. For instance, the Rapiscope technique [15] could not
be used continuously. The reflectometry method [16] does
not offer reliable results in the presence of bronchial
secretions or a tracheobronchial tumor. Finally, the video
imaging method [17] is limited in chest asymmetry; in
addition, in the presence of air leak this method becomes
unusable. Recently, two of the current investigators (NW,
GMG) reported the use of a new monitoring method for
detection of EBI by transforming the lung sounds recorded
by four piezoelectric acoustic sensors into a processed
electronic signal. These studies showed a good correlation
between the real location of the ETT distal tip and the
results of the signal analysis, in cases of both endotracheal
tubes [18] and double lumen tubes [19], but the proposed
method demanded the use of microphones and a complicated algorithm.
We suggest that the AnapnoGuard system could detect
accidental EBI at a very early stage and offers a valid
alternative to the already proposed methods to be used for
this purpose. It can be easily used by the average physician
and its display is easy to understand. One possible incident
during its use could be the accumulation of secretions
around the cuff, but the ETT used with the AnapnoGuard
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Conflict of interest
piration, Ltd.
References
1. Szekely SM, Webb RK, Williamson JA, Russell WJ. Problems
related to the endotracheal tube. Anaesth Intensiv Care.
1992;21:6116.
2. McCoy EP, Russell WJ, Webb RK. Accidental bronchial intubation. An analysis of AIMS incidents report from, 1988 to 1994
inclusive. Anaesthesia. 1997;52:2431.
3. Owen TR, Cheney FW. Endobronchial intubation: a preventable
complication. Anesthesiology. 1987;67:2557.
4. Dornette WHL. Anatomy for the anesthesiologist. Springfield:
Charles C. Thomas; 1963. p. 9737.
5. Brunel W, Coleman DL, Schwartz DE, Peper E, Cohen NH.
Assessment of routine chest roentgenograms and physical
examination to confirm endotracheal tube position. Chest. 1989;
96:10435.
6. Sitzwohl C, Langheinrich A, Schober A, Krafft P, Sessler DI,
Herkner H, Gonano C, Weinstabl C, Kettner SC. Endobronchial
intubation detected by insertion depth of endotracheal tube,
bilateral auscultation, or observation of chest movements: randomised trial. BMJ. 2010;341:c5943.
7. Efrati S, Deutsch I, Gurman GM. Endotracheal tube cuffsmall
important part of a big issue. J Clin Monit Comput. 2012;
26:5360.
8. Alliaume B, Coddens J, Deloof T. Reliability of auscultation in
positioning of double lumen endobronchial tube. Can J Anaesth.
1992;39:68790.
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