Book Thorax

Notes on Thoracic Anaesthesia
April 2011
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Richard W. D. Nickalls
Notes on Thoracic Anaesthesia
Richard W. D. Nickalls
Department of Anaesthesia,
Nottingham University Hospitals,
City Hospital Campus,
Nottingham, UK
dick@nickalls.org
http://www.nickalls.org/
r w d n
revision 6
April 2011
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The author gratefully acknowledges generous financial support from the Nottingham Anaesthetic Trust Fund (Department of Anaesthesia, City Hospital), the City Hospital Medical
Staff Research Fund, Smiths Medical (http://www.smithsmedical.com), SonoSite (http://www.sonosite.com) and
the Anthony Booth Trust (http://www.aplasticanaemia.co.
uk), and Stewarts (http://www.stewartscoffees.co.uk) to
cover printing costs and enable this booklet to be made freely
available to those on the Thoracic and Intensive Care training
modules.
Copyright RWD Nickalls 20032011

All rights reserved
PORTEX Smiths Medical, Hythe, Kent, UK
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1 The
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Preface
introductory booklet is essentially a collection of practical notes on some of the
topics relevant to the thoracic anaesthesia training module, and reflects a distinctly
personal approach. It is largely a vehicle for useful references, and still represents
work in progress; for example, Chapter 1 is clearly rudimentarywaiting to be distilled
further. The main topics are essentially those for which I developed some interest and tried
to establish some underlying conceptual structure. Most chapters were motivated by a
particular question or line of approach, as follows.
HIS
Anatomy what is the useful functional anatomy for thoracic anaesthetists?

Bronchoscopy how does the fibreoptic bronchoscope influence our perceived orientation of the anatomy?
Tracheostomy how can we avoid tracheostomy-related problems?
One-lung anaesthesia is there an optimum sequence for placing a doublelumen tube?
Drugs can particular dilutions facilitate administering vasoactive drugs?
Supporting technologies how did some of the key developments arise?
I would like to thank Dr J James 2 for help with the virtual bronchoscopy part of
Figure 5.1, and all those anaesthetists who contributed data to the TEPID database. Finally,
I would also like to acknowledge the considerable help and assistance I have received
from the Operating Department Practitioners, the Theatre Practitioners, and the staff at the
PGMEC library and Department of Medical Illustration.
RWD Nickalls
April 2011
2 Department
of Radiology, Nottingham University Hospitals, City Hospital Campus, Nottingham, UK.
Contents
Preface
1
General topics
1.1 Syllabus . . . . . . . . . . . . . . . . . . .
1.2 General resources . . . . . . . . . . . . . .
1.3 Preoperative evaluation . . . . . . . . . . .
1.3.1 Lung function evaluation . . . . . .
1.3.2 Cardiac function evaluation . . . .
1.3.3 Obesity-related problems . . . . . .
1.4 Open lung biopsy . . . . . . . . . . . . . .
1.5 Tracheal resection . . . . . . . . . . . . . .
1.6 Differential lung ventilation . . . . . . . . .
1.7 Thymectomy and myasthenia gravis . . . .
1.8 Bilateral pleurectomy via sternal split . . .
1.9 Lung-volume reduction surgery . . . . . . .
1.10 Management of flail-chest . . . . . . . . .
1.11 Pneumothorax . . . . . . . . . . . . . . . .
1.11.1 Radiology . . . . . . . . . . . . . .
1.11.2 Cavity expansion with N2 O . . . .
1.11.3 Chest drains . . . . . . . . . . . . .
1.11.4 Chest-drain bottles . . . . . . . . .
1.11.5 Subcutaneous emphysema . . . . .
1.12 Empyema . . . . . . . . . . . . . . . . . .
1.13 Sickle cell disease . . . . . . . . . . . . . .
1.13.1 Anaesthesia . . . . . . . . . . . . .
1.13.2 The transfusion controversy . . . .
1.13.3 Managing sickle-cell crisis . . . . .
1.13.4 Pathophysiology . . . . . . . . . .
1.13.5 Haemoglobin molecular-chemistry .
1.13.6 HbS & O2 dissociation curve . . . .
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12
12
12
18
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20
20
20
21
21
21
22
22
23
23
23
23
24
24
25
25
25
25
27
27
28
28
29
CONTENTS
Epidural block
2.1 Anatomy . . . . . . . . . . . . . . . . . .
2.1.1 The epidural database (TEPID) . .
2.2 General aspects . . . . . . . . . . . . . . .
2.2.1 Awake or under GA? . . . . . . . .
2.2.2 Midline approach . . . . . . . . . .
2.2.3 Paramedian approach . . . . . . . .
2.2.4 Reducing catheter migration / fallout
2.2.5 Radiographic placement . . . . . .
2.2.6 Fibreoptic guided placement . . . .
2.3 Drugs . . . . . . . . . . . . . . . . . . . .
2.4 Complications . . . . . . . . . . . . . . . .
2.4.1 Epidural catheter disconnection . .
2.4.2 Abscess . . . . . . . . . . . . . . .
2.4.3 Haematoma & DVT prophylaxis . .
2.5 Paravertebral block . . . . . . . . . . . . .
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30
31
32
33
33
33
33
34
34
34
34
36
36
36
37
37
Tracheostomy & related airway problems

3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.1.1 Local anaesthetic for fibreoptic bronchoscopy of the trachea
3.2 Tracheostomy tubes . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.1 Portex . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.2 Tracoe . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.3 Rusch . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.2.4 Moore tube . . . . . . . . . . . . . . . . . . . . . . . . . .
3.3 Tracheostomywhen? . . . . . . . . . . . . . . . . . . . . . . . .
3.4 Percutaneous tracheostomy . . . . . . . . . . . . . . . . . . . . . .
3.5 Surgical tracheostomy . . . . . . . . . . . . . . . . . . . . . . . .
3.5.1 Recommendations . . . . . . . . . . . . . . . . . . . . . .
3.6 Changing a tracheostomy tube . . . . . . . . . . . . . . . . . . . .
3.6.1 Preparation . . . . . . . . . . . . . . . . . . . . . . . . . .
3.6.2 Changing the tube . . . . . . . . . . . . . . . . . . . . . .
3.6.3 Check the position bronchoscopically . . . . . . . . . . . .
3.7 Anaesthetising a patient with a laryngectomy . . . . . . . . . . . .
3.8 Anaesthetising a patient with a tracheostomy in situ . . . . . . . . .
3.8.1 Postoperative management . . . . . . . . . . . . . . . . . .
3.9 Montgomery T-tube placement . . . . . . . . . . . . . . . . . . . .
3.10 Difficult airway & trans-tracheal needle ventilation . . . . . . . . .
3.11 Miscellaneous problems . . . . . . . . . . . . . . . . . . . . . . .
3.11.1 Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . .
3.11.2 Difficulty inserting the inner tube . . . . . . . . . . . . . .
3.11.3 Air leak . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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40
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CONTENTS
3.11.4 Tracheostomy recently removed . . . . . . . . . . . . . . . . . .

4
58
Lung anatomy
4.1 Anatomical terms . . . . . . . . . .
4.2 History of lung anatomy . . . . . .
4.2.1 Bronchopulmonary segment
4.3 Lung development & embryology .
4.4 Nomenclature . . . . . . . . . . . .
4.4.1 Right lung . . . . . . . . .
4.4.2 Left lung . . . . . . . . . .
4.5 Carina . . . . . . . . . . . . . . . .
4.5.1 Factors moving the carina .
4.6 Right-upper lobe orifice . . . . . . .
4.7 Aberrant bronchus . . . . . . . . .
4.8 References . . . . . . . . . . . . . .
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59
59
61
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63
64
64
64
65
65
66
66
74
Fibreoptic bronchoscopy
5.1 History . . . . . . . . . . . . . . .
5.2 Bronchoscopy simulator . . . . . .
5.3 Carina . . . . . . . . . . . . . . . .
5.4 Left subcarina & beyond . . . . . .
5.5 Right subcarina & beyond . . . . .
5.6 Image orientation . . . . . . . . . .
5.6.1 Axial rotation . . . . . . . .
5.6.2 Bending . . . . . . . . . . .
5.6.3 Camera-mode . . . . . . . .
5.7 Anaesthesia for bronchoscopy . . .
5.7.1 Short duration . . . . . . .
5.7.2 Long duration . . . . . . . .
5.7.3 Local anaesthesia & sedation
5.7.4 Venturi jet ventilation . . . .
5.8 References . . . . . . . . . . . . . .
5.8.1 Complications . . . . . . .
5.8.2 Fibreoptic intubation . . . .
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78
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85
85
86
86
87
87
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89
89
89
90
90
Tubes and bronchus blockers

6.1 The Univent tube, 1984 . . . . . . .
6.2 The Hunsaker jet ventilation tube . .
6.3 Bronchus blockers . . . . . . . . .
6.4 Double-lumen tubes . . . . . . . . .
6.4.1 History . . . . . . . . . . .
6.4.2 The BronchoCath . . . . .
6.4.3 The tube database (TEPID) .
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92
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CONTENTS
One-lung anaesthesia
7.1 Right double-lumen tube . . . . . . . . . . . .
7.2 Left double-lumen tube . . . . . . . . . . . . .
7.3 Placing double-lumen tubes . . . . . . . . . . .
7.3.1 Preparation . . . . . . . . . . . . . . .
7.3.2 Intubation . . . . . . . . . . . . . . . .
7.3.3 Stethoscope check . . . . . . . . . . .
7.3.4 Bronchoscopy left-sided tube . . . .
7.3.5 Bronchoscopy right-sided tube . . .
7.3.6 Final tidal volume and pressure check .
7.4 Turning the patient laterally . . . . . . . . . . .
7.5 One-lung anaesthesia . . . . . . . . . . . . . .
7.5.1 Preparation . . . . . . . . . . . . . . .
7.5.2 One-lung ventilation . . . . . . . . . .
7.5.3 Management of one-lung anaesthesia .
7.5.4 Returning to two-lungs . . . . . . . . .
7.6 Turning the patient supine . . . . . . . . . . .
7.7 Extubation . . . . . . . . . . . . . . . . . . . .
7.8 Complications . . . . . . . . . . . . . . . . . .
7.8.1 Intraoperative . . . . . . . . . . . . . .
7.8.2 Postoperative . . . . . . . . . . . . . .
7.9 General references . . . . . . . . . . . . . . .
7.9.1 Tracheostomy and one-lung ventilation
7.9.2 One-lung anaesthesia . . . . . . . . . .
7.9.3 Tracheal bronchus . . . . . . . . . . .
7.9.4 Physiology & pathology . . . . . . . .
7.9.5 Flow/pressure/volume loops . . . . . .
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100
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Drugs
8.1 Cardiovascular drugs . . . . . . . . . . . . . . . . .
8.1.1 Infusions: dilutions and use . . . . . . . . .
8.1.2 Bolus dosage . . . . . . . . . . . . . . . . .
8.1.3 Noradrenaline . . . . . . . . . . . . . . . . .
8.1.4 References . . . . . . . . . . . . . . . . . .
8.2 Somatostatin analogues & carcinoid . . . . . . . . .
8.2.1 Octreotide . . . . . . . . . . . . . . . . . . .
8.2.2 Ketanserin . . . . . . . . . . . . . . . . . .
8.2.3 Carcinoid tumours . . . . . . . . . . . . . .
8.2.4 Anaesthesia for bronchial carcinoid resection
8.2.5 References . . . . . . . . . . . . . . . . . .
8.3 Haemostatic drugs . . . . . . . . . . . . . . . . . .
8.4 Remifentanil . . . . . . . . . . . . . . . . . . . . .
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126
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CONTENTS
8.4.1
8.4.2
8.4.3
9
11
Bolus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Infusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Supporting technologies
9.1 Serendipity . . . . . . . . . . . . . . . . . . . .
9.2 Tuohy needle with Huber point and Lee markings
9.3 Pulse oximetry . . . . . . . . . . . . . . . . . .
9.4 MAC . . . . . . . . . . . . . . . . . . . . . . .
9.4.1 History . . . . . . . . . . . . . . . . . .
9.4.2 Age-corrected MAC . . . . . . . . . . .
9.4.3 Temperature corrected MAC . . . . . . .
9.4.4 Dosage and MAC correction . . . . . . .
9.4.5 References . . . . . . . . . . . . . . . .
9.5 Arterial line . . . . . . . . . . . . . . . . . . . .
9.5.1 History . . . . . . . . . . . . . . . . . .
9.5.2 Anatomy . . . . . . . . . . . . . . . . .
9.5.3 Allen test . . . . . . . . . . . . . . . . .
9.5.4 Systolic pressure variation . . . . . . . .
9.5.5 Complications . . . . . . . . . . . . . .
9.6 Central venous catheter . . . . . . . . . . . . . .
9.6.1 History . . . . . . . . . . . . . . . . . .
9.6.2 References . . . . . . . . . . . . . . . .
9.6.3 Optimum position . . . . . . . . . . . .
9.6.4 Anatomy . . . . . . . . . . . . . . . . .
9.6.5 Position of CVP tip . . . . . . . . . . . .
9.6.6 General . . . . . . . . . . . . . . . . . .
9.6.7 Ultrasound guided . . . . . . . . . . . .
9.6.8 External jugular vein . . . . . . . . . . .
9.6.9 Axillary vein . . . . . . . . . . . . . . .
9.6.10 Femoral vein . . . . . . . . . . . . . . .
9.6.11 Complications . . . . . . . . . . . . . .
9.7 Pulmonary artery catheter . . . . . . . . . . . . .
9.7.1 History . . . . . . . . . . . . . . . . . .
9.7.2 Decline in use . . . . . . . . . . . . . . .
9.8 Computers & information technology . . . . . .
9.8.1 History of the anaesthesia record . . . . .
9.8.2 The anaesthesia workstation . . . . . . .
9.8.3 References . . . . . . . . . . . . . . . .
Colophon
Index
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1
General topics
1.1
Syllabus
thoracic anaesthesia syllabus for the CCT in Anaesthesia is detailed in the

cardiothoracic sections of the Intermediate, Higher and Advanced-level training
documents (2nd edition, August 2010) on the Royal College of Anaesthetists
website as follows:
Intermediate: http://www.rcoa.ac.uk/docs/CCTAnnex C.doc
Higher:
http://www.rcoa.ac.uk/docs/CCTAnnex D.doc
Advanced:
http://www.rcoa.ac.uk/docs/CCT in Anaesthetics Annex E.doc
HE
1.2
General resources
Books
Lewis MI and McKenna RJ (2010). Medical management of the thoracic surgery
patient, 560 pp. (Saunders) ISBN 978-1-4160-3993-8. For TOC 1 see: http://www.
sciencedirect.com/science/book/9781416039938
Searl CP and Ahmed ST (Eds.) (2010). Core topics in anesthesia. 230 pp. (Cambridge University Press) ISBN 978-0-521-86712-2
Mashour GA (2010). Consciousness, awareness and anesthesia. 274 pp. (Cambridge
University Press) ISBN 978-0-521-51822-2
Lumb A (Ed.) (2010). Nunns applied respiratory physiology. 7th ed. (Elsevier).
568 pp. ISBN 978-0-7020-2996-3
1 Table
Of Contents
12
CHAPTER 1. GENERAL TOPICS
RWD Nickalls
Hopkins R, Peden C and Ghandi S [Eds.] (2009). Radiology for anaesthesia and
intensive care. 2nd ed., 328 pp. (Cambridge University Press) ISBN 978-0-52173563-6
Kofke WA and Nadkarni VM [Eds.] (2007). New vistas in patient safety and
simulation. Anesthesiology Clinics; 25 (June), 209390 (Elsevier, Inc)
[chapters: Anesthesiology national CME program and ASA activities in simulation
/ Does simulation improve patient safety?: self-efficacy, competence, operational
performance, and patient safety / Simulation applications for human factors and systems evaluation / Credentialing and certifying with simulation / Statewide simulation
systems: the next step for anesthesiology? / Crew resource management and team
training / Simulation: translation to improved team performance / Virtual worlds and
team training / Virtual reality simulations / Procedural simulation / Debriefing with
good judgment: combining rigorous feedback with genuine inquiry / Integration of
standardized patients into simulation ]
Slinger P [Ed.] (2008). Thoracic anesthesia. Anesthesiology Clinics; 26 (June),
241398 (Elsevier, Inc)
[chapters: Evidence-based management of one-lung ventilation / Oxygen toxicity
during one-lung ventilation: is it time to re-evaluate our practice? / Anesthetic considerations for airway stenting in adult patients / Perioperative anesthetic management
for esophagectomy / Anesthetic considerations for patients with anterior mediastinal
masses / The emerging role of minimally invasive surgical techniques for the treatment of lung malignancy in the elderly / Prevention and management of perioperative
arrhythmias in the thoracic surgical population / Pulmonary vasodilatorstreating
the right ventricle / Post thoracotomy pain management problems / Postthoracotomy paravertebral analgesia: will it replace epidural analgesia? / Advances in
extracorporeal ventilation ]
Allman KG, Wilson IH (Eds.) (2006). Oxford Handbook of Anaesthesia. 2nd. ed.
(Oxford University Press) [good sections on (a) THORACIC ANAESTHESIA (pp. 351
383), and (b) DRUG FORMULARY (pp. 11051165).]
Pearce A and Gould G (2005). Thoracics. In: Allman KG, McIndoe AK and Wilson
IH (Eds.) Emergencies in Anaesthesia, 1st. ed., pp. 193220 (Oxford University
Press).
Cobbold RSC (2006). Foundations of biomedical ultrasound. (Oxford University
Press). 822 pp.
Chassot PG (2003). Cardiovascular and thoracic anaesthesia.
[see book review: Br. J. Anaesth.; 91, 928]
Kaplan JA and Slinger PD [Eds.] (2003). Thoracic anesthesia. 3rd ed., (Churchill
Livingstone, Philadelphia, USA). ISBN 0443066191 [excellent]
RWD Nickalls
Marshall BE, Longnecker DE and Fairley HB [Eds.] (1988). Anesthesia for thoracic
procedures. (Blackwell Scientific Publications). 632 pp.
Articles
Burwell DR and Jones JG (1996). The airways and anaesthesia; I: anatomy, physiology and fluid mechanics. Anaesthesia; 51, 849857 (September issue). II: pathophysiology. Anaesthesia; 51, 943955 (October issue).
Campos JH (2009). Update on selective lobar blockade during pulmonary resections.
Current Opinion in Anaesthesiology; 22, 1822.
Canet J, Gallart L, Gomar C et al. (2010). Prediction of postoperative pulmonary
complications in a population-based surgical cohort. Anesthesiology; 113, 1338
1350.
Levin AI, Coetzee JF and Coetzee A (2008). Arterial oxygenation and one-lung
anesthesia. Current Opinion in Anaesthesiology; 21, 2836 [107 refs]
Metzger RJ, Klein OD, Martin GR and Krasnow MA (2008). The branching program
of mouse lung development. Nature; 453, 745756 (5 June). [editorial: 733735
(Warburton 2008)]
Ott HC, Clippinger B, Cobrad C, Schuetz C, Pomerantseva I, Ikonomou L, Kotton D
and Vacanti JP (2010). Regeneration and orthotopic transplantation of a bioartificial
lung. Nature Medicine; 16, 927933.
Payen J-F (2010). Toward tailored sedation with halogenated anesthetics in the
Intensive Care Unit? Anesthesiology; 113, 12689. [Editorial]
Pearce A (2004). Thoracic anaesthesia update. Update in Anaesthesia (June 2004);
18. http://update.anaesthesiologists.org/2004/ [or follow links to thoracic topics]
Ross AF and Ueda K (2010). Pulmonary hypertension in thoracic surgical patients.
Severinghaus JW (2009). Gadgeteering for health care: [The JW Severinghaus
lecture on translational science] Anesthesiology; 110, 721728.
Shafer SL (2007). Did our brains fall out? Anesthesia & Analgesia; 104, 247248.
Shafer SL (2009). Critical thinking in anesthesia. Anesthesiology; 110, 729737.
Slinger PD (2003). Acute lung injury after pulmonary resection: more pieces of the
puzzle. Anesthesia and Analgesia; 97, 15551557. [49 refs]
Warburton D (2008). Order in the lung Nature; 453 (5 June), 733735 [editorial to
Metzger et al. (2008)].
RWD Nickalls
Book/journal searches
Good starting points are (a) Google books (http://books.google.com/), and (b) the
Wikipedia page on book sources (http://en.wikipedia.org/wiki/book_sources/).
For buying books (secondhand and new) Abebooks (http://www.abebooks.com/)
is particularly useful, since it is usually possible to find the website & telephone number of
the individual booksellers, and then buy from them directly.
PubMed Central (PMC): http://www.ncbi.nlm.nih.gov/pmc/.
A free archive of life sciences journals. See the journal list for list of all available
journals.
Science Direct: http://www.sciencedirect.com/
A particularly useful interface for viewing the tables of contents (TOC) of journals.
Unbound Medicine: http://www.unboundmedicine.com/medline/ebm/
This is a useful free interface to the MEDLINE search engine.
Priory Medical Journals Online: http://www.priory.com/
The Cochrane Library: http://www.thecochranelibrary.com/
Copac: http://copac.ac.uk/
It is the national, academic and specialist library catalogue. It provides free access
to the merged online catalogues of 24 major research libraries in the UK and Ireland,
including the British Library, and the national libraries of Scotland, Wales and
Ireland.
British Library (London): http://www.bl.uk/
The BL integrated catalogue is freely available online.
Nottingham Univ. library catalogue: http://aleph.nottingham.ac.uk/ALEPH/
Project Gutenberg: http://www.gutenberg.org/
Free eBooks on-line.
Anesthesiology Clinics
for TOC 2 see: http://www.sciencedirect.com/science/journal/19322275
Cardiac anesthesia: today and tomorrow (2008); 26 (September)
Thoracic anesthesia (2008); 26 (June)
New vistas in patient safety and simulation (2007); 25 (June)
2 Table
Of Contents
RWD Nickalls
Thoracic Surgery Clinics

for TOC see: http://www.sciencedirect.com/science/journal/15474127
Thymoma (2011); 21 (February)
Chest wall surgery (2010); 20 (November)
Air leak after pulmonary resection (2010); 20 (August)
Technical advances in mediastinal surgery (2010); 20 (May)
Imaging of thoracic diseases (2010); 20 (February)
Surgical conditions of the diaphragm (2009); 19 (November)
Thoracic surgery in the elderly (2009); 19 (August)
Update on surgical and endoscopic management of emphysema (2009); 19 (May)
Diseases of the mediastinum (2009); 19 (February)
Thoracic anatomy: Chest wall, airway, lungs. (2007); 17 (November)
Clinics in Chest Medicine

for TOC see: http://www.sciencedirect.com/science/journal/02725231
Interventional pulmonology (bronchoscopy) (2010); 31 (March)
Tuberculosis (2009); 30 (December)
Obesity and respiratory disease (2009); 30 (September)
Fungal diseases (2009); 30 (June)
Nonpulmonary critical care (2009); 30 (March)
Update in sepsis (2008); 29 (December)
Controversies in mechanical ventilation (2008); 29 (June)
Contemporary chest imaging (2008); 29 (March)
Artificial airways (2003); 24 (September).
Pulmonary function testing (2001); 22 (December).
Prolonged critical illness: management of long-term acute care (2001); 22 (March).
Flexible bronchoscopy update (2001); 22 (June).
RWD Nickalls
Acute respiratory distress syndrome (2000); 21 (September).

Intensive care unit complications (1999); 20 (June).
Flexible bronchoscopy in the 21st century (1999); 20 (March).
History
Comroe JH (1977). Retrospectroscope: insights into medical discovery. (Von Gehr
Press, Menlo Park, California, USA). ISBN 0-9601470-1-2 [a collection of essays
which originally appeared in American Review of Respiratory Disease during the
period 19751977.]
Swazey JP and Reeds K (1978). Todays medicine, tomorrows science: essays
on paths of discovery in the biomedical sciences. (U.S. Department of Health,
Education and Welfare, Public Health Service, National Institutes of Health, USA;
DHEW Publication No. (NIH) 78-244). [available for download from http://
newman.baruch.cuny.edu/digital/2001/swazey_reeds_1978/]
Watson JD (1968). The Double Helix: a personal account of the discovery of the
structure of DNA, (Weidenfeldt & Nicholson); (Penguin Books 1970); (WW Norton
& Co., 1980; Ed. Gunter S. Stent3 ).
Maltby RJ (Ed.) (2002). Notable names in anaesthesia. (Royal Society of Medicine
Press, London). ISBN 1853-155-128. 254 pp.
Sykes K and Bunker J (2007). Anaesthesia and the practice of medicine: historical
perspectives. (224 pp.) ISBN 1-85315-674-4
Medical History is the journal of the Wellcome Historical Medical Library, London.
A useful resource of historical articlessome of which relate to anaesthesia. It is
available on-line via PubMed Central at http://www.ncbi.nlm.nih.gov/pmc/
journals/228/.
The Wellcome Collection. http://www.wellcomecollection.org/
The Wellcome Library. http://library.wellcome.ac.uk/ For a list of free
online titles project see http://library.wellcome.ac.uk/backfiles/.
Miscellaneous
Slingers thoracic anaesthesia site: http://www.thoracic-anesthesia.com/
Chest (see archive, collections and supplements): http://chestjournal.chestpubs.
org/
3 This
excellent edition also includes a commentary, reviews, and copies of the original 1953 papers.
RWD Nickalls
Medscapes clinical reference website: http://emedicine.medscape.com/

There is an extensive database on clinical procedures. See also the sections
on thoracic surgery, radiology, critical care, etc.
Best evidence topics: http://www.bestbets.org.
A collection of mini-reviews presenting the evidence base for various topics.
Virtual Hospital: http://www.uihealthcare.com/vh/
Many interesting thoracic articles available via their search facility.
Bronchoscopy Atlas: http://www.int-med.uiowa.edu/research/tlirp/
BronchoscopyAtlas/Home.html
Clinical Cases and Images website: http://clinicalcases.org/.
Learning Radiology website: http://www.learningradiology.com/
Wikipedia is well worth a trawl occasionally, since it has an increasing number of
surprisingly detailed medical entries with excellent links; for example:
http://en.wikipedia.org/wiki/Tracheal_intubation
http://en.wikipedia.org/wiki/History_of_tracheal_intubation
http://en.wikipedia.org/wiki/History_of_anatomy
http://en.wikipedia.org/wiki/History_of_general_anaesthesia
Anesthesia Patient Safety Foundation (APSF): (http://www.apsf.org/).
SHEPHERDS FALKINERS, 76 Southampton Row, London, WC1B 4AR. Tel: 020783-11151 http://store.falkiners.com/ (fine paper & bookbinding supplies)
1.3
1.3.1
Preoperative evaluation
Lung function evaluation
The British Thoracic Society guidelines article (BTS/SCTS Working Group 2001) recommends an FEV1 > 2 litres for pneumonectomy, and FEV1 > 15 litres for a lobectomy.
Patients with values less than these are high risk and should be evaluated further (transfer
factor; exercise test). However, some patients with diffuse interstitial lung disease may
well have a low transfer factor in spite of good spirometry, and should be evaluated further.
This document gives details of preoperative respiratory and cardiovascular function tests
for all such patients, and is well worth reading. Good general reviews are Datta and Lahiri
(2003), Powell and Caplan (2001), Portch and McCormick (2009).
Role of supine LFTs? Finally, we should not overlook the possibility that some
supine lung-function testing (and cardiac testing) might be more appropriate for supine
patients under anaesthesiabut I have failed to find any literature on this as yet.
RWD Nickalls
Brunelli A (Ed.) (2008). Preoperative evaluation of lung resection candidates.

Thoracic Surgery Clinics; 18, No. 1.
BTS/SCTS Working Group (2001). Guidelines on the selection of patients with
lung cancer for surgery. Thorax; 56, 89108. [182 refs] [can be downloaded from:
http://thorax.bmj.com]
Datta D and Lahiri B (2003). Preoperative evaluation of patients undergoing lung
resection surgery. Chest; 123, 20962013 [review article]
Gould G and Pearce A (2006). Assessment of suitability for lung resection. Continuing Education in Anaesthesia, Critical Care & Pain; 6 (No 3), 97100. [BJA related
journal] [good overview]
Kearney DJ et al. (1994). Assessment of operative risk in patients undergoing lung
resection: impact of predicted pulmonary function. Chest; 105, 753759.
Kinnear WJM (1997). Lung function tests: a guide to their interpretation. (Nottingham University Press, Nottingham, UK). ISBN 1-897676-80-8.
Mark JBD (Ed) (1999). Perioperative cardiopulmonary evaluation and management.
Chest; 115 Supplement (May). http://chestjournal.chestpubs.org/
Melendez JA and Fischer ME (1997). Preoperative pulmonary evaluation of the
thoracic surgical patient. In: Wilson RS [Ed.] Anaesthesia; Chest Surgery Clinics of
North America; 7, 641654. (Philadelphia, PA: WB Saunders, USA).
Portch D and McCormick B (2009). Pulmonary function tests and assessment for
lung resection. Update in Anaesthesia (June 2009), p. 1321. http://update.
anaesthesiologists.org/2009/ [good overview]
Powell CA and Caplan CE (2001). Pulmonary function tests in preoperative pulmonary evaluation [92 refs]. In: Chupp GL (Ed), Clinics in Chest Medicine; 22
(no. 4, December)
[this vol of Clinics in Chest Medicine also includes useful articles by Pride NB
(Tests of forced expiration and inspiration), and Gibson CJ (Lung volumes and
elasticity)]
Rennotte MT, Bacle P, Aubert G and Rodenstein DO (1995). Nasal continuous
positive airway pressure in the perioperative management of patients with obstructive
sleep-apnoea submitted to surgery. Chest; 107, 367374.
Rielly JJ (1999). Evidence-based pre-operative evaluation of candidates for thoracotomy. Chest; 116 (Suppl 6), 474S476S.
Smetana GW (1999). Pre-operative pulmonary evaluation. N. Engl. J. Med.; 340,
937944. [see also the follow-up letters stressing significance of detecting preoperative sleep apnoea: Marx JJ et al. (1999), 341, 613614]
1.3.2
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Cardiac function evaluation
Eagle KA et al. (2002). ACC/AHA guideline update for perioperative cardiovascular

evaluation for noncardiac surgeryexecutive summary. Anesth. Analg.; 94, 1052
1064. [see editorial P 1378-9]
Fleisher LA (1998). Pre-operative cardiac evaluation before non-cardiac surgery.
In: Baillières Clinical Anaesthesiology; Chapter 4, 373390. (Baillière Tindall,
London).
Mark JBD (Ed) (1999). Perioperative cardiopulmonary evaluation and management.
Chest; 115 Supplement (May). http://chestjournal.chestpubs.org/
1.3.3
Obesity-related problems
This list is included here since one-lung anaesthesia in obese patients is such a formidable
technical exercise. It is sometimes worth considering the use of temporary post-extubation
CPAP or BIPAP support in recovery.
Obesity and respiratory disease. Clinics in Chest Medicine (2009); 30 (September)
Adams JB and Murphy PG (2000). Obesity in anaesthesia and intensive care. Br. J.
Anaesth.; 85, 91108 [164 refs].
Marik P and Varon J (1998). The obese patient in the ICU. Chest; 113, 492498.
Shenkman Z, Shir Y and Brodsky JB (1993). Perioperative management of the
obese patient. Br. J. Anaesth.; 70, 349359. [excellent: 120 refs]
von Ungern-Sternberg BS, Regli A, Schneider MC, Kunz F and Reber A (2004).
Effect of obesity and site of surgery on perioperative lung volumes. Br. J. Anaesth.;
92, 20022207.
1.4
Open lung biopsy
These patients usually have diffuse lung disease and relatively poor lung function, and are
generally referred to the surgeons following a failed percutaneous or bronchoscopic lung
biopsy. Although a single-lumen tube is often all that is required for a supine procedure
(e.g., a mediastinotomy or mediastinoscopy), a double-lumen tube and lateral position
is sometimes necessary. Consider selective lobar isolation if lung function is poor (see
Mentzelopoulos, Rellos, Tzoufi et al. 2003).
Mentzelopoulos SD, Rellos K, Tzoufi MJ et al. (2003). A double-lumen tube
technique for selective lobar isolation. European Journal of Anaesthesiology; 20,
984992.
1.5
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Tracheal resection
Cokis C and Strang T (2000). Airway management for carinal tumour resection.
Anaesthesia and Intensive Care; 28, 570572.
1.6
Differential lung ventilation
This is occasionally indicated in patients where the two lungs have a significantly different
compliance. The Drager ventilators have the facility to be linked in pairs such that one
functions as the slave of the other, allowing the phase relations of the two ventilators to be
easily controlled.
Hedenstierna G (1985). Differential ventilation in bilateral lung disease. Europ. J.
Anaesthesiol.; 2, 1.
Hedenstierna G et al. (1984). Ventilation and perfusion of each lung during differential ventilation with selective PEEP. Anesthesiology; 61, 369.
1.7
Thymectomy and myasthenia gravis
Good articles on the anaesthetic management of myasthenia gravis are few in number;
the most useful ones I have found are those by Zielinski (2011), Eisenkraft (1987) and
Redfern et al. (1987). Note that the February 2011 issue of the Thoracic Surgery Clinics is
on thymoma.
A patient with myasthenia gravis is typically maintained on oral pyridostigmine tablets.
Postoperatively either pyridostigmine (subcutaneously) or neostigmine 4 is generally used
until the patients usual oral maintenance dose (pyridostigmine tablets) can be resumed.
Note that 60 mg of the oral pyridostigmine preparation is equivalent to 2 mg of the parenteral product.5 A typical adult total daily parenteral dose of pyridostigmine is approximately 1040 mg (14 mg given 34 hrly).
The exact neuromuscular defect (presynaptic vs. postsynaptic) seems not to be fully
resolved as yet. The presynaptic acetylcholine stores and their release are not diminished
in myasthenia (Cull-Candy et al. 1980).
Zielinski M (2011). Management of myasthenic patients with thymoma. Thoracic
Surgery Clinics; 21 (February), 4757.
Cull-Candy SG et al. (1980). On the release of transmitter at normal, myasthenia
gravis, and myasthenic syndrome affected human end-plates. Journal of Physiology
(Lond.); 299. 621638 [from Sosis (1985)]
4 Pyridostigmine
5 CHN
is the preferred agent owing to its longer action.

Pharmacy factsheet.
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Eisenkraft JB (1987). Myasthenia gravis and thymic surgery: anaesthetic considerations. In: Gothard JWW [Ed.], Thoracic anaesthesia. Clinical Anaesthesiology;
1 (March); Chapter 8, 133162. [excellent]
Redfern N et al. (1987). Thymectomy. Ann. Roy. Coll. Surg. Eng.; 68, 289292.
1.8
Bilateral pleurectomy via sternal split
An important aspect of this procedure is taking care to avoid having both lungs partially
deflated at the same time! This can easily happen once both pleura are open, and the
resulting desaturation can be both severe and slow to recover.
The problem tends to occur when the surgeons have almost finished working on the
first lung, as then one of the surgeons may start investigating (& collapsing) the other lung
before the first lung has been fully re-expanded. Note there is sometimes quite a long
time-lag after re-expanding a lung and the saturation improving.
The fact that the patient is supine compounds the problem, as there is no bottom lung
receiving most of the cardiac output. This is an important difference, since with a normal
thoracotomy in the lateral position not only is the bottom lung always fully expanded but it
is also receiving the majority of the cardiac output.
The key principles are therefore (a) use a double-lumen tube, (b) use some PEEP,
and (c) make sure the first lung is fully re-expanded before allowing the surgeons to start
working on the other lung. The same general principles probably also apply for lungvolume reduction surgery, as this is usually a bilateral procedure via a sternal split as well
(see below).
1.9
Lung-volume reduction surgery
Calverley PMA (2003). Closing the NETT on lung volume reduction surgery.
Thorax; 58, 651653. [review of the National Emphysema Treatment Trial (NETT)]
Conacher ID (1997). Anaesthesia for the surgery of emphysema. Br. J. Anaesth.; 79,
530538.
Cooper JD and Lefrak SS (1999). Lung-reduction surgery: 5 years on. The Lancet;
353 (Suppl. 1[surgery]), 2627. [At 2 years pulmonary function had improved in
the surgical group, but had worsened in the control (no-surgery group). By 354
yrs mortality during follow up was 30% (surgery) and 52% (no-surgery)]
Szekely LA et al. (1997). Pre-operative predictors of operative morbidity and
mortality in COPD patients undergoing bilateral lung-volume reduction surgery.
Chest; 111, 550558.
1.10
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Management of flail-chest
Ahmed Z and Mohyuddin Z (1995). Management of flail chest injury: internal

fixation versus endotracheal intubation and ventilation. The Journal of Thoracic and
Cardiovascular Surgery; 110, 16761680.
[Internal fixation (IF) is better; with IF mean period of IPPV was 39 days versus 15
days with IPPV only].
1.11
Pneumothorax
http://emedicine.medscape.com/thoracic_surgery/ >pneumothorax
Baumann MH and Strange C (1997). Treatment of spontaneous pneumothorax: a
more aggressive approach? Chest; 112, 789804 [132 refs]
Beauchamp G (1995). Spontaneous pneumothorax and pneumomediastinum. In:
Pearson FG, [Ed.] Thoracic surgery. (Churchill Livingstone, New York, USA).
pp. 10381040.
Henry M, Arnold T and Harvey J (2003). BTS guidelines for the management of
spontaneous pneumothorax. Thorax; 58 (Suppl 2), 3952.
1.11.1
Radiology
OConnor AR and Morgan WE (2005). Radiological review of pneumothorax.

British Medical Journal ; 330, 14931497.
1.11.2
Cavity expansion with N2 O
Eger EI (1974). Nitrous oxide transfer to closed gas spaces. In: Eger EI Anaesthetic
uptake and action (Williams & Wilkins Company, Baltimore, USA), Chapter 10,
pp. 171183. [lung cavity expansion is fast: volume doubles with 50% N2 O; vol
increases 4-fold with 75% N2 O. Bowel expansion is much slower and less complete;
with 75% N2 O bowel gas volume increased 18-fold in 2 hrs, 25-fold in 4 hrs.]
Eger EI and Saidman LJ (1965). Hazards of nitrous oxide in bowel obstruction and
pneumothorax. Anesthesiology; 26, 6166.
Gold MI and Joseph SI (1973). Bilateral tension pneumothorax following induction
of anaesthesia in two patients with chronic obstructive airway disease. Anesthesiology; 38, 9397.
1.11.3
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Chest drains
Chest drains are potentially dangerous, and in May 2008 the National Patient Safety
Agency (NPSA) issued an alert following 12 deaths and 15 serious adverse incidentssee
the paper by Akram and Hartung (2009).
The sizes of chest drains generally used in thoracic surgery are as follows: ward
insertion 28 Fr; theatre insertion 36 Fr.
Pneumonectomy: 1 drain;
Lobectomy: 2 chest drains:- (anterior/apical/air) - (back/basal/blood).
Chest drains are sometimes put on suction postoperatively in order to facilitate lung reexpansion (spontaneously breathing patients only). However, in the presence of a lung leak
suction can be the cause of a tension pneumothorax if the total drain air flow is significant
(i.e., if the suction cannot handle the total flow). Consequently, if you suspect a tension
pneumothorax always disconnect the suction 6 from the under-water seal until the problem
has been resolved. Never apply suction to a ventilated patient.
There is also a nice You tube internet video on securing a chest drain (search google
for this).
Akram AR and Hartung TK (2009). Intercostal chest drains: a wake-up call from
the National Patient Safety Agency rapid response report. J. R. Coll. Physicians
Edinb.; 39, 117120. [a nice review of chest drain-related complications]
Cerfolio RJ, Minnich DJ and Bryant DJ (2009). The removal of chest tubes despite
an air leak or a pneumothorax. The Annals of Thoracic Surgery; 87, 16901694
(discussion: 1694-1696).
Harriss DR and Graham TR (1991). Management of intercostal drains (a review).
British Journal of Hospital Medicine; 45, 383386.
Harriss DR and Graham TR (1990). Management of intercostal drains British
Medical Journal ; 301, 1165.
Hyde J, Sykes T and Graham T (1997). Reducing morbidity from chest drains
[editorial]. British Medical Journal ; 314, 914915.
Laws D, Neville E and Duffy J (2003). BTS guidelines for the insertion of a chest
drain. Thorax; 58, 5359.
1.11.4
Chest-drain bottles
Hunter J (2008). Chest drain removal. Nursing Standard ; 22(45), 3538.

Kam AC, OBrien M and Kam PCA (1993) Pleural drainage systems. Anaesthesia;
48, 154161. [excellent]
6 If there is a tension pneumothorax, then disconnecting the suction will result in an immediate discharge of
air through the under-water seal.
RWD Nickalls
Thompson R, Parker E, Sivaprakasam J and Hong V (2007). Observational study

of the practice of chest drain removal in postoperative cardiac surgical patients.
Anaesthesia; 62, 207208.
Woodrow P (2005). Caring for patients with intrapleural chest drains. [East Kent
Hospitals guidelines] Available on the internet [google key words: clinical guidelines
Interpleural chestdrain guidelines (4)]
1.11.5
Subcutaneous emphysema
Beck PL, Heitman SJ and Mody CH (2002). Simple construction of a subcutaneous

catheter for treatment of severe subcutaneous emphysema. Chest; 121, 647649.
Cesario A, Margaritora S, Porziella V and Granone P (2003). Microdrainage via
open technique in severe subcutaneous emphysema. Chest; 123, 21622163 [letter]
Herlan DB, Landreneau RJ and Ferson PF (1992). Massive spontaneous subcutaneous emphysema: acute management with infraclavicular blow holes. Chest;
102, 503505.
Leo F, Solli P, Veronesi G et al. (2002). Efficacy of microdrainage in severe subcutaneous emphysema. Chest; 122, 14981499.
1.12
Empyema
DTB (2006). Managing empyema in adults. Drug and Therapeutics Bulletin;

44 (March), 1721. http://www.dtb.org.uk/
1.13
Sickle cell disease
One-lung anaesthesia in patients with a sickle-cell condition is a formidable problem

requiring preparation and coordination with the Haematology department. Unfortunately
good references which are useful for thoracic anaesthetists are few in number.7 The NHS
sickle cell and thalassaemia screening programme website (http://sct.screening.
nhs.uk) is a useful source of information.
1.13.1
Anaesthesia
The main principles are: (a) optimise Hbaim for [HbA] greater than 70%and treat
anaemia, (b) chest physiotherapy and breathing exercises, (c) good hydration, (d) preoxygenation, (e) minimise factors which right-shift the Hb dissociation curve,8 (f) use at
7 See
8 i.e.,
those I have indicated with a triangle 4.

correct acidosis, and avoid letting ETCO2 or temperature rise above normal.
RWD Nickalls
least 50% FIO2 , (g) keep the patient warm,9 (h) no tourniquets (tourniquet deaths have been
reported even with sickle-cell trait), (i) consider regional blocks to facilitate vasodilation,
(j) avoid pre- and postoperative sedation.
The most useful references I have come across from a purely practical point of view
are marked by a triangle 4.
Bannerjee AK, Layton DM, Rennie JA et al. (1991). Safe surgery in sickle-cell
disease. Br J Surg; 78, 516517.
Davies SC, Cronin E, Gill M, Greengross P, Hickman M and Normand C (2000).
Screening for sickle cell disease and thalassaemia: a systematic review with supplementary research. Health Technology Assessment; 4 (No. 3). http://sct.
screening.nhs.uk/ [see chapter 8: Prevalence of sickle cell and -thalassaemia
in England. (pp. 2732)].
Derkay CS, Bray G, Milmoe GJ et al. (1991). Adeno-tonsillectomy in children with
sickle-cell disease. South Med J ; 84, 205208.
Esseltine DW, Baxter M, Bevan JC (1988). Sickle cell states and the anesthesiologist.
Can. J. Anaesth ; 35, 385403.
4 Firth PG (2005). Anaesthesia for peculiar cellsa century of sickle cell disease.
Br. J. Anaesth.; 95, 287299. [excellent review; 96 refs]
4 Firth PG and Head CA (2004). Sickle cell disease and anesthesia. Anesthesiology;
101, 766785. [excellent review; 180 refs]
4 Gibson JR (1987). Anesthesia for the sickle-cell diseases and other hemoglobinopathies. Seminars in Anesthesia; 6, 2735.
Henderson K (1994). Sickle-cell disease and anaesthesia. Update in Anaesthesia;
No. 4, 912. http://update.anaesthesiologists.org/1994/
Homi J, Reynolds J, Skinner A et al. (1979). General anaesthesia and sickle-cell
disease. BMJ ; i, 15991601.
4 Howells TH, Huntsman RG, Boys JE and Mahmood A (1972). Anaesthesia and
sickle-cell haemoglobin. Br. J. Anaesth.; 44, 975987.
Marchant WA and Wright S (2001). Aortic cross-clamping in sickle cell disease.
Anaesthesia; 56, 286287. [letter] [exchanged transfused to Hb 10, HbA 61%, good
hydration, warm, mild alkalosis: bypass cross-clamp 9 min; no problems]
4 McClain BC, Redd SA and Turner EA (1999). Sickle cell disease: a 90s
perspective on an old disease. In: Lake CL, Rice LJ and Sperry RJ (Eds) Advances
in Anaesthesia; 16, 129161 [97 refs].
9 To
facilitate vasodilation.
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4 Neumayr L, Koshy M and Haberkern C et al. (1998). Surgery in patients with

Haemoglobin SC Disease. American Journal of Hematology; 57, 101118. [cited
from Marchant WA and Wright S, 2001]
Koshy M, Weiner SJ et al. (1995). The co-operative study of sickle-cell disease.
Surgery and anaesthesia in sickle-cell disease. Blood ; 86, 36763684.
Raff JP, Dobson CE and Tsai HM (2002). Transfusion of polymerised haemoglobin
in a patient with severe sickle-cell anaemia. Lancet; 360, 464465.
Vipond AJ and Caldicott LD (1998). Major vascular surgery in a patient with sickle
cell disease. Anaesthesia; 53, 12041206.
1.13.2
The transfusion controversy
These articles discuss two pre-operative treatments: (a) aggressive transfusion aimed at
decreasing [HbS] to less than 30%, and (b) a more conservative approach designed simply
to increase [Hb] to greater than 10 gm/100mls. While both regimens were equally effective
in preventing post-operative complications, the conservative regimen was associated with
half as many transfusion reactions.
Buchanan GR and Rogers ZR (1995). Preoperative transfusion in sickle-cell disease.
N Eng J Med ; 333, 1641. [letter] [reply to Vichinsky et al. 1995]
Haberkern CM, Neumayr LD, Orringer EP et al. (1997). Cholecystectomy in sicklecell anemia patients: peri-operative outcome in 364 cases from the national preoperative transfusion study. Blood ; 89, 15331542.
Vichinsky EP, Haberkern CM, Neumayr L et al. (1995). A comparison of conservative and aggressive transfusion regimes in the peri-operative management of
sickle-cell disease. N Eng J Med ; 333, 206.
1.13.3
Managing sickle-cell crisis
Ballas SK (1998). Sickle cell disease: clinical management. In: Baillieres Clinical
Haematology, 11, (No. 1, March issue), 185214.
Davies SC and Oni L (1997). Management of patients with sickle-cell disease.
Br. Med. J.; 315, 65660.
Konotey-Ahulu FID (1998). Opiates for sickle-cell crisis? Lancet; 351, 1438.
Serjeant GR (1997). Sickle-cell disease. Lancet; 350, 72530.
Steinberg MH (1999). Management of sickle cell disease. New Engl. J. Med.; 340,
10211030.
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Vichinsky E (2002). New therapies in sickle cell disease. Lancet; 360, 629631.
[L-arginine augments nitric oxide production anti-sickling and vaso-dilation]
Vijay V, Cavenagh JD and Yate P (1998). The anaesthetists role in acute sickle-cell
crisis. Br. J. Anaesth.; 80, 820828.
1.13.4
Pathophysiology
Mozzarelli A, Hofrichter J, and Eaton WA (1987). Delay-time of hemoglobin-S

polymerization prevents most cells from sickling in vivo. Science; 237, 500506.
Serjeant GR and Serjeant BE (2001). Sickle cell disease. (Oxford University Press,
Oxford, UK)
Steinberg MH (1998). Pathophysiology of sickle cell disease. In: Baillieres Clinical
Haematology, 11, (No. 1, March issue), 163184.
1.13.5
Haemoglobin molecular-chemistry
The famous chemist Linus Pauling was instrumental in the discovery that sickle-cell disease
was due to a haemoglobin abnormality. Max Perutz and John Kendrew received the Nobel
Prize in 1962 for determining the structure of haemoglobin.
Cooper C and Wilson M (1997). Cold feet. New Scientist; The Last Word, (February 1st). [a fascinating note on the mechanism by which the amount of heat (H)
associated with the exothermic oxygen-binding to haemoglobin and its reverse
allows the feet of antarctic penguins to remain non-frozen. Its role in other animals
is also explored.]
Itano HA and Pauling L (1949). A rapid diagnostic test for sickle cell anemia.
Blood ; 4, 66.
Pauling L and Itano HA, Singer SJ and Wells IC (1949). Sickle cell anaemia, a
molecular disease. Science; 110, 543548.
Perutz MF (2003). The second secret of life. In: I wish Id made you angry earlier.
(Cold Spring Harbor Laboratory Press; ISBN 0879696745). pp. 315337.
Perutz MF (1997). Science is not a quiet life: unravelling the atomic mechanism
of haemoglobin. (World Scientific Publishing Co. Pte. Ltd.; London/Singapore)
636 pp. ISBN 9810230575 (pbk.) [annotated collection of key papers by Perutz
relating to the structure of haemoglobin; includes a section on molecular pathology
of human haemoglobin.]
Perutz MF (1990). Mechanism of cooperativity and allosteric regulation in proteins.
(Cambridge University Press; ISBN 0521386489). 101 pp.
RWD Nickalls
Swazey JP and Reeds K (1978). Todays medicine, tomorrows science: essays

on paths of discovery in the biomedical sciences. (U.S. Department of Health,
Education and Welfare, Public Health Service, National Institutes of Health, USA;
DHEW Publication No. (NIH) 78-244). See: Chapter 5: The lesson of rare maladies:
sickled cells, molecular disease, and the genetic control of protein structure, pp. 73
92. [available for download from http://newman.baruch.cuny.edu/digital/
2001/swazey_reeds_1978/] [excellent historical overview of the science relating
to sickle cell disease]
1.13.6
HbS & O2 dissociation curve
Becklake MR et al. (1955). Oxygen dissociation curves in sickle-cell anemia, and

in subjects with the sickle-cell trait. J. Clin. Invest.; 34, 751755.
Gill SJ et al. (1979). Oxygen binding to sickle-cell hemoglobin. J Mol Biol ; 130,
175189. [cited from Hsia, 1998]
Hsia CCW (1998). Respiratory function of hemoglobin. N Engl J Med ; 338,
239247.
Ueda Y, Nagel RL and Bookchin RM (1979). An increased Bohr effect in sickle-cell
anemia. Blood ; 53, 472480. [from Hsia, 1998]
2
Epidural block
IRTUALLY all thoracic patients at the City Hospital have an epidural block unless
this is contraindicated for some reason. Note the recent epidural best practice
publication (RCoA 2010). For history of the development of the epidural needle see
Section 9.2.
RCoA (2010). Best practice in the management of epidural analgesia in the hospital
setting. Faculty of Pain Medicine, Royal College of Anaesthetists, UK (November
2010)
Ballantyne JC (2004). Does epidural analgesia improve surgical outcome? Br. J.
Anaesth.; 92, 46. [answer: yes, but . . . ]
Desborough JP (1996). Thoracic epidural analgesia in cardiac surgery. Anaesthesia;
51, 805807. [editorial]
Gould TH, Grace K, Thorne G and Thomas M (2002). Effect of thoracic epidural
anaesthesia on colonic blood flow. Br. J. Anaesth.; 89, 446451.
Howell CJ, Dean T, Lucking L, Dziedzic K, Jones PW and Johanson RB (2002).
Randomised study of long term outcome of epidural versus non-epidural analgesia
during labour. Br. Med. J., 325, 357359. [no difference in incidence of back-pain]
Rigg JR, Jamrozik K, Myles PS et al. (2002). Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial. Lancet, 359, 12761282.
[correspondence: Lancet, 360, 568569.]
Sielenkamper AW and van Aken H (2003). Thoracic epidural anesthesia: more
than just anesthesia/analgesia? Anesthesiology; 99, 523525. [neurophysiological
effects & experiments in rats]
30
CHAPTER 2. EPIDURAL BLOCK
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Teoh DA, Santosham KL, Lydell CC, Smith DF and Beriault MT (2009). Surface
anatomy as a guide to vertebral level for thoracic epidural placement. Anesthesia
and Analgesia; 108, 17051707.
Wheatley RG, Schug SA and Watson D (2001). Safety and efficacy of postoperative
epidural analgesia. Br. J. Anaesth., 87, 4761.
2.1
Anatomy
Two excellent books on intercostal and epidural anatomy for anaesthetists are those by
Mackintosh and Bryce-Smith (1953) and Mackintosh and Lee (1973). A convenient way of
identifying the thoracic levels is to use the surface markings of the scapula; T2 = top border
of scapula (superior angle); T5 = middle of scapula; T8 = bottom of scapula (inferior
angle).
Since a typical thoracotomy incision follows the 5th rib, the aim is to locate the tip of
the catheter at about T5 (middle of scapula). Inserting the Tuohy needle at the level T7T8
(bottom of the scapula one space) generally works well.
For a thoraco-abdominal incision and also for an Ivor-Lewis operation, the tip of the
epidural catheter needs to be at about T7 (middle of the range T4T10). Consequently,
inserting the Tuohy needle twothree spaces further down from the bottom of the scapula
( one space) is generally satisfactory.
Carnie J, Boden J and Gao Smith F (2002). Prediction by computerised tomography of distance from skin to epidural space during thoracic epidural insertion.
Anaesthesia; 57, 701704. [midline, T6T9]
Harrison GR and Clowes NWB (1985). The depth of the lumbar epidural space
from the skin. Anaesthesia; 40, 685687.
Hoffmann VLH, Vercauteren P, Buczkowski PW and Vanspringel GLJ (1997). A new
combined spinal-epidural apparatus: measurement of the distance to the epidural
and subarachnoid spaces. Anaesthesia; 52, 350355.
Hogan QH (1998). Epidural anatomy: new observations. Can. J. Anaesth.; 45
(Suppl.), R40R44. [part of the refresher course outline]
Kao MC, Tsai SK, Chang WK, Liu HT, Hsieh YC, Hu JS and Mok MS (2004). Prediction of the distance from skin to epidural space for low-thoracic epidural catheter
insertion by computed tomography. Br. J. Anaesth., 92, 271273. [paramedian
approach only]
Mackintosh RR and Bryce-Smith (1953). Local analgesia: abdominal surgery.
(E & S Livingstone).
Mackintosh RR and Lee JA (1973). Lumbar puncture and spinal analgesia, 3rd ed.
(Churchill Livingstone). ISBN 0-443-00997-X
2.1.1
RWD Nickalls
The epidural database (TEPID) 1
Several studies have tried to correlate the depth of the epidural space from the skin with a
single parameter (e.g., height, weight or BMI), but none has proved particularly useful (see
references in Section 2.1). This suggests that using only a single parameter is probably the
wrong approach. Consequently my TEPID database uses three parameters (height, weight
and gender) and gives quite accurate predictions (560+ patients in the database). Although
the TEPID database was started in order to serve as a guide to the depth of the epidural
space, it was John Alfred Lee (19061989), who was sufficiently concerned about the
depth that he introduced the standard 1 cm markings on the Tuohy needle (Section 9.2) in
order to try and reduce the number of inadvertent dural taps (Lee 1960; Maltby 2002).
The midline depth of the epidural space in the region T6L3 decreases from above
downwards, and is, typically, most superficial at the the L2/3 space. The TEPID data for
an average male and female are shown in Table 2.1. The predictive value of paramedian
data was poor, and consequently this is no longer collected or displayed.
Table 2.1:
TEPID data for midline epidural depths (cm). The epidural spaces are counted
up (ve) and down (+ve) from the bottom of the scapula (BS) in the lateral
position (or sitting). The T7/8 space is generally level with the bottom of the
scapula and is therefore defined as BS(0). In the UK the average male and female
heights are approximately 5ft 9in (176 cms) and 5ft 4in (164 cms) respectively.
The results are given as: mean(SD)[range](n)
average male
average female
wt 76 75 kg
wt 67 75 kg
ht 176 75 cm
ht 165 75 cm
BS(+0) T7/8
57(059) [4567] (20)
55(066) [3770] (35)
BS(+1) T8/9
53(053) [4565] (12)
50(060) [4065] (14)
BS(+2) T9/10
50(10) [4065] (6)
49(12) [3570] (11)
BS(+3) T10/11
44(056) [3552] (8)
40(054) [3050] (11)
BS(+4) T11/12
37(11) [3045] (2)
BS(+5) T12/L1
4 (n=1)
The TEPID database, together with a Perl program, is freely available. After entering
the patients height/weight/gender the program displays both the epidural data and the
relevant tube data (single and double-lumen).
1 Tube and EPIdural Database (TEPID). This is a collection of thoracic epidural and tube data accumulated
over many years. It is freely available from http://www.nickalls.org/dick/xenon/rwdnXenon.html
RWD Nickalls
Lee JA (1960). Specially marked needle to facilitate epidural block. Anaesthesia;

15, 186. [cited from Maltby 2002]
Maltby JR (2002). Lees Synopsis of Anaesthesia & Lee epidural needle; John
Alfred Lee (19061989). In: Notable names in anaesthesia. (The Royal Society of
Medicine Press Limited, London). p. 114116. [ISBN 1853-155-128.]
2.2
2.2.1
General aspects
Awake or under GA?
There is currently some discussion regarding whether epidurals should be performed under
GA or not (following a couple of reported cases from Germany of paraplegia following
epidural under GA).
Drasner K (2004). Thoracic epidural anaesthesia: asleep at the wheal? Anesthesia
& Analgesia; 99, 578579. [editorial]
Fischer HBJ (1998). Anaesthesia; 53, 727729. [editorial]
Gruning T (1999). Regional anaesthesiabefore or after general anaesthesia?
Anaesthesia, 54, 8687. [letter]
Kao M-C, Tsai S-K, Tsou M-Y, Lee H-K, Guo W-Y and Hu JS (2004). Paraplegia
after delayed detection of inadvertent spinal cord injury during thoracic epidural
catheterization in an anesthetized elderly patient. Anesthesia & Analgesia; 99,
580583.
Wildsmith JAW & Fischer HBJ (1999). Regional anaesthesiabefore or after
general anaesthesia? Anaesthesia, 54, 8687. [letter]
2.2.2
Midline approach
The midline depth of the epidural space appears to decrease from above downwards in the
region T6L3, probably being most superficial at the the L2/3 space. Data from our own
thoracic database (TEPID; see section 2.1.1) for an average male and female are shown in
Table 2.1.
2.2.3
Paramedian approach
The paramedian depth of the epidural space at T7T8 is approximately 35 cms. Use the
depth of the lamina as a guide: the epidural space is usually 2 cm deeper than the lamina.
2.2.4
RWD Nickalls
Reducing catheter migration / fallout
At the skin
Catheter fall-out rate is significantly reduced by (a) good strapping, and (b) leaving
more catheter in the epidural space. I originally used to leave about 45 cm inside the
epidural space but this was associated with a significant fall-out rate during the first few
postoperative days. Some years ago I therefore decided to experiment by having the 15 cm
mark at the skin, and since then (a) none has fallen-out as far as I am aware, and (b) no
adverse effects have been noticed.
At the filter
A recent letter by Picton and Das (2004) described taping the catheter to the filter (including
a small redundant loop of catheter) as a good method for reducing catheter disconnection
at the filter. The problem of how to proceed if the epidural catheter itself becomes
disconnected from the filter is addressed in Section 2.4.1.
Picton P and Das S (2004). Decreasing epidural failure. Anaesthesia; 59, 729.
2.2.5
Radiographic placement
The following two reports describe a paramedian radiographic technique for locating the
tip of the Tuohy needle, and for checking loss of resistance using radio-opaque contrast.
Johnson T and Haslett R (2000). X-ray image intensifier assisted placement of a
thoracic epidural. Anaesthesia, 55, 822823. [letter]
Johnson TW, Morgan R and Smalley P (2003). Radiographic guided epidural
placement. Anaesthesia; 58, 485486. [letter]
2.2.6
Fibreoptic guided placement
Chien-Kun Ting et al. (2010). A new technique to assist epidural needle placement:
fiberoptic-guided insertion using two wavelengths. Anesthesiology; 112, 11281135.
[successful pilot in pigs]
2.3
Drugs
A fairly typical intraoperative epidural dose for a thoracotomy in an adult would be

approximately 100200 g fentanyl plus 1520 mls 025 % bupivicaine during the course
of the operation. One approach is to mix 200 g fentanyl plus 6 mls 025% bupivicaine
into the first 10 ml syringe, and give this initial dose over about 1530 mins depending on
the blood pressure. In elderly patients consider reducing the dose of fentanyl.
RWD Nickalls
The usual postoperative regimen at the City Hospital is to use a standardised pre-filled
bag (500 mls) containing a mixture of fentanyl 2 mg + bupivicaine 0125%, starting at
about 5 mls/hr (range 010 mls/hr). These bags are kept in the recovery room in the DDA
cupboard. Typically this standard regimen is started at the begining of the operation and
adjusted accordingly.
An alternative system, suitable for either ITU or HDU, is to use a syringe-driverin
this case a typical regimen for an adult would be to mix 200 g fentanyl plus 56 mls of
025% bupivicaine (total 60 mls), starting at about 5 mls/hr (range 010 mls/hr).
The ideal mixture of fentanyl and bupivicaine is somewhat controversial, and practice
varies widely. The optimum concentration for epidural fentanyl was stated to be 10 g/ml
fentanyl by Welchew EA (1983), who also noted that the addition of 0125% bupivicaine
can improve the analgesia. A greater strength of bupivicaine is said not to significantly
improve analgesia, while a lower concentration of bupivicaine appears to have no advantage
over using fentanyl alone (Badner et al. 1994).
A recent study by Tan et al. (2004) compared fentanyl concentrations of 2, 5, and
10 g/ml in bupivicaine 01% (plain) for thoracic epidurals, found that a concentration of
fentanyl 5 g/ml gave the optimum balance between excessive pain and excessive sedation.
Clonidine was used in thoracic epidurals for laparotomy by Curatolo et al. (2000); they
suggested that an optimum combination was clonidine (5 g/hr) plus bupivicaine (9 mg/hr)
plus fentanyl (21 g/hr). The addition of adrenaline to bupivicaine and fentanyl reduced
plasma fentanyl concentrations.
Postoperative pain-relief algorithm: There is a comprehensive algorithm printed on a
poster in the thoracic high-dependency ward. Copies can be obtained from the thoracic
surgeons.
Badner NH, Bhandari R, Komar WE (1994). Bupivicaine 0125% improves continuous postoperative epidural fentanyl analgesia after abdominal or thoracic surgery.
Can. J. Anaesth.; 41, 387392.
Casati A, Alessandrini P, Nuzzi M, Litti E et al. (2006). A prospective, randomised,
blinded comparison between continuous thoracic paravertebral and epidural infusion
of 02% ropivacaine after lung resection surgery. European Journal of Anaesthesiology; 23, 9991004. [paravertebral is just as effective as epidural for analgesia, and
has fewer haemodynamic complications]
Curatolo M, Schnider TW, Petersen-Felix S, Weiss S, Signer C,
Scaramozzino P and Zbinden AM (2000). A direct search procedure to optimize
combinations of epidural bupivicaine, fentanyl and clonidine for postoperative analgesia. Anesthesiology; 92, 325337. [thoracic epidurals]
Tan CNH, Guha A, Scawn NDA, Pennefather SH and Russell GN (2004). Optimal
concentration of epidural fentanyl in bupivicaine 01% after thoracotomy. Br. J.
Anaesth.; 92, 670674. [fentanyl 5 g/ml was optimum]
RWD Nickalls
Welchew EA (1983). The optimum concentration for epidural fentanyl. A randomised double-blind comparison with and without 1:200,000 adrenaline. Anaesthesia; 38, 10371041.
2.4
2.4.1
Complications
Epidural catheter disconnection
The problem of how to proceed if the epidural catheter itself becomes disconnected from
the filter is addressed by Grewal, Hocking and Wildsmith (2006), as follows.
A common concern is what to do if the epidural infusion system becomes disconnected
somewhere between the bacterial filter and the patient. An interesting laboratory study
using deliberately contaminated catheters suggested that reconnection is safe within
8 hrs provided that the fluid inside the catheter is static (or the meniscus has moved
< 125 cm) and does not move when lifted above the level of the patient. The outside
must be soaked in 10 % povidone iodine solution, or similar, for 3 mins and allowed
to dry thoroughly before up to 20 cm is cut from the end with a sterile instrument. If
these conditions are not met, the catheter must be removed.
Grewal, Hocking and Wildsmith (2006)
Grewal S, Hocking G and Wildsmith JAW (2006). Epidural abscesses. [review

article] Br. J. Anaesth.; 96, 292302.
2.4.2
Abscess
Literature reports of epidural abscess suggest that this complication is not uncommon
(about 01%). Patients should be examined frequently for fever, local tenderness and
neurological deficit. The excellent review by Grewal, Hocking and Wildsmith (2006) and
the AAGBI (2002) guidelines should be essential reading for all.
AAGBI (2002). Infection control in anaesthesia. (Association of Anaesthetists of
Great Britain and Ireland).
Gosavi C, Bland D, Poddar R and Horst C (2004). Epidural abscess complicating
insertion of epidural catheters. Br. J. Anaesth.; 92, 294.
Grewal S, Hocking G and Wildsmith JAW (2006). Epidural abscesses. [review
article] Br. J. Anaesth.; 96, 292302. [see reply by Jeffreys Horton and Evans 2006]
Jeffreys A, Horton R and Evans B (2006) Epidural abscesses. Br. J. Anaesth.; 97,
115116.
Ng KP (1996). Complete heart block during laparotomy under combined thoracic
epidural and general anaesthesia. Anaesthesia and Intensive Care; 24, 257260.
RWD Nickalls
Roberts CJ (2004). Epidural abscess complicating insertion of epidural catheters.

Br. J. Anaesth.; 92, 294295.
2.4.3
Haematoma & DVT prophylaxis
Low molecular weight heparin (LMWH, enoxaparin, tinzaparin) is currently used in

thoracic surgery. It is given once daily in the evening in order to facilitate day-time
epidurals. Peak plasma concentrations occur at 4 hours and activity persists up to 24 hours.
The PT and APTT are not generally affected by therapeutic doses, so monitoring requires
measurement of anti-factor Xa levels (Roberts et al. 2004; Hirsh et al. 2001).
Epidural catheters should not be removed earlier than 8 hours following anticoagulation.
See Mcleod and Cumming (2004) for an overview. European guidelines recommend
(a) once daily dosing with LMWH, (b) 12 hr interval between injection and either epidural
catheter insertion or removal (Wheatley et al. 2001).
McLeod GA and Cumming C (2004). Thoracic epidural anaesthesia and analgesia.
Continuing Education in Anaesthesia, Critical Care and Pain; 4 (No. 1), 1619.
[BJA]
Hirsh J, Warkentin TE, Shaughnessy SG, Anand SS, Halperin Jl, Raschke R,
Granger C, Ohman EM and Dalen JE (2001). Heparin and low-molecular-weight
heparin: mechanisms of action, pharmacokinetics, dosing, monitoring, efficacy and
safety. Chest; 119 (Suppl); 64S94S.
Horlocken TT and Heit JA (1997). Low molecular weight heparin: biochemistry,
pharmacology, perioperative prophylaxis regimens and guidelines for regional anaesthetic management. Anaesthesia and Analgesia; 85, 874885.
Kearon C and Hirsh J (1997). Management of anticoagulation before and after
elective surgery. NEJM ; 336, 15061511.
Roberts HR, Monroe DM and Escobar MA (2004). Current concepts of hemostasis:
implications for therapy. Anesthesiology; 100, 722730.
2.5
Paravertebral block
Naja, Ziade et al. (2004) suggest that the paravertebral space is divided into a potential
anterior (extrapleural) and posterior (sub-endothoracic) compartments by a so-called
endothoracic fascia, and that such spaces influence drug spreadsee reply letters by
Fitzgerald and Harmon (2004) and by Naja and Lonnqvist (2004) for more references and
discussion.
RWD Nickalls
As regards efficacy, it seems that a paravertebral block compares well with an epidural
block (see Casati et al. 2006; Mathews and Govenden 1989).
Casati A, Alessandrini P, Nuzzi M, Litti E et al. (2006). A prospective, randomised,
blinded comparison between continuous thoracic paravertebral and epidural infusion
of 02% ropivacaine after lung resection surgery. European Journal of Anaesthesiology; 23, 9991004. [paravertebral is just as effective as epidural for analgesia, and
has fewer haemodynamic complications]
Conacher ID and Kokri M (1987). Postoperative paravertebral blocks for thoracic
surgery. Br. J. Anaesth.; 59, 155161.
Eason MJ and Wyatt R (1979). Paravertebral thoracic blocka reappraisal. Anaesthesia; 34, 638642.
Fitzgerald K, Harmon D et al. (2004). Thoracic paravertebral blockage. Anaesthesia;
59, 10281029. [letter: reply to Naja et al. 2004]
Govenden V and Mathews PJ (1988). Percutaneous placement of paravertebral
catheters during thoracotomy. Anaesthesia; 43, 256.
Loader J and Ford P (2009). Thoracic paravertebral block. Update in Anaesthesia
(June 2009), p. 47. http://update.anaesthesiologists.org/2009/ [good
practical overview]
Karmakar MK (2001). Thoracic paravertebral block. Anesthesiology; 95, 771780.
[review]
Mathews PJ and Govenden V (1989). Comparison of continuous paravertebral and
extradural infusions of bupivicaine for pain relief after thoracotomy. Br. J. Anaesth.;
62, 204205. [paravertebrals were associated with less hypotension and less urine
retention; analgesia was the same in both groups]
Naja MZ, Ziade MF, Rajab El et al. (2004). Varying anatomical injection points
within the thoracic paravertebral space: effect on spread of solution and nerve
blockade. Anaesthesia; 59, 459463. [see interesting reply letter by Lang and Saito
(2005): Anaesthesia; 60, 930931]
Naja MZ et al. (2005). Distance between the skin and the thoracic paravertebral
space. Anaesthesia; 60, 680684. [median depth was 55 mm; the depth was least in
the T4T8 zone]
Naja MZ, Lonnqvist PA et al. (2004). Thoracic paravertebral blockage. Anaesthesia;
59, 10281029. [letter: reply to Fitzgerald et al. 2004]
RWD Nickalls
Richardson J, Cheema SPS, Hawkins J and Sabanathan S (1996). Thoracic paravertebral space location. Anaesthesia; 51, 137139. [used pressure measurement
during needle advancement; sudden pressure fall as needle traverses the superior
costo-transverse ligament]
3
Tracheostomy & related airway
problems
A tracheostomy is like a snakeit can rear up and bite you when you least
expect it.
is a path littered with unforeseen hazard. Some basic guidelines can therefore
be useful since most of us anaesthetise relatively few patients with, or for, a
tracheostomy. The key skills to learn are (a) changing a tracheostomy (Section 3.6)
and (b) bronchoscopy (Chapter 5).
HIS
Intensive Care Society UK (2008). Standards for the care of adult patients with a
temporary tracheostomy. pp. 53.
Lesmo A and Ripamonti D (2010). Anatomical particularities and difficulty in tracheostomy: three case reports. Minerva Anestesiologica; 76, 649652. [experience
using the Fantoni Trans-Laryngeal Technique (TLT)]
Russell C and Matta B (2004). Tracheostomy: a multiprofessional handbook.
(Cambridge University Press), 392 pp. ISBN 1841101524.
Ernst A and Mehta C [Eds.] (2003). Artificial airways (2003); Clinics in Chest
Medicine; 24 (September).
[chapters: Endotracheal tubes / Tracheotomy: application and timing / Percutaneous dilational tracheotomy techniques / Percutaneous tracheostomyspecial
considerations / Techniques of surgical tracheostomy / Comparison of surgical and
percutaneous dilational tracheostomy / Minitracheostomy / The Montgomery T-tube
tracheal stent / Acute complications of artificial airways / Long-term complications
of artificial airways / Long-term care of the tracheostomy patient / Transtracheal
oxygen catheters / Management of hypoxemia during flexible bronchoscopy]
40
CHAPTER 3. TRACHEOSTOMY & RELATED AIRWAY PROBLEMS
3.1
RWD Nickalls
Introduction
As a general rule, whenever there is a problem with a tracheostomy (in theatre or on

a ward) have a very low threshold for inspecting the position of the tracheostomy with
a fibrescopeeither with the intubating fibrescope or with the usual large fibrescope.
Many significant complications arising from a blind manoeuvre would have been avoided
completely if only a fibrescope had been used initially.
Simple visualisation of the trachea in order to check the position of the tracheostomy
does not require local anaesthesia, since this generally can be done by positioning the
fibrescope just at the tracheal-end of the tracheostomy, i.e., without needing to touch the
tracheal mucosa. However, sometimes it is advantageous to give some local anaesthetic to
allow more freedom with the fibrescope. The following simple technique generally works
very well.
3.1.1
Local anaesthetic for fibreoptic bronchoscopy of the trachea
A reasonably effective adult dose is 80 mg plain lignocaine (2 mls of 4% lignocaine) which

can either be blown down the bronchoscope, or down the dilator 1 of a Portex Seldinger
Mini-Trac (since this has a very useful Luer connector) with the tip positioned well down
the tracheostomy.
Take a 20 ml syringe (with a straight Luer connector so it can be pushed into the
fibrescope inject port) and pull the plunger out to the 20 ml position; now inject 2 mls of 4%
lignocaine into the empty syringe via the nozzle and then hold it vertically (nozzle down);
now connect the 20 ml syringe vertically into the inject-port of the fibrescope (tip now
positioned at the tracheal-end of the tracheostomy) and inject quickly (ideally at the end of
expiration) all 20 mls (2 mls lignocaine + 18 mls air). This will deliver the lignocaine as a
fine spray throughout the trachea, and usually gives very effective local analgesia above
the carina.
3.2
Tracheostomy tubes
There is a huge range of tracheostomy tubescuffed and uncuffed, fenestrated & nonfenestrated; standard forms with and without inner-tubes (e.g., Portex, Tracoe); specialised
forms (e.g., Montgomery tube (Section 3.9), Mini-Trac, double-lumen), as well as various
attachments (speaking valves, humidifiers). Most of these are well described by Russell
and Matta (2004).
When purchasing standard tracheostomy tubes it is useful to consider only those for
which the number defining the tube size is the same as the internal diameter of the
1 In this case use a 20 ml syringe having a Luer-lock connector (available in ITU), as you generally have to
push the syringe plunger in with significant force (since the Portex Mini-Trac dilator has a very narrow channel).
Unless you lock the syringe nozzle onto the Luer connector of the dilator it will probably disconnect as you inject,
owing to the relatively high resistance to flow.
RWD Nickalls
inner-tube, as is standard with endo-tracheal tubes. The tracheostomy tubes currently used
by the City Hospital are Portex and Tracoe, both of which follow this rule.
3.2.1
Portex2 (Smiths Medical)
(Smiths Medical, Hythe, Kent, UK; tel: +44-(0)-1303-260-551)

The Portex brand (Smiths Medical) includes a percutaneous dilation kit (UniPerc), as
well as a range of tracheostomy tubes:
1. Non-fenestrated versions which are intended for short-term use only (usually changed
weekly). The internal and external diameter specifications for the standard tracheostomy tube are given in Table 3.1.
2. Adjustable flange versions (e.g., the UniPerc) for use in obese patients.
3. A left double-lumen tracheostomy tube.
3.2.2
Tracoe
(Kapitex Healthcare Ltd., Kapitex House, 1 Sandbeck Way, Wetherby, West Yorkshire
LS22-7GH, UK; tel: 01937580211. http://www.kapitex.com)
The Tracoe tracheostomy tubes used at the City Hospital (TRACOE twist MODEL 302)
are fenestrated (multiple small holes) polyurethane radio-opaque low-pressure cuffed tubes,
intended for medium-term use (up to 31 days). Note that neither the duration nor latex
status seems to be specified in their documentation. The twist-lock connection is fully
locked when the two arrow heads are opposite one another. Each Tracoe box includes
Outer tube with swivelling neck-plate
A removable non-fenestrated inner-tube (white 15 mm connector; for suctioning and
ventilation).
A removable fenestrated inner-tube (blue 15 mm connector; for spontaneous respiration weaning)
Obturator (for insertion) and neck strap
While Tracoe do make decannulation plugs and speaking valves, these are not included in
the package (i.e., they are extras). These speaking-valves and other extras are stocked
by ITU. The Passey-Muir clinical information pack relating to tracheostomy tubes and
speaking-valves is available from Kapitex Healthcare.
2 In 1940 Sydney Leader, a dental surgeon at the Dental Hospital, London, set up a company based in his flat
in Great Portland Street. His company, which was called Portland Plastics Ltd., was later renamed Portex Ltd.
in 1967 (see: Russell CA (1996). Developments in thermoplastic tracheal tubes. In: Essays on the History of
Anaesthesia. (Royal Society of Medicine Press Ltd., London). p. 9497).
3.2.3
RWD Nickalls
Rusch
(Rusch UK Ltd.,High Wycombe, Bucks, HP12 3NB. UK; tel: 01494532761).

Make a left and right 39 Fr double-lumen tracheostomy tube. Three intratracheal
lengths are available (75, 85, 95 mm).
3.2.4
Moore tube
(Kapitex Healthcare Ltd., Kapitex House, 1 Sandbeck Way, Wetherby, West Yorkshire
LS22-7GH, UK; tel: 01937580211. http://www.kapitex.com)
The Moore tracheostomy tube (Boston Medical Products, Westborough, MA, USA)
is a soft and flexible long (115 mm) silicone non-cuffed tracheostomy (with a similar
inner tube), which is typically used to maintain tracheostomy access (in a spontaneously
breathing patient) following removal of a long adjustable-flange tracheostomy. It can be
easily cut to the appropriate length. Two sizes are available: 6 (ID 6.6 mm; OD 11 mm)
and 8 (ID 7.5 mm; OD 12 mm).
3.3
Tracheostomywhen?
Commonly at 710 days or so, depending on likely duration of ITU care. A failed trial of
extubation is a common indication for tracheostomy. Patients with concomitant respiratory
disease tend to have a tracheostomy performed at an early stage. While a tracheostomy
greatly facilitates nursing and respiratory care and shortens ITU stay, it does not generally
reduce hospital stay as it tends to lengthen HDU stay, since most hospital wards cannot
accommodate tracheostomy patients.
Griffiths J, Barber VS, Morgan I and Young JD (2005). Systematic review and
meta-analysis of studies of the timing of tracheostomy in adult patients undergoing
artificial ventilation. Br. Med. J. (2005); 330, 1243 [see also letters: 331, 404405]
3.4
Percutaneous tracheostomy
Percutaneous tracheostomy owes its popularity to the introduction of the Blue-Rhino

(William Cook Europe) modification of the dilational technique by the American surgeon
Pasquale Ciaglia in 1985 (Eggert and Jerwood 2003). Careful patient selection is important,
and there is a significant learning curve.
While a percutaneous tracheostomy tends to have lower rate of long-term complications
(e.g., tracheal stenosis) than a surgical tracheostomy, the early percutaneous complication
rate (e.g., bleeding, tracheal damage, pneumothorax) tends to be higher. Percutaneous
complications, when they do occur, tend to be serious. The advantages of prior ultrasound
scanning for aberrant vessels is suggested by several authorssee Gwilyn and Cooney
RWD Nickalls
(2004), Shlugman et al. (2003), Toni et al. (2003). Damage to the posterior tracheal wall is
an ever present dangersee Madden et al. (2004) on one approach to this problem using a
covered stent.
For a good overview see the handbook by Paw and Bodenham (2004); for details of
two meta-analysis studies see the article by Eggert and Jerwood (2003). For experience
with the Fantoni Trans-Laryngeal Technique see Lesmo and Ripamonti (2010).
Ciaglia P, Firsching R and Syniec C (1985). Elective percutaneous dilational tracheostomy. Chest; 87, 715719. [from Eggert and Jerwood 2003]
Dulguerov P, Gysin C, Perneger TV and Chevrolet J-C (1999). Percutaneous or
surgical tracheostomy: a meta-analysis. Critical Care Medicine; 27, 16171625.
Eggert S and Jerwood C (2003). Percutaneous tracheostomy. Br. J. Anaesth.
CEPD Reviews; 8, 139142. [good review of two recent meta-analysis studies]
Fikkers BG, van Veen JA, Kooloos JG et al. (2004). [surgical] Emphysema and
pneumothorax after percutaneous tracheostomy: case report and anatomic study.
Chest; 125, 18051814. [highlights danger of the fenestration in the outer tube
damaging the posterior wall mucosa]
Gwilyn S and Cooney A (2004). Acute fatal haemorrhage during percutaneous
dilational tracheostomy. Br. J. Anaesth.; 92, 298. [letter]
Lesmo A and Ripamonti D (2010). Anatomical particularities and difficulty in tracheostomy: three case reports. Minerva Anestesiologica; 76, 649652. [experience
using the Fantoni Trans-Laryngeal Technique (TLT)]
Madden BP, Sheth A, Ho TBL and McAnulty G (2004). Novel approach to management of a posterior tracheal tear complicating percutaneous tracheostomy. Br. J.
Anaesth.; 92, 437439. [see also reply letter by Fritz, Buerschaper and Wolf (2004);
93, 598]
Paw HGW and Bodenham AR (2004). Percutaneous tracheostomy: a practical
handbook. (Cambridge University Press).
Phukan DK and Andrzejowski J (2004). Percutaneous tracheostomy: a guidewire
complication. Br. J. Anaesth.; 92, 891893. [fracturing of the J-wire causing damage
to the mucosa]
Ryan DW and Kilner AJ (2003). Another death after percutaneous dilational tracheostomy. Br. J. Anaesth.; 91, 925926.
Shlugman D, Satya-Krishna R and Loh L (2003). Acute fatal haemorrhage during
percutaneous dilational tracheostomy. Br. J. Anaesth.; 90, 517520.
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Toni R, Della Casa C, Mosca S, Malaguti A, Castorina S and Roti E (2003). Anthropological variations in the anatomy of the human thyroid arteries. Thyroid ; 13,
183192.
Walz MK et al. (1998). Percutaneous dilational tracheostomyearly results and
long-term outcome in 326 critically ill patients. Intensive Care Medicine; 24,
685690. [2 deaths in 326 patients. They also review the literature, revealing a
further 7 deaths in 2034 patients (total death rate 1/263 ! Causes of death:- bleeding;
obstruction & hypoxia]
William Cook Europe. Ciaglia Blue RhinoTM : instructions for use. (Denmark), 2000;
91 pp. [from Eggert and Jerwood 2003]
3.5
Surgical tracheostomy
Assuming the patient already has a single-lumen endotracheal tube in place, then the main
considerations are as follows (Rogers et al. 2001).
Make sure the cuff is not damaged by the surgeon.
To this end it is recommended that the endo-tracheal tube be first pushed down close
to the carina, using a fibreoptic bronchoscope to position the tube safely. Consider
changing the endo-tracheal tube if it is too short to reach the carina.
Be alert to the potential fire risk (see recommendations below).
Although flammable anaesthetic agents are no longer used in the UK, fires in the
operating theatre continue to be an occasional hazard, particularly with operations
on the airway. Thankfully, most such fires are evanescent and cause no harm, but
unfortunately deaths do still occur. For example, in two separate fatalities reported
by Stouffer (see Rogers et al. 2001), the fires spread uncontrollably with alarming
speed, and in one case the operating theatre had to be evacuated. Interestingly,
tracheostomy fires tend not to be as catastrophic as other airway fires, possibly
because the tracheostomy acts as a vent.
3.5.1
Recommendations
The following recommendations for anaesthesia for surgical tracheostomy are from the
article by Rogers et al. (2001). The emphasis is on (a) avoiding a fire, and (b) avoiding
surgical damage to the ETT cuff. Note the interesting idea of instilling carbon dioxide
directly into the tracheostomy wound described by Mani et al. (2007).
1. All theatre staff should be aware that an airway fire may occur during tracheostomy.
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Have a fire extinguisher immediately available. It should be mounted inside the operating theatre near the entrance. In practice a carbon-dioxide
fire-extinguisher will be the usual choice. Halon fire extinguishers are significantly better for operating theatre fires, but their use is declining owing to
environmental concerns.
Have a bowl of saline and wet drapes available on the surgical instrument
trolley at all times.
Have a self-filling ventilation bag (e.g., Ambu bag) available for ventilating
the patient with room air.
Do not use nitrous oxide or any of the other flammable/explosive anaesthetic
agents.
2. Use a single-lumen endotracheal tube which is long enough to allow the tip to be
advanced to the carina (the carina is approximately 2425 cms from the teeth in
an average male). If a single-lumen endotracheal tube is in situ and is too short to
reach the carina, then change it for one with a suitable length. If a double-lumen
endotracheal tube (or a nasotracheal tube) is already in situ then change it for a
single-lumen tube before tracheostomy.
3. Use saline to inflate the endotracheal cuff. Make sure there is no leak of anaesthetic
gases past the endotracheal cuff.
4. Use the lowest safe FIO2 in either nitrogen (air/oxygen mixture) or helium.
5. If the tracheostomy wound is significantly deep (e.g., in an obese patient), use a
suction device to clear any build up of diathermy products from within the wound.
6. Before the trachea is opened, advance the endotracheal tube down the trachea so the
tip is close to the carina, in order to minimise the likelihood of damage to the cuff
when the trachea is incised. Use a fibreoptic bronchoscope to position the tip of the
endotracheal tube close to the carina, and mark the tube at the teeth when correctly
positionedthis will serve as a useful position guide later if the surgeon fails to
place the tracheostomy and you need to push the tube down quickly to get the cuff
below the tracheal hole.
7. Incise the trachea using either a scalpel, scissors, or a harmonic knife. Do not use
diathermy to cut through the trachea.
8. Once the trachea has been opened and the surgeon is ready to insert the tracheostomy
tube, stop ventilating, deflate the endotracheal tube cuff and withdraw the endotracheal tube carefully under direct vision until the tip is just above the tracheal
hole (do not withdraw the tube any further at this stage). Be prepared to push
the endotracheal tube back down the trachea to secure the airway if there are any
difficulties, either while inserting the tracheostomy, or during the initial ventilation
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through the tracheostomy. Remember to keep the oral ETT in situ so you can put
the bronchoscope down it (after suctioning) to inspect the tracheostomy.
9. Once the tracheostomy tube is secure in the trachea, inflate the tracheostomy cuff and
suck out the tube using a suction catheter, checking that the suction tube passes easily
through the whole length of the tube. If this is satisfactory then commence ventilation
through the tracheostomy. However, always check that the tracheostomy tube is
correctly located/positioned within the trachea using a fibreoptic bronchoscope
either now (if in doubt), or at the end of the procedureremember to keep the oral
ETT in situ so you can put the bronchoscope down it. This is primarily to check that
the new tube is not partially obstructed or in a false passage (note that being able to
pass a suction catheter does not exclude these possibilities), and to check that the
end of the tracheostomy tube is not too close to the carina (this can occasionally be
a problem with a long adjustable-flange tracheostomy tube).
10. If any difficulties arise with the tracheostomy tube, remove the tracheostomy tube
and advance the endotracheal tube down the trachea so that the cuff lies below the
tracheal hole. Have a long endotracheal bougie available (e.g., a gum-elastic bougie),
to facilitate advancing the endotracheal tube in case of difficulties. Sometimes, if the
tube is soft, it may bend in the pharynx and fail to go down into the trachea when
you push it, in which case consider placing a bougie down the tube to stiffen it; a
long gum-elastic bougie can also be useful in this situation.
11. If the endotracheal tube cuff has been damaged and the leak is significant, then
adequate ventilation can usually be maintained by (a) using large tidal volumes,
(b) pushing swabs firmly onto the tracheostomy hole to occlude the leak. Consider
using a wide plastic occlusive dressing (e.g., OpSite or Tegaderm) under the swabs to
reduce the leak further. Control the leak intermittantly as necessary between surgical
attempts to insert the tracheostomy tube. Consider re-intubating if necessary.3

Hazard note: If a significant leak occurs during a tracheostomy when using a

pressure-cycled ventilator (e.g., an ITU ventilator in BIPAB mode), the ventilator
may fail to cycle and not ventilate the patient. Have a low threshold for switching to
manual bag-ventilation whenever there is a leak in this particular setting.
12. In the event of fire, immediately disconnect the patient from the anaesthetic machine,
switch off the anaesthetic gas flow, disconnect the gas pipelines, and ventilate with
air using a self-inflating bag. Use an airway filter if there is smoke in the theatre.
Consider flushing saline down the endotracheal tube to extinguish any intraluminal
fire. Consider removing or changing the tube to minimise the inhalation of toxic
products of combustion and spread of fire into the tracheobronchial tree. However,
3 The neck will likely be well extended and without a pillow at this stage, and so you may need to insert a
pillow to get good visualisation of the larynx. Also, use an uncut tube in order to make sure you will be able to
get the cuff below the tracheostomy hole, and check the position relative to the carina with a fibrescope.
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changing the tube may be more risky than leaving it in if the patient was previously
difficult to intubate, or the airway has become oedematous.
13. Finally: It is important to check the position of a fenestrated tracheostomy with
the fibreoptic-bronchoscope by viewing it from abovefrom the larynxin order
to check whether the whole of the fenestration, or fenestration holes, of the outer
tube are within the trachea. In practice this is most easily done via the original
oral ETTwhich should still be in situ for just this purpose. Note that the Tracoe
tracheostomies have a total of nine small fenestrations symmetrically arranged in a
circle on the larynx side of the tube; the three holes forming the vertical diameter
should all be visible through the fibreoptic bronchoscope.
In obese patients the distance between the skin and the anterior tracheal wall is
often too big for the tracheostomy, resulting in some of the fenestration(s) being
outside the trachea. The potential consequence of this, especially for ventilated
patients, is that air may track back up the tracheostomy (between the inner and
outer tubes) and out through the fenestration and into the tissue spaces of the neck,
resulting in surgical emphysema. If the neck is too big, then use an adjustable flange
tracheostomy instead.
References
ASA Taskforce (2008). Practice advisory for the prevention and management of
operating room fires. [a report by the American Society of Anesthesiologists Task
Force on operating room fires] Anesthesiology; 108, 786801.
ECRI (2003). A clinicians guide to surgical fires: how they occur, how to prevent
them, and how to put them out [guidance article]. Health Devices; 32(1), 524. From:
Sentinel Event Alert, Issue 29: June 24, 2003. (Joint Commission on Accreditation
of Healthcare Organisations) http://www.jointcommission.org/sentinel_
event_alert_issue_29_preventing_surgical_fires/
Eipe N and Choudhrie A (2005). Airway fires: gas-bugs providing the fuel? Anesth.
& Analg.; 101, 15631564. [letter]
Hamza M and Loeb RG (2000). Fire in the operating room. Journal of Clinical
Monitoring and Computing; 16, 317320.
Mani N, Malik V, Brewis C and Gray R (2007). Prevention of airway fire during a
tracheostomy a further precaution. Annals of the Royal College of Surgeons of
England ; 89, 818. [describe using an NG-tube via the larynx to pass carbon dioxide
into the trachea close to the tracheostomy site]
Molodecka J and Long TMW (1992). Difficult tracheostomy and the adjustable
flange tracheostomy tube. Todays Anaesthetist; 7, 100.
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Rogers ML, Nickalls RWD, Brackenbury ET, Salama FD, Beattie MG and Perks
AGB. (2001). Airway fire during tracheostomy: a review for surgeons and anaesthetists. Annals of the Royal College of Surgeons of England ; 83, 376380.
Wolf GL (2000). Danger from OR fires still a serious problem. Journal of Clinical
Monitoring and Computing; 16, 237238 [APSF Newsletter]
Yardley IE and Donaldson LJ (2010). Surgical fires, a clear and present danger. The
Surgeon; 8, 8792. [review]
A useful list of references relating to Fire prevention and safety during surgical procedures
can be found at: http://www.valleylabeducation.org/fire/pages/fire-read.
html
3.6
Changing a tracheostomy tube
See also Section 3.11

Typically a tracheostomy is changed because it is either time-expired,4 damaged
(hole in the cuff), or because a different size or format is now required. Occasionally a
tracheostomy has to be changed as an emergency procedure owing to malposition, in which
case particular care has to be taken as regards bronchoscopic visualisation and railroading
over a suitable guide (bougie, oxygenating catheter, bronchoscope etc.).
The main practical considerations are (a) whether the tracheostomy was percutaneous or
surgical, (b) the external diameter of the existing tracheostomy tube, (c) whether the patient
is ventilated or breathing spontaneously, (d) whether the patient is awake or anaesthetised,
(e) how long since tracheostomy formation or last tube change, (f) whether malposition is
suspected.
Percutaneous: Since a percutaneous tracheostomy tube is often tightly held by the
skin it may be quite difficult to remove and replace. In view of this it is important to use
only tracheostomies having an inner-tube, in order to avoid the necessity of having to
change it soon after when the patient goes to the ward, or to facilitate weaning.
It is important to be aware of the external diameter of the existing tracheostomy and
aim to replace it with one having the same or slightly smaller external diameter if the skin
is tight around it.
Surgical: Since a surgically placed tracheostomy tube is usually only loosely held by
the skin, changing the tracheostomy tube rarely presents a problem with regard to the size
of the new tube, and it can usually be replaced (even with a slightly larger tube) without
difficulty.
4 A tracheostomy without an inner-tube (e.g., Portex) should be changed weekly; a tracheostomy with an
inner-tube (e.g., Tracoe) should be changed monthly.
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Table 3.1:
Portex and Tracoe tracheostomy tubes
PORTEX
Size
3.6.1
ID mm
OD mm
TRACOEtwist (fenestrated)
ID mm
OD mm
(inner-tube)
(outer-tube)
40
40
72
50
50
86
60
83
60
92
70
105
70
104
80
119
80
114
8 Long
80
110
90
133
90
125
10
100
140
100
138
10 Long
100
138
Preparation
Always check the chest x-ray, listen to the chest, check pulse & blood pressure,
oxygen saturation, inspired oxygen, and make sure there is venous access (flush an
existing cannula to make sure it is working). Check the notes to see (a) if the patient
was difficult to intubate through the mouth, (b) if previous tracheostomy changes
were problematic, and (c) if there is any drug allergy. Have drugs and intubation
equipment available.
Check whether the tracheostomy was percutaneous or surgical.
Check the size and make of the existing tracheostomy tube. Check its external
diameterif this is smaller than that of the one you propose to replace it with then
you may have difficulties, particularly if the tracheostomy was made percutaneously
(usually this is not a problem if the tracheostomy was a surgical one). The external
diameters of tracheostomy tubes are given in Table 3.1.
Check if the tracheostomy has a cuff (look for the pilot balloon). If there is no cuff
then the patient may be breathing via the tracheostomy and via the nose/mouth (this
will have implications for pre-oxygenationsee next Section).
Check the status of the inner-tube. If a fenestrated inner-tube is in situ (Tracoe blue
connector) first change it for the non-fenestrated version (Tracoe white connector),
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since this (a) allows you to ventilate the patient if you need to, and (b) allows easy
passage for a suction catheter/bougie since there is no hole for it to get stuck against.
3.6.2
Changing the tube
If the patient is awake, explain exactly what you are going to do.
Preoxygenate the patient. If there is no cuff (or it is damaged) then remember to
preoxygenate via both the mouth (with a mask) and the tube. If there is a cuff then
preoxygenate via a catheter mount at the tracheostomy, and check that you can
gently ventilate the patient by hand, inflating the cuff as necessary. If there is no
cuff, then preoxygenate both via a catheter mount at the tracheostomy and with a
face mask, as the patient may be breathing via both routes.
Suck out the tracheostomy checking that the suction catheter passes easily into the
trachea. If there is a lot of secretions, then continue suctioning until it is as dry as
possible before changing the tube.
Have a large (orange tipped) suction catheter available for railroading the new tube.
Extend the patients neck using a supporting pillow under the shoulders for maximum
access.
Prepare the new tracheostomy tube by first checking the cuff is intact, and then
deflate the cuff fully and lubricate the cuff with some KY-jelly. Make sure that
you have the non-fenestrated inner-tube inside, and that the suction catheter (for
railroading) passes easily through the middle (use KY-jelly as necessary). Use the
largest diameter suction catheter you can (orange is usually best) which will pass
through the non-fenestrated inner-tube, and remember to cut the connector off the
suction catheter. Have a smaller size tracheostomy available just in case.
Remove the neck ties holding the tracheostomy in place.
Have an assistant hold the patients head as a precaution. Have an assistant ready
with a suction device for sucking out the stoma if necessary once the tracheostomy
is out, since removing the tracheostomy often releases a lot of secretions into the
stoma.
Insert the railroading catheter through the existing tracheostomy and pass it a good
way into the trachea.
Remove the existing tracheostomy (remember to let the cuff down), suction the
stoma as necessary, and railroad the new one into position. Be prepared to use a
smaller tracheostomy if necessary.
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Once the new tracheostomy is in place inflate the cuff and check (a) you can pass a
suction catheter easily into the trachea, (b) that you can ventilate the patient easily
and that there is no cuff leak, (c) if the patient is breathing spontaneously check that
the bag moves easily, and (d) listen carefully to the chest.
If there are difficulties consider (a) removing the new tracheostomy and trying again
after suctioning, (b) railroading the tube over a bronchoscope, (c) intubating through
the mouth if necessary.
3.6.3
Check the position bronchoscopically
Always check at the end of the procedure that the new tracheostomy tube is correctly
located/positioned within the trachea using a bronchoscopecheck you can see
the carina. This is the only reliable way of confirming that the new tube is not
partially obstructed or in a false passage (note that being able to pass a suction
catheter does not exclude these possibilities). Note the distance between the end of
the tracheostomy and the carina.
Finally, do a chest X-ray, and make an entry in the medical notes (size, method,
problems, and bronchoscopy findings).
3.7
Anaesthetising a patient with a laryngectomy
Patients with a well established laryngectomy will of course be familiar with tracheostomy
use and its management. Consequently, I find the most convenient approach is to insert a
cuffed tracheostomy on the ward preoperatively on the day of the operation, thus allowing
plenty of time for the patient to get used to the tracheostomy before arriving in the
anaesthetic room. This greatly facilitates induction and reduces the incidence of coughing.
3.8
Anaesthetising a patient with a tracheostomy in situ
A few basic precautions are worth bearing in mind. Be prepared to change the tracheostomy
if necessary (Section 3.6), and always have a bronchoscope handy so you can check
position/location if necessary. Before inducing the patient make sure you can actually
ventilate the patient through the tracheostomy; i.e., check whether (a) the tracheostomy has
a working cuff, and (b) if there is an inner-tube, make sure it is the non-fenestrated one.
Check the notes to see if the patient was difficult to intubate through the mouth.
Check the notes to see whether the tracheostomy was surgical (usually easy to
replace with the same or larger size), or percutaneous (usually more difficult to
change; may need a smaller size available).
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Check the tracheostomy itself carefully to determine (a) the manufacturer, (b) the
size, (c) whether it has a cuff (look for the pilot balloon), (d) is the inner-tube
fenestrated or not? (remove it and see if there is a posterior hole in it), (e) is the
inner-tube locked in position? (check that the two small arrows (Tracoe) are
aligned; Shiley tracheostomy tubes have two small dots which need to be aligned).
Turn the inner tube clockwise to lock it.
Check you have a new (unopened) 5 same-size same-make tracheostomy tube available. For tracheostomy tubes having an inner-tube this precaution will also guarantee
that you have to hand the all-important non-fenestrated inner-tube (white connector
for both Shiley and Tracoe tubes). If the tracheostomy is a percutaneous one, then
have the next size smaller also available.
Since a spontaneously-breathing patient may come to theatre with a fenestrated
inner-tube in situ (Shiley green connector; Tracoe blue connector) remember to
check before induction the status of the inner-tube (remove it and see if it has a
posterior hole), and change to the non-fenestrated version (white connector for both
Shiley and Tracoe) if necessarythis is why it is important to have a new unopened
tracheostomy tube of the same size immediately available in theatre. Note that if
you induce a patient with a fenestrated inner-tube in situ you may well not be able
to ventilate the patient adequately owing to the huge leak into the pharynx which
will become apparent as soon as you try to ventilate the patient.
If the patient comes to theatre with a fenestrated inner-tube in situ, do any suctioning
after first changing to a non-fenestrated inner-tube (white connector), as otherwise
the suction catheter may get held up by the fenestration in the inner-tube. In the case
of a Shiley tracheostomy tube the catheter may even pass through the large single
fenestration in the outer tube and damage the posterior wall of the trachea. Note that
Tracoe tracheostomy tubes have multiple small holes in the outer tube which prevent
this problem.
Check that the patients tracheostomy is a cuffed one (i.e., look for the pilot balloon)
and that the cuff is intact (check with a bag that there is no leak, and that you
can (gently) ventilate the patient by hand). If the cuff leaks consider replacing the
tracheostomy before induction (but remember, a fenestrated inner-tube will also
cause a leaksee above).
Have some large (orange tipped) suction catheters available (for railroading) in case
you need to change the tracheostomy tube.
Disconnection hazard: Since the anaesthesia circuit connects directly on to the
inner-tube of the tracheostomy, then if the alignment arrows (or dots) at the connection become misaligned during the operation (e.g., if the patient is turned laterally),
5 Check that the plastic bag inside the box is unopenedit is not uncommon (unfortunately) for someone to
have opened it and taken the non-fenestrated inner-tube!
RWD Nickalls
the anaesthesia circuit may rotate (anticlockwise) sufficiently to unlock the innertube, and may cause the inner-tube to fall out resulting in a disconnection. It is
therefore extremely important to make sure that the tracheostomy and the alignment
arrows (or dots) are clearly visible at all times, and that no anticlockwise torque is
exerted by the circuit on the inner-tube.
3.8.1
Postoperative management
While patients with a tracheostomy generally wake up very smoothly, they do present an
unusual airway risk with regard to aspiration should they vomit. Consequently, the recovery
staff need to be familiar with tracheostomy care, and be aware of the aspiration risk. A
useful approach is to protect the airway using a catheter mount (on the tracheostomy), and
have it directed to one side.
3.9
Montgomery T-tube placement
These T-tubes are used to stent a collapsing trachea. Surgical placement is via the trachea,
and is usually extremely difficult (may take up to 1 hour). Anaesthesia ideally requires two
anaesthetistsone to manage the airway and jet-ventilation, and one to control TIVA and
relaxation (see Section 5.7.2). Note that once the tube is in place it is then not possible
to use an endotracheal tube for ventilation, and so the options are either an LMA, bag &
mask, or perhaps jet-ventilation via a catheter.
Ernst A and Mehta C [Eds.] (2003). Artificial airways. Clinics in Chest Medicine,
24 (September). (WB Saunders Company, London) [includes a chapter on the
Montgomery T-tube tracheal stent]
Guha A, Mostafa SM and Kendall JB (2001). The Montgomery T-tube: anaesthetic
problems and solutions. Br. J. Anaesth.; 87, 787790 [excellent article]
3.10
Difficult airway & trans-tracheal needle ventilation
See also Section 5.7.4 for references regarding Sanders jet ventilation via endotracheal
tubes and rigid bronchoscopes.
Benumof JL (1999). Airway exchange catheter: simple concept, potentially great
danger [editorial] Anesthesiology; 91, 342344.
Debenham TR (1985). Emergency transtracheal ventilation in anaesthesia or casualty
department. Anaesthesia; 40, 599-560. [describes use of a standard IV fluid givingsetcut off the drip chamber and insert the sharp point (which is usually inserted
into the infusion bag) into the trachea, and then connect the oxygen to the drip
chamber using some connector]
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Gerig HJ, Schnider T and Heidegger T (2005). Prophylactic transtracheal catheterisation in the management of patients with anticipated difficult airways: a case
series. Anaesthesia; 60, 801805. [see excellent reply by Higgs and Vijayanand,
pp. 12451246 (7 refs)]
Kaiser EF, Seschachar AM and Popovich MJ (2001). Tracheostomy tube replacement: role of the airway exchange catheter. Anesthesiology; 94, 718719 [letter
reply to Benumof 1999]
Layman P (1996). Difficult intubation. Todays Anaesthetist; April, p. 52 [letter
describing his technique of elective trans-tracheal (crico-thyroid) needle placement
under local anaesthesia prior to a gas induction or difficult intubation. This letter
cites the following three references.]
Layman P (1983). Trans-tracheal ventilation in oral surgery. Annals of the Royal
College of Surgeons; 65, 318320.
Layman P (1983). By-passing a problem airway. Anaesthesia; 38, 478480.
Layman P (1983). An alternative to blind nasal intubation. Anaesthesia; 38, 165.
Mentzelopoulos SD and Tzouf MJ (2002). Anesthesia for tracheal and endobronchial
interventions. Current Opinion in Anesthesiology; 15, 8594.
Paw HGW and Sharma S (2006). Cricothyroidotomy; a short-term measure for
elective ventilation in a patient with challenging neck anatomy. Anaesthesia &
Intensive Care ; 34 (June), 384387. [used the Melker cuffed device (Cook); 9 refs]
3.11
Miscellaneous problems
You may sometimes be called to see a patient whose tracheostomy tube has developed
some problem. In general, the problem is either obstruction (partial or total), an air leak,
or the tube has come out slightly and cannot be re-sited. If in doubt bronchoscope down
the tracheostomy to check alignment and position.
If the patient is paralysed & ventilated and the problem cannot be fixed quickly, then
consider reintubating through the mouth using an uncut 6 tube and advance the tube so
it is just below the stoma (taking care not to inadvertently intubate a main bronchus 7 ),
6 Uncutsince
the tube must be long enough to get the cuff below the stoma.
is a very common error, and all too easy to make when using a long (uncut) tube in an emergency
situation. Unfortunately, if you are intubating orally in order to overcome an obstructed tracheostomy (and are
already wondering whether the tracheostomy tube has made a false passage), and then you discover the new oral
tube seems to be obstructed as well, it is easy to wrongly assume that the cause is somehow related to the original
tracheostomy problem and fail to appreciate that this new obstruction is simply due to the uncut oral tube being
too far down. Checking the tube distance at the teeth is the best clue, since even a quick bronchoscopy at this
stage may well be confusing (for example, showing strange and unfamiliar anatomy of small lower-lobe basal
bronchi) unless you are already considering the possibility of the tube being too far down.
7 This
RWD Nickalls
and then bronchoscope to check position in relation to the carina. If you have to bag the
patient on a mask after the tracheostomy has been removed, then cover the hole with a
wide plastic occlusive dressing (e.g., OpSite, Tegaderm) and ask someone to press on it
to keep it in place and make it air-tight. If oral intubation is difficult, consider intubating
through the tracheostomy stoma, railroading over a bougie if necessarystop as soon as
the cuff is in the trachea, since you will be very close to the carinaand bronchoscope to
check position.
If the patient is breathing spontaneously and the problem cannot be fixed easily, then
consider removing the tracheostomy and railroading a new one. Consider oxygenating
using both a face mask and a tracheostomy circuit, since the patient may be breathing
through both routes.
3.11.1
Obstruction
The commonest presenting problem is difficulty to pass a suction catheter.8 Any suggestion
from the nursing staff that there are difficulties with suctioning must be taken seriously
and investigated urgently. It is essential to use a bronchoscope in such cases in order to
exclude partial (or even total) obstruction due either to malposition (e.g., where the tip of
the tracheostomy may be only partially within the tracheal lumen), or to dried secretions.9
Remove any valve attachment (e.g. speaking valve etc) connected to the tracheostomy.
Remove the inner-tube and check the lumen is patent. Check whether a suction catheter
can be passed easily; check air movement with a bag (note that one can often pass a suction
catheter and see bag movement even in cases of severe partial obstruction). Consider the
cuffthis may be overinflated and obstructing the end (unlikely though as the cuff will be
made of plastic and not rubber)and see if letting the cuff down makes any difference.
Consider malposition, especially if recent tracheostomy, recent tracheostomy change, or
if the tracheostomy flanges do not lie flush with the skin. Sometimes simply releasing the
retaining straps completely and observing whether the tracheostomy flanges sit nicely on
the skin or not (sometimes this manoeuvre reveals a malpositioned tracheostomy being
forced into an apparently normal position by the straps). Finally, consider removing the
tracheostomy tube altogether if necessary. Always inspect with a bronchoscope.
Kazi ST, Ali MA and Donohoe BO (2006). Accidental oro-endtracheostomy intubation. Anaesthesia, 61, 918.
[death following tracheal obstruction, owing to failure of oral intubationthe oral
ETT made an undetected anterior false passage at the tracheostomy stoma: importance of inspecting and then railroading over a fibrescope even with oral intubation
if difficulties occur; may have overcome the problem if had fibrescope down ETT
for guidance, or had railroaded the tracheostomy over a fibrescope initially]
8 It is quite alarming in ITU how often ETTs are found to be partially obstructed, even after quite short periods
of intubation. Even moderate secretions (and especially with thick secretions) should alert you to the posibility of
impending obstruction, and to consider pre-emptive check-bronchoscopy and tube change if necessary.
9 Note that ability to pass a suction catheter does not exclude significant obstruction due to dried secretions.
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McGurie G and El-Beheiry H (2001). Loss of the airway during tracheostomy: rescue oxygenation and re-establishment of the airway. Canadian Journal of Anesthesia;
48, 697700. [from Kazi et al. 2006]
McNamara J and Chisholm DG (1996). Use of a fibreoptic intubating laryngoscope
to replace a misplaced tracheostomy tube. Anaesthesia, 51, 894. [from Kazi et al.
2006]
Mirza S and Cameron DS (2001). The tracheostomy tube change: a review of
techniques. Hospital Medicine; 62, 15863. [from Kazi et al. 2006]
Rajendram R and McGuire N (2006). Repositioning a displaced tracheostomy tube
with an Aintree intubation catheter mounted on a fibre-optic bronchoscope. Br. J.
Anaesth.; 97, 576579.
3.11.2
Difficulty inserting the inner tube
Just occasionally, in a long term tracheostomy patient on a ward, the inner tube becomes
difficult to insert. The most likely causes are (a) wrong size inner tube, (b) deformed inner
tube etc. Try a new inner tube from a new tracheostomy package. Otherwise, consider
inspecting the tube fenestrations with a fibreoptic bronchoscope (from the inside without
the inner tube in) and also checking whether the tracheostomy is seated correctly on the
skin. If the outer tube is not in sufficiently far, it may be that some of the more superficial
holes are outside the trachea, in which case inspecting these from the inside with the
bronchoscope reveals that the superficial holes appear pink (outside the trachea), while
the deep ones appear black (inside the trachea). Tissue growing in through the holes may
be enough to make it difficult to insert the inner tube. The solution is either to push the
tracheostomy in fully, or possibly, just change the tracheostomy.
This sort of problem arises because the tracheostomy has come out slightly on the
ward, and remained not properly seated on the skin for several days or more. Although
the bronchoscope and light-source can be taken to the ward, it is usually more practical to
bring the patient to the ITU for investigation.
3.11.3
Air leak
Consider a damaged cuff, poor position of the tracheostomy, wrong inner-tube (e.g., trying
to ventilate a patient with a fenestrated inner-tube), or tracheostomy being too small (cuff
leaks even when fully inflated). Finally, consider untying the straps and looking at the
natural position of the tube and its flange in relation to the neck. Occasionally this reveals
an obviously malpositioned tube, with the flange not sitting on the skin; the tracheostomy
being forced into an apparently normal looking position by tight straps.
3.11.4
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Tracheostomy recently removed
Its not uncommon for a patient whose tracheostomy has recently been removed (decannulated) to experience renewed secretion or airway problems, and require a new tracheostomy
to facilitate suction, bronchoscopy and airway management. If the interval since decannulation is less than about one week then it is generally a simple matter to insert a new
tracheostomy since there is usually still a hole, albeit small, at this stage.
Since the aim is typically to facilitate suctioning, then occasionally just a Portex
Mini-Trac may suffice, but generally a small tracheostomy (say, size 7) is the minimum
requirement,10 at least initially. Note that for ward use, the tracheostomy must have an
inner-tube.11 Both the Portex Seldinger Mini-Trac dilator,12 and also the blue rhino
dilator,13 are extremely useful tools to have handy when dealing with this problem.
10 Note that while a size 7 will allow tracheal inspection/visualisation with the small intubating fibrescope
(available from theatres), a size 8 tracheostomy is the smallest which will allow you to use the full-size suctioning
fibrescope.
11 A patient with a tracheostomy which does not have an inner-tube must be managed on HDU/ITU since this
form of tracheostomy can easily get blocked by dried secretions.
12 This has a very useful Luer connector and hence allows you to inject local anaesthetic down it directly
into the trachea via even the smallest tracheal orifice. I have even used it in this way down a malpositioned
tracheostomy tube (see Section 3.1.1).
13 This is in the percutaneous tracheostomy pack, and can be used to further dilate the tracheal orifice if
necessary.
4
Lung anatomy
thoracic anaesthetists interest in anatomy relates mainly to thoracic epidurals,
bronchoscopy and tube positioning. While epidural anatomy is well catered for
(see Section 2.1), copies of the primary texts on the relevant lung anatomy (Brock
19421944, Brock 1954, Boyden 1955, Hollinger and Johnston 1957, Kavuru and Mehta
2004) are difficult to find.1 I am pleased, therefore, to be able to include (with permission)
some diagrams and plates from Brock 2 (19421944, 1954), which contain quite the best
lung anatomy diagrams for thoracic anaesthetists that I have found so far, not withstanding
the excellent diagrams in Kavuru and Mehta (2004). See also references to the anatomy of
the epidural space (Section 2.1), radial artery (Section 9.5.2), central veins (Section 9.6.4),
and bronchoscopic anatomy (Chapter 5). Other useful texts are Burwell and Jones (1996),
Ellis et al. (2004), Itoh et al. (2004), Minnich and Mathisen (2007), Deslauriers (2007).
HE
4.1
Anatomical terms 3
Alveolus (Gk): Diminutive of alveus (cavity) alveolus (small cavity).

Azygos (Gk): a (without) + zugon (yoke) azygos (not yoked), i.e., not a paired structure.
A non-paired body part, especially a vein.
Azygos vein: A vein of the right superior thorax draining into the superior vena cava.
Azygos lobe: A lung zone separated by an indentation (typically from above down) formed
by an azygos vein and its superior mesentery (meso-azygos). The so-called azygos lobe
is not a true lobe (it does not have a constant bronchus and vessels). First described by HA
Wrisberg (17371808) in 1778hence the lobule of Wrisberg (Brock 1954, p. 216).
1 Copies
are available in the British Library, London.

RC Brock; thoracic surgeon at Guys Hospital, London.
3 Modified from: The New Sh. Oxf. Eng. Dict. (1993); Jaeger EC and Page IH (1953), A source-book of
medical terms (CC Thomas, Springfield, Illinois, USA); Field EJ and Harrison RJ (1968), Anatomical terms:
their origin and derivation, 3rd ed. (W Heffer & Sons, Cambridge, UK.)
2 Lord
59
CHAPTER 4. LUNG ANATOMY
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Bougie (Fr): bougie (candle).

Bronchus (Gk): brogkhos, bronchos (windpipe).
Bulla (L): bulla (bubble-like).
Carina (L): carina (keel of a boat); carinatus (keel-like). The last ring of the trachea has a
keel-like inferior projection carried back in the fork between the major bronchi.
Chyle (Gk): chyl (juice).
Clavicle (Gk): kleis (a key). (L): clavis; dim. clavicular (a bar for closing a window).
Some suggest it is named from the Greek owing to its fancied resemblance to a key.
However, it is most likely derived from the Latin because it resembles a curved window
fastener, and joins or locks the shoulder girdle to the body, The Roman clavis was also
an S-shaped metal bar used to strike bells.
Costal (L): costa (rib).
Cricoid (Gk): krikos (a ring). The shape of the cricoid cartilage is like a signet-ring.
Diaphragm (Gk): dia (through, across) + phragma (fence).
Effusion (L): effundere (pour out); effusus is past participle of effundere.
Empyema (Gk): empyesis (suppuration), empyematos (abscess).
Fissure (L): fissus (split, cloven).
Hiatus (L): hiatus (a gap).
Hilum (L): hilum (a trifle, a small thing). Point of attachment; point where an organ is
attached by vessels & nerves.
Lingula (L): lingere (to lick); lingula (tongue-like). Part of the left upper lobe (equivalent
to the right middle lobe), consisting of superior and inferior segments supplied via the
lingula bronchus. It is occasionally separated by a partial fissure from the rest of the upper
lobe. The following is from Brock (1954, p. 82).
The term lingula really refers to the tip or tongue-like projection of the lowest and
most anterior part of the left upper lobe, but it is justifiable to make use of the name
to describe the whole portion of which the lingula is really but a part. . . . Its chief
practical importance lies in the frequency of which it is involved by bronchiectasis in
common with the left lower lobe.
Lung (Anglo-Saxon): lungen (light). The lungs were originally known as lights because
they were so light in weight.
Manubrium (L): manubrium (a handle). The manubrium sterni is shaped like the handle
of a sword.
Mediastinum (L): Probably from per medium tensum (that which is tight down the middle);
hence between the two lungs.
Oesophagus (L): -phagos (eating) ysophagus. From the Greek oisophagos (gullet).
Pharynx, pharyngeal (Gk): pharyngos (throat).
Phrenic (Gk): phren (the mind). Taken to mean the seat of emotion around the heart,
hence associated with the diaphragm.
Pleura (Gk): pleura (side, rib).
Sternum (Gk): sternon (the male breast).
Stomach (Fr): estomac, stomaque; (L) stomachus; (Gk) stomakhos.
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Thorax (Gk): thorax, thorakos (the chest).

Thymus (Gk): thymos (thyme; an aromatic herb). The thymus gland is so named owing to
a resemblance to a bunch of thyme.
Throid (Gk): thyra (a door) thyreos (shield with a notch for the chin). Apparently
the name thyroid was introduced in 1646 by Thomas Wharton (16161673), English
anatomist and physician at St. Thomas Hospital, London.
Trachea (L): trachia (rough). (Gk): trachys. Also: Aspera arteria (air conduit).
Vertebra (L): vertebra (a joint). From verto (I turn).
4.2
History of lung anatomy 4
Lung anatomy was initially investigated using the process of injecting coloured wax into
the bronchi and vesselsa technique largely developed by Jan Swammerdam 5 (1637
1680). Two types of wax models were developed: the so-called wax corrosion cast, and
the later wax-injected dried dissections; details of these techniques were often included in
early anatomy books.6 A fine example of an early wax corrosion cast in a glass bell-jar is
shown in the portrait of William Hunter (17181783) at the Royal College of Surgeons,
London (Tompsett, 1965).
The process of establishing the true basic anatomy of the lung was very slow, the first
serious attempt to describe the anatomy in any useful detail being that by the famous
Swiss anatomist Christoph Theodor Aeby (18351885). However, the models he worked
from were poor and he made significant errorsbased on comparative anatomywhich
were perpetuated through his writings (Aeby 1880). Fortunately, these errors were soon
revealed 7 by the pathologist William Ewart, whose careful work led to the modern concept
of the bronchopulmonary segment.
4.2.1
Bronchopulmonary segment
William Ewart (18481929) was a pathologist at the Brompton Hospital, London, and
is generally regarded as the father of segmental anatomy (Tompsett, 1965). Ewart was
uneasy about the somewhat casual approach to lung anatomy, as he tells us in his treatise
(Ewart 1889):
Moreover, a suspicion had arisen in my mind that the present deficiencies in our
anatomical knowledge . . . might perhaps be held responsible for the halting . . . in the
development of Pulmonary Surgery, contrasting with the steady progress made in the
surgery of other organs.
Ewart 1889 (from Tompsett 1965)
4 For
overviews see Tompsett (1965), Boyden (1955), Sealy et al. (1993), Fell and Pearson (2007).
(1965).
6 Pole (1790) was one of the first to include details of the injection process for making anatomical models.
7 This is highlighted in the title of Ewarts book (Ewart, 1889) in which he includes the following: . . . with a
criticism of Professor Aebys views on the bronchial tree . . .
5 Tompsett
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Ewarts magnificent achievement was the realisation that the lung consists of a number
of functionally and anatomically separate components, which he termed respiratory units.
He summarises his key findings regarding the bronchi as follows:
(3) The bronchial tubes do not anastomose. Each lobe therefore receives from
the main bronchus a distinct air-supply. The same principle of separate supply extends,
within the lobe, as far as the infundibula. This absence of anastomosis is physiologically
of great moment. . . .
Respiratory districts At the root of the lung the conditions are very different,
since the primary, secondary, and tertiary branches from the main bronchus radiate
towards the periphery for considerable distances, without bearing any lobules. Within
each lobe, large groups of lobules being served by separate bronchi are thus kept in
practical isolation from each other as regards their air-supply. Each of these sublobar
groups may be considered as forming a separate respiratory district, within which the
tidal air, or the bronchial contents in general, may, perhaps, be capable of interchange
from lobule to lobule. . . .
A knowledge of the situation, within each lobe of the respiratory districts of which
it is composed, is likely to be valuable to the clinical physician. But an attempt to
define their anatomical boundaries would with advantage be postponed until a full
description of the bronchial tree had supplied a sound basis for the subdivision of each
lobe into its lobular groups.
Ewart 1889, p. 6566.
Ewart died 8 in 1929, only a few years before the surgical significance of his respiratory
districts became widely appreciated. Just three years later Kramer and Glass (1932)
extended Ewarts concept, viewing his respiratory districts as pathological units. Glass
(1933) then coined the term bronchopulmonary segment, and soon after Churchill and
Belsey (1939) demonstrated the surgical resectability of bronchopulmonary segments
establishing that they were effectively also surgical units. A new era of thoracic surgery
was being ushered in by developments in anatomy, as Boyden (1955) describes:
The modern period begins with the suggestive studies of Kramer and Glass (1932),
the one a bronchoscopist,9 the other a surgical resident at the Mount Sinai Hospital in
New York. Pressed by surgical colleagues for a better localization of lung abscesses,
including a knowledge of where to enter the chest for drainage, Glass proposed to
establish a smaller and more accurate unit of localization than the lobe. Unaware
of Ewarts pioneer work, he named the bronchopulmonary segment and stated that it
represented not only an anatomic but a pathologic unit: this, by virtue of the fact
that its orifice occupies a prominent position in the lobar bronchus and therefore is
vulnerable to aspiration of infected material. Besides giving us the now generally
accepted name for this unit, Glass injected the main divisions of each lobar bronchus
with different colored fluid dyes, thereby providing the first diagrams of surface
distribution. Relationship to the thoracic cage was determined from bronchograms of
8 Obituary
9 Dr
of Ewart W. (18481929). Lancet; 217, 408409 [from Boyden 1955]

Rudolph Kramer: see also Kirschner (2003).
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the lung. Altogether, eleven segments were recognized. In general these corresponded
to Ewarts districts, except that the two subsegments of the pectoral district and two
subdivisions of the middle lobe were given the status of segments.
Boyden 1955, p. 14
These were important and exciting times for thoracic surgery. Kirschner (2003) puts these
great achievements in context as follows:
. . . Recognized today as a momentous advance in the surgical anatomy of the lung,
this laid the groundwork for the localization and precise drainage of lung abscess, and
the anatomical basis for precise pulmonary resection.
Kirschner (2003), p. 329.
4.3
Lung development & embryology
The recent advent of molecular biology and gene expression promises a seriously detailed
understanding of the development of the lung, as indicated by a recent paper by Metzger
et al. (2008). Using a mouse model they reveal thatto use a computer programming
analogylung development appears to be largely under the control of a molecular master
branching-program coordinating three slaves (branching-subroutines).
The development of lung branching is therefore perceived as proceeding according
to a relatively fixed sequence of repeating functional molecular branching-instructions,
controlled by a relatively small number of genes operating at branch tips. The editorial
relating to this paper summarises the interest in this area, as follows:
Whether a master branch generator controlling a select few slave subroutines represents
a general developmental strategy that has been reused over evolutionary time in
different branched organs, remains an intriguing possibility. Also, solving the specific
problem of gas diffusion as a limit on size, and discovering how simplified, genetically
controlled branching routines interact with physical and biological factors to direct
complex yet reproducible patterns of development, will be matters of great interest.
To quote Charles Darwin as interpreted by biologist Sean Carroll,10 they will aid our
understanding of how endless forms most beautiful11 have evolved from a relatively
simple tool-box of genetic modules.
Warburton (2008).
10 SB Carroll (2007). Endless forms most beautiful: the new science of Evo Devo and the making of the animal
kingdom, (Norton, New York) ISBN 987-0393060164.
11 This is a quote from the last paragraph of Darwins The origin of species (1859): There is grandeur in this
view of life, with its several powers, having been originally breathed into a few forms or into one; and that, whilst
this planet has gone cycling on according to the fixed law of gravity, from so simple a beginning endless forms
most beautiful and most wonderful have been, and are being, evolved (Nickalls, 2009).
4.4
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Nomenclature
In May 1949 the nomenclature of the bronchi and segments was standardised by the
Thoracic Society (BTS, 1950). For discussion see Boyden (1953).
4.4.1
Right lung
The bronchus to the right upper lobe should no longer be called the eparterial bronchus
use upper lobe bronchus instead. The part of the bronchus between the upper lobe
bronchus and the middle lobe bronchus should be called the upper part of the right main
bronchus, and the lower part should be called the lower part of the right main bronchus.
Upper lobe
1. Apical bronchus and segment
2. Posterior bronchus and segment
3. Anterior bronchus and segment
Middle lobe
4. Lateral bronchus and segment
5. Medial bronchus and segment
Lower lobe
7. Medial basal (cardiac) bronchus and segment
8. Anterior basal bronchus and segment
9. Lateral basal bronchus and segment
10. Posterior basal bronchus and segment
4.4.2
Left lung
(a) No segment 7, (b) the upper lobe has an upper division and a lower (lingula) division,
(c) use the term lingula in preference to lower division
Upper lobe
upper division bronchus
2. Posterior bronchus and segment
3. Anterior bronchus and segment
lingula (lower division) bronchus
4. Superior bronchus and segment
5. Inferior bronchus and segment
Lower lobe
8. Anterior basal bronchus and segment
9. Lateral basal bronchus and segment
10. Posterior basal bronchus and segment
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4.5
Carina
The safe positioning of an endotracheal tube relies not only on an understanding of the
applied anatomy and an awareness of the likely position of the carina, but also on an
appreciation of those factors which can move the carina relative to the end of the tube.
In particular, the distance of the tip of a tube from the teeth is a very useful guide for
recognising when a tube is likely to be close to the carina, or even beyond it. The surface
marking of the carina in a supine patient is the manubrio-sternal angle (Burwell and Jones
1996, Ellis et al. 2004, Minnich and Mathisen 2007).
Table 4.1:
Approximate distances in an average supine adult male.
4.5.1
Teeth vocal cords

Trachea
Carina left-subcarina
Carina right-upper lobe orifice
15 cm
10 cm
5 cm
25 cm
Teeth carina
Teeth left-subcarina
25 cm
30 cm
Factors moving the carina
The distance of the carina from the teeth varies quite markedly with (a) neck position
(2 cm with flexion/extension), (b) body position (supine, lateral, lithotomy, Trendelenberg) particularly in obese patients or those with a large or distended abdomen, and
(c) body height/weight. The length of the trachea (and hence position of the carina) is
greatly influenced by the position of the diaphragm.12
While the carina is typically about 24 cms from the teeth in a lean supine adult male
of normal height, it can be as little as 18 cms in an equivalent obese patient in lithotomy.
The recent letter by Greenland (2004) gives some useful references regarding anatomy and
how to position an endotracheal tube safely.
With a single-lumen tube it is not uncommon for the tip to be inadvertently positioned
at or below the carina in short and/or obese patients; the risk increasing further when such
patients are head-down and/or in lithotomy. The risk is even more significant if there is also
raised intra-abdominal pressure, as in laparoscopy (Nishikawa et al. 2004). Furthermore,
in short patients the larynx-intubation guide-marks on standard endotracheal tubes may
locate the tip of the tube too close to the carina (Chong et al. 2006; Cherng et al. 2002).
Appreciating the factors which influence the position of the carina is especially important when positioning double-lumen tubes, since in this setting even small movements
of the carina may not only jeopardise the adequacy of lung isolation and ventilation (see
12 Hence:
what moves the diaphragm also moves the carina (see Section 7.4).
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Section 7.4), but can equally well lead to obstruction and lobar collapse. The TEPID
database (see Section 6.4.3) is a good predictor of the distance to the carina in supine
patients, and has proved to be a useful practical guide in this regard. It is important to have
a low threshold for using a fibreoptic bronchoscope to check the tube position following
any change in the patients position.
Note that tube/carina problems are particularly likely to arise in the ITU, owing to the
fact that patients ventilated in the ITU are subject to the combination of (a) PEEP, and
(b) being nursed in a 45 deg semi-sitting position. This combination of factors typically
results in the carina being significantly further away from its usual supine location. For
example, when trainees bronchoscope such patients they often express surprise at how far
away the carina is. One must take care to avoid inadvertently positioning the ETT close to
the carina if the patient is in a semi-sitting position, since later, when the patient is supine
(for nursing or other reasons), the carina may rise too close to the end of the tube. The
expected number of cms from the teeth is usually the best initial guide to ETT position in
this setting.
4.6
Right-upper lobe orifice
Typically the right-upper lobe (RUL) orifice is 225 cm below the carina, and is often
positioned very slightly anterio-lateral (i.e., a right-sided endo-bronchial tube often needs
to be rotated slightly anticlockwise in order to align the side hole with the RUL orifice).
The location of the RUL orifice relative to the carina is somewhat variable, and can
even originate from the trachea directly (see below).
4.7
Aberrant bronchus
Supernumerary bronchus: A bronchus supplying a (supernumerary) segment which is

additional to the usual bronchus (supplying its usual lung zone or segments). It is most
frequently associated with the right upper lobe, and typically arises laterally from the right
side of the trachea, about 2 cm above the normal right upper-lobe bronchus (Brock 1954,
p. 201). For clinical implications see Section 7.9.3.
Displaced bronchus: A bronchus which is otherwise normal (i.e., supplies its usual lung
zone or segment), but is displaced (up or down) from its usual location. Displaced bronchi
are much more common than supernumerary bronchi. The commonest displaced bronchus
is an upward displacement of the apical bronchus of the right upper lobe. On the left
side, a not uncommon displaced bronchus is that of the medial basal (cardiac) bronchus,
arising medially from the left lower-lobe bronchus above the origin of the anterior basal
bronchusexactly analogous to the cardiac bronchus of the right lower lobe (Brock
1954, p. 207). For clinical implications see Section 7.9.3.
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Figure 4.1:
Drawing of a dissection to show the relation of the fissures of the right lung, and
to demonstrate the depth from the skin surface of the termination of the fissure
(From Brock (19421944), with permission)
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Figure 4.2:
Similar drawing of the left lung to show the fissure (From Brock (19421944),
with permission)
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Figure 4.3:
Top: Chest diagrams to show the level of the lobes and interlobar fissures of the
lungs as seen from the front and back.
Bottom: Similar diagrams to show the bronchopulmonary segments.
The lateral subsegments of the right upper lobe are indicated by broken lines
(From Brock (19421944), with permission)
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Figure 4.4:
Top: Chest diagrams to show the bronchopulmonary segments as seen in the
lateral view. The lateral subsegments of the right upper lobe are indicated by
broken lines.
Bottom: Similar diagrams to show the bronchi supplying the bronchopulmonary
segments (From Brock (19421944), with permission)
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injected with coloured gelatin. (From Brock (19421944), with permission)
Figure 4.5: Right lung: Lateral and medial views in which the individual segments have been
injected with coloured gelatin. (From Brock (19421944), with permission)
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Figure 4.6: Left lung: Lateral and medial views in which the individual segments have been
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Figure 4.7:
Drawings of normal bronchi as seen at bronchoscopy in a supine patient. However, in my experience the left upper bronchial orifice in the left lower bronchi
drawing is generally seen much closer to the 1011 oclock positioncompare
with Figures 5.1 and 5.2. See Section 4.4 for the more modern nomenclature.
(From Brock (19421944), with permission).
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4.8
References
Anatomy Atlases: see the link from the Virtual Hospital website:
http://www.uihealthcare.com/vh/
Aeby C (1880). Der Bronchialbaum der Saugethiere und des Menschen. Nebst Bemerkungen u ber den Bronchialbaum der Vogel und Reptilien. (Wilhelm Engelmann,
Leipzig). [from: Boyden 1955]
Atkinson RS, Rushman GB and Lee JA (1987). A synopsis of anaesthesia. (IOP
Publishing Ltd, Bristol, UK)
BTS (1950). Nomenclature of broncho-pulmonary anatomy; an international nomenclature accepted by the Thoracic Society. Thorax; 5, 222228. [from Brock, 1954]
Boyden EA (1949). A synthesis of the prevailling patterns of the bronchopulmonary
segments in the light of their variations. Dis. Chest; 15, 657668.
Boyden EA (1953). A critique of the international nomenclature on bronchopulmonary segments. Dis. Chest; 23, 266269.
Boyden EA (1955). Segmental anatomy of the lung. (McGraw-Hill Book Co. Ltd.,
London, UK).
Brock RC (1942). The level of the interlobar fissures of the lungs. Guys Hospital
Reports; 91, 140146;
Brock RC (19421944). Observations on the anatomy of the bronchial tree, with
special reference to the surgery of lung abscess. Guys Hospital Reports;
Part I . Introduction. 91, 111130;
Part II. The left upper lobe. 92, 2637;
Part III. The middle lobe. 92, 8288;
Part IV. The lower lobes. 92, 123144;
Part V. The whole lung: anomalies and compound abscesses. 93, 90107.
Brock RC (1954). The anatomy of the bronchial tree. 2nd. ed., (Oxford University
Press, Oxford, UK) [first published in Guys Hospital Reports (19421944), 9193]
Brock RC, Hodgkiss F and Jones HO (1942). Bronchial embolism and posture in
relation to lung abscess. Guys Hospital Reports; 91, 131139;
Burwell DR and Jones JG (1996). The airways and anaesthesia; I: anatomy, physiology and fluid mechanics. Anaesthesia; 51, 849857 (September issue). II: pathophysiology. Anaesthesia; 51, 943955 (October issue).
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Cherng CH, Wong CS, Hsu CH and Ho ST (2002). Airway length in adults:
estimation of the optimal endotracheal tube length for orotracheal intubation. Journal
of Clinical Anesthesia; 14, 271274.
Chong DYC, Greenland KB, Tan ST, Irwin MG and Hung CT (2006). The clinical
implication of the vocal chords-carina distance in anaesthetized Chinese adults
during orotracheal intubation. Br. J. Anaesth.; 97, 489495.
Churchill ED and Belsey R (1939). Segmental pneumonectomy in bronchiectasis.
Annals of Surgery; 109, 481499. [from Patnaik and Saha 1999]
Deslauriers J [Ed.] (2007). Thoracic anatomy, Part I Chest wall, airway, lungs.
Thoracic Surgery Clinics; 17 (November), 443666 (Elsevier, Inc)
[chapters: Historical perspectives of thoracic anatomy / Surface anatomy and surface
landmarks for thoracic surgery / Muscles of the chest wall / The anatomy of the
ribs and the sternum and their relationship to chest wall structure and function /
The intercostal space / The costovertebral angle / Anatomy of the thoracic outlet
/ Correlative anatomy for the sternum and ribs, costovertebral angle, chest wall
muscles and intercostal spaces, thoracic outlet / Anatomy of the neck and cervicothoracic junction / The glottis and subglottis: an otolaryngologists perspective /
Glottis and subglottis: a thoracic surgeons perspective / Anatomy of the trachea,
carina, and bronchi / Lobes, fissures, and bronchopulmonary segments / Pulmonary
vascular system and pulmonary hilum / Bronchial arteries and lymphatics of the lung
/ Correlative anatomy for thoracic inlet; glottis and subglottis; trachea, carina, and
main bronchi; lobes, fissures, and segments; hilum and pulmonary vascular system;
bronchial arteries and lymphatics]
Eagle CCP (1992). The relationship between a persons height and appropriate
endotracheal tube length. Anaesthesia and Intensive Care; 20, 156160.
Ellis H, Feldman S and Harrop-Griffiths (2004). Anatomy for anaesthetists; 8th ed.
(Blackwell Scientific Publications, Oxford, UK).
Ewart W (1889). The bronchi and pulmonary blood-vessels: their anatomy and
nomenclature; with a criticism of Professor Aebys views on the bronchial tree
of mammalia and of man. (JA Churchill, London, UK). [Obituary of Ewart W.
(18481929). Lancet; 217, 408409 [from Boyden 1955]]
Fell SC and Pearson FG (2007). Historical perspectives of thoracic anatomy. Thoracic Surgery Clinics; 17 (November), 443448. (Elsevier, Inc) [In: Deslauriers J
[Ed.] (2007)].
Goodman LR, Conrardy P, Laing F and Singer MM (1976). Radiographic evaluation
of endotracheal tube position. American Journal of Roentgenology; 127, 433434.
[tube can move 2 cm with flexion and extension of the neck]
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Glass A (1934). The bronchopulmonary segment with special reference to putrid

lung abscess. Am. J. Roentgenol.; 31, 328332.
Greenland K (2004). A response to Auscultation of the chest after tracheal intubation by: Kahn AW and Morris S, Anaesthesia; v59, 62662 . Anaesthesia; 59,
929930.
Hannallah MS, Benumof JL and Ruttiman UE (1995). The relationship between
left mainstem bronchial diameter and patient size. J. Cardiothorac. Vasc. Anesth.; 9,
119121. [see also editorial pp. 117118; and article pp. 784785]
Hollinger PH and Johnston KC (1957). Clinical aspects of congenital anomalies
of the trachea and bronchi. Dis. Chest; 31, 613621. http://chestjournal.
chestpubs.org/content/31/6/613.full.pdf
Itoh H, Nishino M and Hatabu H (2004). Architecture of the lung; morphology and
function. J. Thoracic Imaging; 19, 221227. [lung parenchyma; macroscopic and
histological detail]
Joseph JE and Merendino KA (1957). The dimensional interrelationships of the
major components of the human tracheobronchial tree. Surg. Gynecol. Obstet.; 105,
210214.
Kavuru MS and Mehta AC (2004). Applied anatomy of the airways. In: Wang et al.
(2004), Chapter 5, p 3638. [contains many excellent colour diagrams showing the
relationship between the cardio-pulmonary vessels and the bronchial tree]
Kirschner PA (2003). The history of thoracic surgery at Mount Sinai. The Mount
Sinai Journal of Medicine; 70, No. 5, October 2003. (http://mountsinai.siteym.com/)
Kramer R and Glass A (1932). Bronchoscopic localization of lung abscess. Annals
of Otology, Rhinology and Laryngology; 41, 12101220.
Mackenzie M and MacLeod K (2003). Repeated inadvertent endobronchial intubation during laparoscopy. Br. J. Anaesth.; 91, 297298.
Merendino KA and Kiriluk LB (1954). Human measurements involved in tracheobronchial resection and reconstruction procedures; report of a case of bronchial
adenoma. Surgery; 35 (Apr), 590597. [ISSN 0039-6060]
Metzger RJ, Klein OD, Martin GR and Krasnow MA (2008). The branching program
of mouse lung development. Nature; 453 (5 June),745756. [editorial: p. 733735
(Warburton 2008)]
Minnich DJ and Mathisen DJ (2007). Anatomy of the trachea, carina and bronchi.
Thoracic Surgery Clinics; 17, 571585.
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Netter Images. This is a commercial site (Elsevier) giving high quality medical
illustrations. For their excellent figure of bronchopulmonary segments see http:
//www.netterimages.com/image/4426.htm
Nickalls RWD (2009). Evolution of the end of ORIGIN. Science; 326, 801.
Nishikawa K. Nagashima C, Shimodate Y, Igarashi M and Namili A (2004).
Migration of the endotracheal tube during laparoscopy-assisted abdominal surgery
in young and elderly patients. Can. J. Anaesth.; 51, 10531054. [migration was
greater in the elderly, owing to effects of age on lung volumes.]
Patnaik VVG and Saha JC (1999). Incidence of subsuperior bronchus morphological and bronchographic study. J. Anat. Soc. India; 48, 99104.
Pole T (1790). The anatomical instructor, (W Darton & Co., London); (2nd ed
1824).
Sealy WC, Connally SR and Dalton ML (1993). Naming the bronchopulmonary
segments and the development of pulmonary surgery. Annals of Thoracic Surgery;
55, 184188.
Tompsett DH (1965). The bronchopulmonary segments. Medical History; April,
9 (2), 177181. http://www.ncbi.nlm.nih.gov/pmc/journals/228/
Wang Ko-Pen, Mehta AC and Turner JF (2004). Flexible bronchoscopy. 2nd ed.
(Blackwell Publishing, UK)
Warburton D (2008). Order in the lung. Nature; 453 (5 June), 733735 [editorial to
Metzger et al. (2008)].
5
Fibreoptic bronchoscopy
bronchoscopy is an essential tool for viewing bronchial anatomy, and
for facilitating correct placement of single and double-lumen endotracheal tubes,
bronchial blockers and tracheostomies. In the Intensive Care Unit 1 it is also used
for bronchoalveolar lavage (BAL), secretion control and to facilitate lung re-expansion.
Facility with a fibreoptic bronchoscope and familiarity with the endobronchial anatomy
should be essential for all anaesthetists. Note the recent bronchoscopy issue of Clinics in
Chest Medicine edited by Mehta (2010).
Fibreoptic brochoscopy should, in my view, be a much more routine procedure in the
general operating room, since in my experience there are many general surgery patients
who stand to benefit from a quick peri-operative bronchoscopy while they are intubated for
surgery. For example, all those patients with pulmonary secretions, recent chest infection,
COPD, smokers etc 2 . Bronchoscoping such patients for secretion control 3 may well
improve their oxygenation during anaesthesia, and will greatly reduce the likelihood
of their suffering postoperative lobar collapsea common cause for ITU admission
postoperatively. Obese patients will often benefit from having the position of the ETT
checked using a fibrescope, especially if in Trendelenberg.
IBREOPTIC
BTS (2001). British Thoracic Society guidelines on diagnostic flexible bronchoscopy.

Thorax; 56 (Suppl I), i1121.
http://www.brit-thoracic.org.uk/clinical-information/bronchoscopy/
bronchoscopy-guidelines.aspx
Hawkins N (2000). Fibreoptic intubation. (Greenwich Medical Media Ltd, Lond.)
1 Although it is common practice to use a size 8 mm ETT for females in ITU, I find 8.5 mm a better size with
regard to fibreoptic bronchoscopy. Once an 8 mm ETT has been in place for more than about 24/hrs, even a small
amount of tube secretions is often sufficient to make passing the regular (large) fibrescope difficult, sometimes
requiring the ETT to be changed to 8.5 mm.
2 If the ETT requires suctioning, then a quick bronchoscopy will probably be of greater perioperative benefit.
3 Remember to send off a sputum or BAL sample for Gram stain, microscopy and culture.
78
CHAPTER 5. FIBREOPTIC BRONCHOSCOPY
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Campos JH (2009). Update on tracheobronchial anatomy and flexible fiberoptic

bronchoscopy in thoracic anesthesia. Current Opinion in Anaesthesiology; 22, 410.
Jolliet PH and Chevrolet JC (1992). Bronchoscopy in the intensive care unit.
Intensive Care Medicine; 18, 160169.
Mehta AC (Ed.) (2010). Interventional pneumonology [bronchoscopy] Clinics
in Chest Medicine, 31 (March). (WB Saunders Company, London). For table
of contents (TOC) see http://www.sciencedirect.com/science/journal/
02725231
Mehta AC (Ed.) (2001). Flexible bronchoscopy update. Clinics in Chest Medicine,
22 (June). (WB Saunders Company, London).
Oho K and Amemiya R (1984). Practical fiberoptic bronchoscopy. 2nd ed. Translated by JP Barron. (Igaku-Shoin Medical Publishers, Inc., New York) pp. 218.
ISBN 0-89640-103-0
Slinger PD (1989). Fibreoptic bronchoptic positioning of double-lumen tubes. J.
Cardiothoracic Anesthesia; 3, 486496. (http://www.thoracic-anesthesia.
com/)
Wang Ko-Pen, Mehta AC and Turner JF (2004). Flexible bronchoscopy. 2nd ed.
(Blackwell Publishing, UK). [see the excellent cardio-thoracic anatomy diagrams
in chapter 5, showing how the vessels are related to the bronchial tree (Applied
anatomy of the airways) by Kavuru MS and Mehta AC (2004), pp. 3638]
Watson CB (1987). Fibreoptic bronchoscopy in thoracic anaesthesia. In: Gothard
JWW [Ed.], Thoracic anaesthesia. Clinical Anaesthesiology; 1 (March); pp. 3360.
5.1
History
Although the Englishman John Tyndall described the optical properties of flexible glass
fibres in 1870, it was not until 1957 that the first gastro-fibrescope was developed by
B. Hirschowitz in the USA. An improved version was subsequently developed in Japan by
the Machida Endoscope Co. Ltd in 1962. In 1964 the Japanese physician Shigeto Ikeda,
in collaboration with the Machida Endoscope Co. Ltd, started developing a fibreoptic
bronchoscope which was eventually manufactured in 1967 (Ikeda et al. 1968; Ikeda 1974).
Ikedas conference presentation of an early prototype in 1966 is remembered by Dr Ono as
follows:
It was at this transitional period of decreasing pulmonary tuberculosis to increasing
lung cancer that a flexible bronchofibrescope came to be recognized. The credit for
the first to report on the subject must go to Dr Shigeto Ikeda. He demonstrated it with
motion pictures . . . in Copenhagen in August 1966. Also, Dr Ikeda was first to publish
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an article on the use of the flexible bronchofibrescope which appeared in the Journal
of Japan Broncho-esophagological Society and Keio Journal of Medicine in 1968.
Ono J (Foreword; In: Ikeda, 1974).
Becker DH (2010). Bronchoscopy: the past, the present and the future. Clinics in
Chest Medicine, 31 (March), 118.
Ikeda S (1974). Atlas of flexible bronchofiberscopy. (Igaku Shoin Ltd., Tokyo).
[Chapter 1 describes the historical development of the flexible bronchoscope]
Ikeda S, Yani N and Ishikawa S (1968). Flexible bronchofiberscope. Keio J.
Medicine; 17, p. 1. [First journal article on the use of the fibreoptic bronchoscope]
Shore JM and Lippman HN (1965). A flexible choledochoscope. Lancet; i, 1200.
5.2
Bronchoscopy simulator
There is a useful online simulator for demonstrating endobronchial anatomy on Peter

Slingers thoracic anaesthesia website (http://www.thoracic-anesthesia.com/).
You first have to take a brief test on double-lumen tube placement, giving a username
and password, after which you can access the simulator. Importantly, you are then free to
log-in and use the simulator anytime thereafter. Unfortunately some of the video images in
the test are poor and unclear, but the simulator is generally good value and quite realistic.
5.3
Carina
The position of the carina is surprisingly variable (see Section 4.5), and depends on body
shape, size, posture, operation (e.g., laparoscopy). Factors which alter the position of the
diaphragm generally move the carina in a similar direction. Consequently, one should
have a low threshold for using the fibrescope to check the position of the tubewhen in
doubtand especially in the various cases described in Section 4.5. The TEPID database
predicts the distance to the carina in supine patients reasonably well (see Section 6.4.3).
To measure the distance between the end of the ETT and the carina, first place the tip
of the fibrescope on the carina and then grip the fibrescope at the ETT swivel-connector.
Now, while maintaining the same grip on the fibrescope, slowly withdraw the fibrescope
until the end of the ETT just comes into view. Now the distance between your grip on the
fibrescope and the ETT swivel-connector is the same as the distance between the end of
the ETT and the carina.
5.4
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Left subcarina & beyond
Figures 5.1 and 5.2 show the anatomy as seen down the fibrescope by an anaesthetist
positioned at the head end of a supine patient (without the camera attachment.4 )
The key features to note are (a) the orifices of the second-order bronchi either side
of the left subcarina lie on a line running from top left to bottom right (see dashed line
in Figure 5.1), (b) the first part of the left lower-lobe bronchus is characterised by the
orifice of the bronchus to the apical segment of the left lower lobe at the 67 oclock
position, and (c) the orifice of the lingula bronchus (lower division of the left upper lobe
bronchus) is the first division (on the RHS) of the left upper lobe bronchus (see Section 4.4
for nomenclature).
Figure 5.1:
Left: The left subcarina viewed from the carina, constructed from a CT-scan (so-called virtual
bronchoscopy), showing the typical orientation of the left upper and lower second-order bronchi
when viewed from the head end in a supine patient. Copyright RWD Nickalls & J James 2005
Right: Schematic of the left picture, showing how the left upper-lobe bronchus divides into the
lingula bronchus (Li) and the left upper division bronchus (LUL). In addition we see the characteristic
position of the orifice of the apical bronchus (A) of the apical segment of the left lower lobe (LLL) just
inside the entrance of the left lower-lobe bronchus, typically at the 67-oclock position. Note the
typical orientation (straight dashed line) of the second-order bronchi either side of the subcarina. The
schematic shows the view associated with the closest safe approach of the end of the double-lumen
tube (dashed circle) with respect to the left subcarina and second-order bronchi. Copyright RWD
Nickalls 2005
4 See
Section 5.6.3
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Figure 5.2:
Top left: Left lung medial supine view.
Top right: Supine view of left lower-lobe bronchus.
Bottom: Close up view of the left supine hilum.
Note that the lung is shown in the supine position being viewed medially (cf. Figure 4.6), and hence
the orientation of the left subcarina here is consistent with the images in Figure 5.1. Since this view
also has the same orientation as that seen down the bronchoscope (viewed from the head end), it
makes the anatomy much easier to understand. For example, we can now see clearly how in the
supine position the bronchus to the apical segment (yellow) of the left lower-lobe descends almost
vertically down from the first part of the lower lobe bronchus (see also Figure 5.1 opposite). (From
Brock (19421944), with permission).
5.5
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Right subcarina & beyond
Figure 5.3 shows the right upper lobe and the typical arrangement of the three bronchopulmonary segments.
Figure 5.3:
Left: The RUL viewed from the right main bronchus in the supine position, showing the typical
orientation of the three bronchopulmonary segments; apical (blue), posterior (red), anterior (green).
Right: Lateral prone viewcf. Figures 4.5 and 5.4 (From Brock (19421944), with permission).
Figure 5.4 shows the anatomy as seen down the bronchoscope by an anaesthetist
positioned at the head end of a supine patient (without the camera attachment.5 ) While
the entrance to the right upper lobe is straightforward to recognise, its exact distance from
the carina is fairly variable. The part between the right upper lobe and the middle lobe
bronchus is known as the lower part of the right main bronchus.6
The key bronchoscopic features to note are (a) the entrance to the right upper lobe,
and the configuration of its immediate subdivisions,7 (b) the orifice of the bronchus to
the apical 8 segment (yellow) of the lower lobe typically at the 56 oclock position, and
(c) the orifice of the middle lobe bronchus typically at the 122 oclock position.
5 See
Section 5.6.3
known as the bronchus intermediussee Section 4.4 for correct nomenclature.
7 Typically three symmetrical sub-bronchi as shown in Figure 4.7but quite variable.
8 Sometimes known (incorrectly) as the superior segmentsee Section 4.4.
6 Historically
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Figure 5.4:
Top left: Right lung medial supine view. Top right: Supine view of right lower lobe bronchus.
Bottom: Close up view of the right supine hilum.
Note that the lung in these views is shown in the supine position (cf. Figure 4.5). The orifice of the
bronchus to the apical segment (yellow) of the lower lobe is typically in the 56 oclock position.
The orifice of the middle lobe bronchus is at the same level but in the 122 oclock position. (From
Brock (19421944), with permission).
5.6
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Image orientation
A significant but seemingly neglected aspect of the fibreoptic bronchoscope (fibrescope)

is the influence of the 3-D geometry of the combined set of optical fibres on the fidelity
of the perceived orientation of the viewed image associated with (a) axial rotation, and
(b) bending of the fibrescope. This is an interesting, if somewhat non-intuitive, feature
of fibreoptics which has a significant bearing on the interpretation of the viewed images.
Surprisingly, I have not as yet found any texts which discuss this.
It is important to be aware of this aspect of fibreoptic geometry, since appreciation
of position within the essentially fractal structure of the bronchial tree is largely a matter
of orientation and knowledge of asymmetric anatomical features. In my experience axial
rotation (Section 5.6.1) can cause gross distortion of image orientation, whereas that
associated with bending (Section 5.6.2) is generally minimal in a clinical setting.
To further complicate matters, these effects vary depending on whether the fibrescope
is being used normally (monocular-mode) or with the camera attachment (camera-mode).
We will address camera-mode at the end, but in the meantime unless specified, we will
assume that we are dealing with normal monocular-mode.
5.6.1
Axial rotation
Under normal circumstances (monocular-mode) when a fibrescope is rotated axially (and

able to freely rotate throughout its length), the visual image remains fixed (on the retina)
providing the observers head is fixedand hence the image does not rotate. However, if,
during manual proximal axial rotation, the fibrescope is gripped distally (i.e., fails to rotate
synchronously with the proximal end) then the observer (fixed) will see the image rotate
with, and in the same sense as, the proximal end of the fibrescope.
Consequently, I routinely use the following simple manoeuvre to determine whether
a given image reflects the true orientation of the object, namely:- manually rotate the
fibrescope (axially) back and forth slightly and observe whether the image rotates accordingly or not. If the image fails to rotate (i.e., the fibrescope is not gripped or restricted
distally) we can be confident 9 that the image shows the true orientation of the object, in
which case the observed orientation can be safely used to guide the observer regarding true
location within the bronchial tree.
If the image does rotate with the fibrescope (i.e., the fibrescope is gripped or restricted
distally), then a situation of false orientation can be said to exist, and hence the orientation
must be assumed to be false unless proven otherwise,10 in which case the user should not
place any reliance on the perceived orientation of the image when determining location. In
this case, only those anatomical landmarks having a known asymmetry can be relied upon
for determining location within the bronchial tree.
9 Because
no rotation implies that the fibrescope is not gripped, and therefore we know the view is true.
the same way that although a stopped watch will occasionally be correct (twice a day if it is an analogue
watch), in practice the time shown must be assumed to be false until proven otherwise.
10 In
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For example, the left upper- and lower-lobe orifices are orientated either side of the
left subcarina typically on a line running from top-left to bottom-right when viewed in a
supine patient from the head end (see Figure 5.1). If the fibrescope is gripped sufficiently
so that false orientation exists, then the apparent orientation of the left subcarina will vary
with the rotation of the fibrescope. Consequently, the anaesthetist may be misled by the
perceived orientation unless the existence of false orientation is checked for (see above)
and recognised. If false orientation is confirmed, then the anaesthetist will need to check
for known asymmetries (e.g., the location of the bronchus to the apical segment of the left
lower lobe) in order to confirm that the object in question is actually the left subcarina.
Naturally, in the context of thoracic surgery, one must be alert to the posibility that
local pathology may alter the expected orientation of structures.
5.6.2
Bending
As the fibrescope passes further into the bronchial tree, it is necessarily bent in various
directions. For example, in order to look at the left subcarina the fibrescope must pass
down the trachea (inclined approximately 15 degrees below the horizontal) and then down
the left main bronchus (deviated about 45 degrees towards the left). Bending the fibrescope
successively through these two directions results in the tip of the fibrescope being rotated
axially in a clockwise direction (compared with a straight fibrescope held horizontally
in the direction of the trachea), resulting in a small false anti-clockwise rotation of the
image of the left subcarina. The magnitude of the image rotation is the product of the first
angle multiplied by the sine of the second angle, and in this particular example would be a
barely noticeable 10 degree anticlockwise rotation,11 namely 15 sin 45 = 106 .
This represents another interesting, if somewhat even more non-intuitive, example of
orientation distortion arising from the 3-D geometry of the fibrescope. If you removed the
left main bronchus, mediastinum and right lung so as to be able to look directly at the left
subcarina in the supine position (see Figure 5.2) you would see the true orientation, as
shown by a CAT scan (see Figure 5.1).
5.6.3
Camera-mode
A camera attachment is often used with the fibrescope for teaching purposes, and also to
facilitate visualisation during percutaneous dilational tracheostomy.
Hazard for the unwary: It is very important to appreciate that camera-mode introduces two significant differences with respect to image orientation compared with
monocular-mode, and hence the orientation must be assumed to be false unless proven
otherwise. Firstly, the camera introduces a systematic and arbitrary image rotationsince
11 Note
that assigning a negative sign to the directions Lower and Left (and conversely)when viewed
monocularly from the head-end of a supine patientassociates anticlockwise with +ve, and clockwise with
ve image rotation. Thus, in the above example of the left subcarina, we have (15 ) (sin 45 ) = +106 ,
i.e., there is anticlockwise image rotation.
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it can be attached to the eye-piece in any position. Second, the camera reverses the axial
rotation effect on the screen image compared to monocular-mode.
For orientation to be correct during camera-mode, the camera position relative to the
bronchoscope needs to be calibrated against reality; i.e., when attaching the camera
one must first rotate it relative to the bronchoscope in order to align the screen image
appropriately with the patient before locking it in position. For example, when using
camera-mode while performing a tracheostomy, we first calibrate by rotating the camera
relative to the bronchoscope until anterior movement on the trachea corresponds with
vertical motion on the monitor/screen. Failure to calibrate accurately can result in a true
anterior indentation of the trachea appearing instead to be from one side.
As before, there are two scenarios to consider: (1) fibrescope free to rotate, and
(2) fibrescope gripped distally.
1. Fibrescope free to rotate: When the fibrescope-camera unit is rotated axially the
screen image rotates in the opposite direction, since the image mapping from the
camera to the monitor screen is fixed [in monocular-mode, assuming the viewers
head is fixed, there is no such rotation]
This is typically the situation when surgeons use the camera attachment on a fibrescope passed down the lumen of a rigid bronchoscope, since in this setting the
fibrescope is always free to rotate as there is nothing to grip it.
2. Fibrescope gripped: If the fibrescope is gripped distally while the proximal end is
manually rotated, then the screen image does not rotate. [in monocular-mode there
is rotation in the same direction]
This situation often arises when the fibrescope is passed down an endotracheal tube,
since the fibrescope is usually gripped to some extent by the rubber air-tight seal at
the entrance of the endotracheal tube.
5.7
5.7.1
Anaesthesia for bronchoscopy
Short duration
Intermittent boluses of propofol, suxamethonium and remifentanil 12 increments.
5.7.2
Long duration
Propofol TIVA is particularly useful for prolonged bronchoscopy (e.g., for reboring tracheal
tumours, multiple biopsies, insertion of stents.13 ) With the Alaris pump use the Schnider
12 See
Section 8.4.
Montgomery tubes (see Section 3.9)
13 e.g.,
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algorithm for propofol TCI,14 and the Minto algorithm for remifentanil TCI (Absalom
and Struys 2007), since both of these use the Lean Body Mass (LBM) calculated from the
entered total body weight and height. An arterial line is worth considering, especially with
frail patients and difficult cases.
An induction plasma concentration (Cp) target for adults of 7 g/ml followed (once
the rigid bronchoscope has been inserted) by a maintenance target of about 56 g/ml
plus a narcotic (e.g., remifentanil) generally works well (reduce these somewhat if the
patient is elderly and/or frail). Consider an initial remifentanil bolus of about 100 g (for a
70 kg patient) followed by about 250 g/hr. Sometimes it is more convenient to give the
remifentanil as intermittent boluses rather than run a second pump. A long acting relaxant
is generally best, but sometimes it is worth starting with intermittent suxamethonium and
converting later if necessary.
Historically, a suxamethonium infusion would often have been used in this setting;
it can still be useful on occasions. The technique for adults is to use 500 mg in 500 mls
salinerun at about 3 mg/min (a normal blood giving-set has 25 drops 1 ml, so 3 mg/min
is 75 drops/min). Avoid using the infusion for more than about 30 mins (in order to keep
the total suxamethonium dose less than about 3 kg), and always use a nerve stimulator
to help minimise the total dose and avoid a type-II block (always take care to label the
infusion very clearly).
Absalom AR and Struys MMRF (2007). Overview of target controlled infusions
and total intravenous anaesthesia. 108 pp. (Academia Press, Ghent, Belgium;
http://www.academiapress.be/) ISBN 978-90-382-11077 [excellent small book
sponsored by Cardinal Health, Basingstoke, Hampshire, UK.]
Aly EE (2002). Anaesthesia for bronchoscopy. Anaesthesia; 57, 9394. (letter and
reply) [using propofol and remifentanil]
Gillbe C and Hillier J (2005) Anaesthesia for bronchoscopy, tracheal and airway
surgery. Anaesthesia and Intensive Care Medicine; 6, 422425.
McKeage K and Perry CM (2003). Propofol. A review of its use in intensive care
sedation of adults. CNS Drugs; 17, 235272. [excellent]
Prakash N et al. (2001). Effects of remifentanil on haemodynamic stability during
anaesthesia for rigid bronchoscopy. Anaesthesia; 56, 576580. [see Aly 2002]
Purugganan RV (2008). Intravenous anesthesia for thoracic procedures. Current
Opinion in Anaesthesiology; 21, 1-7.
14 Note that there is a potential problem when using TCI with lean body mass (LBM) algorithms in obese
patients. For any given height the calculated LBM rises to a maximum and then falls as weight increases, and
so in obese patients you need to use that body weight which generates the maximum LBMsee Absalom and
Struys (2007), pp. 3033 for details and useful charts.
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Russell D (2002). Practical aspects of target-controlled infusion. Anaesthesia

Rounds; (TMG Healthcare Communications Ltd., 62 Stert Street, Abingdon, Oxfordshire, UK). 27 pp. + CD ROM. [Sponsored by AstraZenica]
5.7.3
Local anaesthesia & sedation
Conacher ID and Curran E (2004). Local anaesthesia and sedation for rigid bronchoscopy for emergency relief of central airway obstruction. Anaesthesia; 59,
290292. [describes use of oral and trans-cricothyroid lignocaine, propofol and
midazolam]
5.7.4
Venturi jet ventilation
The first practical venturi jet system for ventilating down a rigid bronchoscope was developed in 1967 by Richard Douglas Sanders (Buckley 1992; Sanders 1967; Aikens and
Bancroft 1977; Maltby 2002). See article by Baraka et al. (2001) for details of its use
for ventilating down an endotracheal tube (above a tracheal stenosis). Robinson (1997)
describes the use of a Hunsaker jet ventilation tube. The potential dangers (e.g., pneumothorax) associated with jet ventilation via exchange catheters is addressed by Benumof
(1991). See also Section 3.10 on difficult airways.
5.8
References
Bronchoscopy Atlas: html://www.int-med.uiowa.edu/research/tlirp/

BronchoscopyAtlas/Home.html
Baraka AS, Siddik SS, Taha SK, Jalbout MI and Massouh FM (2001). Low frequency
jet ventilation for stent insertion in a patient with tracheal stenosis. Can. J. Anaesth.;
48, 701704.
Buckley JJ (1992). Richard Douglas Sanders, MD. Anesthesiologist, inventor,
painter (19061977). In: Fink BR, Morris LE, Stephen CR (Eds.) The history of
anesthesia third international symposium. (Wood Library-Museum of Anesthesiology). p. 7277. [cited from Maltby 2002]
Benumof JL (1999). Airway exchange catheter: simple concept, potentially great
danger [editorial] Anesthesiology; 91, 342344.
Carden E, Burns WW, McDevitt NB and Carson T (1973). A comparison of venturi
and side-arm ventilation on anesthesia for bronchoscopy. Can. Anaesth. Soc. J.; 20,
569574.
Carden E and Schwesinger WB (1973). The use of nitrous oxide during ventilation
with the open bronchoscope. Anesthesiology; 39, 551555.
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Carlon GC, Ray C, Griffin et al. (1983). Tidal volume and airway pressure on high
frequency jet ventilation. Crit. Care Med.; 11, 8386.
Cromwell SB, Hirshman CA, McCullough RE and Cohen PJ (1975). Simplified
delivery of volatile anesthetics for bronchoscopy. Anesthesiology; 43, 377379.
Maltby RJ (Ed.) (2002). Sanders injector: Richard Douglas Sanders (19061977).
In: Notable names in anaesthesia. (Royal Society of Medicine Press, London).
p. 187189. [ISBN 1853-155-128].
Miyasaka K, Sloan IA, and Froese AB (1980). An evaluation of the jet injector
(Sanders) technique for bronchoscopy in pediatric patients. Can. Anaesth. Soc. J.;
27, 117124.
OSullivan TJ and Healy GB (1985). Complications of venturi jet ventilation during
microlaryngeal surgery. Arch. Otolaryngol.; 111, 127131.
Patel C and Diba A (2004). Measuring tracheal airway pressures during transtracheal
jet ventilation: an observational study. Anaesthesia; 59, 248251. [carinal pressure
changes were small; approximately 13 mm Hg only]
Robinson RJ (1997). One-lung ventilation for thoracotomy using a Hunsaker jet
ventilation tube. Anesthesiology; 87, 15721574.
Sanders RD (1967). Two ventilating attachments for bronchoscopes. Delaware Med.
J.; 39, p. 170176.
Spoerel WE and Grant PA (1971). Ventilation during bronchoscopy. Can. Anaesth.
Soc. J.; 18, 178188.
5.8.1
Complications
Suratt PM, Smiddy JF and Gruber B (1976). Death and complications associated
with fibreoptic bronchoscopy. Chest; 64, 747751.
5.8.2
Fibreoptic intubation
Hawkins N (2000). Fibreoptic intubation. (Greenwich Medical Media Ltd, Lond.)

Murphy PA (1967). Fibre-optic endoscope used for nasal intubation. Anaesthesia;
22, 489.
Taylor PA and Towey RM (1972). The bronchofibrescope as an aid to endotracheal
intubation. Br. J. Anaesth.; 44, 611.
Mason RA (1992). Learning fibreoptic intubation: fundamental problems. Anaesthesia; 47, 729.
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Mason RA (1998). Education and training in airway management. Br. J. Anaesth.;

81, 305307.
Morris IR (1994). Fibreoptic intubation. Canadian J. of Anaesthesia; 41, 996.
Ovassapian A (1996). Fibreoptic endoscopy and the difficult airway. 2nd ed.
(Lipincott-Raven, Philadelphia, USA).
6
Tubes and bronchus blockers
Two recent articles are worth noting.
Brodsky JB (2009). Lung separation and the difficult airway. Br. J. Anaesth.;
103 (Suppl. I): i66i75. [137 refs]
Campos JH (2009). Update on selective lobar blockade during pulmonary resections.
Current Opinion in Anaesthesiology; 22, pp. 1822.
6.1
The Univent tube, 1984
The Univent tube is a combined blocker and ETT, and made in Japan. The literature
suggests that they are not as good as a well positioned double-lumen tube, but may well be
useful in unusual situations.
Campos JH, Reasoner DK and Moyers JR (1996). Comparison of a modified doublelumen endotracheal tube with a single-lumen tube with enclosed bronchial blocker
[Univent tube]. Anesthesia and Analgesia; 83, 12681272. [conclusion:- DLT better
than Univent tube (more malpositions with the Univent tube)]
Hultgren BL, Krishna PR and Kamaya H (1986). A new tube for one lung ventilation:
experience with the Univent Tube. Anesthesiology; 65(3A), A481.
Inoue M, Shohtsu A, Ogawa J et al. (1984). Endotracheal tube with movable blocker
to prevent aspiration of intratracheal bleeding. Annals of Thoracic Surgery; 37,
497499.
Kamaya H and Krishna PR (1985). New endotracheal tube (Univent tube) for
selective blockade of one lung. Anesthesiology; 63, 342343.
92
CHAPTER 6. TUBES AND BRONCHUS BLOCKERS
6.2
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The Hunsaker jet ventilation tube

6.3
Bronchus blockers
Although Fogarty catheters have been used as bronchial blockers in adults (Ginsberg
1981) and in children (Tan and Tan-Kendrick 2002), special bronchus-blocker kits are
now available. The one we generally use at the City Hospital is the Arndt endobronchial
blocker set manufactured by Cook.1 This consists of a 9 Fr-gauge bronchus blocker
(78 cm) having a blue balloon at the end, together with a special tube-adaptor having three
channels one each for anaesthesia gases, the bronchus blocker, and the fibrescope. A new
form of blocker has recently been described by Mungroop et al. (2010).
The Arndt bronchus blocker has a small loop at its tip, and is guided into position by
first sliding it along the fibrescope, and then positioning it under direct vision. The art
seems to be to place the tip of the fibrescope just inside the required main bronchus (i.e., not
right down to the subcarina) 2 and then push the blocker down. Once the blocker falls off
the end of the fibrescope it will be visible and can then be manipulated into position under
direct vision. It is important to make sure that both the end loop and balloon remain within
the main bronchus (i.e., do not migrate further down into a second-order bronchus where
they might stray into surgical territory).
Note that two slightly different shaped balloons are supplied; one is long and thin (for
the left main bronchus), and the other is fatter in the middle (for the right main bronchus).
The length of each is about 225 cm (i.e., about half the length of the left main bronchus
in an average adult man).
Campos JH (2003). An update on bronchial blockers during lung separation techniques in adults. Anesthesia and Analgesia; 97, 12661274.
Culp WC and Kinsky MP (2004). Sequential one-lung isolation using a double
Arndt bronchial blocker technique. Anesthesia & Analgesia; 99, 945946.
Ginsberg RJ (1981). New technique for one-lung anaesthesia using an endobronchial
blocker. Journal of Thoracic and Cardiovascular Surgery; 82, 542544.
Mungroop HE, Wai PTY, Morei MN, Loef BG and Epema AH (2010). Lung
isolation with a new Y-shaped endobronchial blocking devicethe EZ-blocker. Br.
J. Anaesth.; 104, 119120.
1 William Cook Europe A/S, Sandet 6, DK-4632 Bjaeverskov, Denmark;
http://www.cookmedical.com/cc/products.do/
2 Described to me by Dr K Alagesan.
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Tan GM and Tan-Kendrick APA (2002). Bronchial diameters in childrenuse of

the Fogarty catheter for lung isolation in children. Anaesthesia & Intensive Care;
30, 615618.
Uzuki M, Kanaya N, Mizuguchi A et al. (2003). One-lung ventilation using a new
bronchial blocker in a patient with tracheostomy stoma. Anesthesia and Analgesia;
96, 15381539.
6.4
Double-lumen tubes
Several modern well engineered versions are available (e.g., Mallinckrodt, Portex, Rusch).
While none is perfecteach has its own advantages and disadvantagesall are certainly far
better than the old red-rubber versions. The Mallinckrodt BronchoCath would seem to be
the best of those currently available in the UK as regards ease of placement, bronchoscopic
access, and having good robust connectors. Both Portex and Rusch also make doublelumen tracheostomy tubes (see Section 3.2).
6.4.1
History
Initial progress in thoracic anaesthesia seems to have been held up largely by trying to
figure out how to overcome the problems associated with pneumothorax in a spontaneously
breathing patient. Although physiologists have been ventilating the lungs of animals using
bellows via a tube in the trachea for centuries,3 there seems to have been a mental-block
about this in the medical community until relatively recently.
The double-lumen tube was originally developed by the physiologist Henry Head
(1889). He was interested in separating gas entering and leaving each of the two lungs in
animals. His tube was widely used for determining differential lung function well before it
was used in thoracic anaesthesia (Comroe 1977, p. 15).
In 1949 Carlens (19081990) designed a double-lumen endobronchial tube for use in
broncho-spirometry (Carlens 1949), and subsequently for one-lung anaesthesia (Bjork and
Carlens 1950). A series of different modifications by Bryce-Smith 4 (1959), Bryce-Smith
and Salt (1960), White (1960a) and Robertshaw (1962) followed. Note that the routine use
of one-lung ventilation for lung resection was first advocated only in 1957 (see Slinger
1990).
3 The physicist Robert Hooke showed that a dog could be kept alive indefinitely by IPPV via the trachea using
a set of bellows (Hooke, 1666). Importantly, he also indicated in this paper that after making numerous holes in
the lungs, the dog could be maintained just as easily using a continuous through flow of air. Hence he proved that,
contrary to contemporary thinking, the physical movement of the lungs did not of itself benefit an animal other
than by simply ensuring the necessary movement of air in and out of the lungs, and that the lungs were simply a
device for oxygenating the blood flowing through them. Note that the book De Motu Cordis by William Harvey
(15781657) describing the circulation of blood through the lungs was published in 1632.
4 Anaesthetist Roger Bryce-Smith (19182006) died in March 2006. See his obituary in British Medical
Journal (2006); 332, 1277 (May 27).
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See also articles on the general history of endobronchial anaesthesia (White 1960b), and
on the history of the various tubes (Pappin 1979) and instruments (Hillard and Thompson
1963). See also the cardiothoracic section in Rushman, Davies and Atkinson (1996) for
various historical references.
The Robertshaw tube (1962)
A red-rubber tube with D-shaped lumina which has a lower resistance to gas flow than
either the Carlens or White double-lumen tubes (Robertshaw 1962). Angular deviation
of the endobronchial part from the midline is 20 on the right and 45 on the left. Three
sizes only; large, medium, small.
References
Bjork VO and Carlens E (1950). The prevention of spread during pulmonary
resection by the use of a double-lumen catheter. Journal of Thoracic Surgery; 20,
151 [from Pappin 1979]
Brodsky JB (2005). The evolution of thoracic anesthesia. Thoracic Surgery Clinics;
15, 110.
Bryce-Smith R (1959). A double-lumen endobronchial tube. Br. J. Anaesth.; 31,
274 [from Pappin 1979]
Bryce-Smith R and Salt R (1960). A right-sided double-lumen tube. Br. J. Anaesth.;
32, 230 [from Pappin 1979]
Carlens E (1949). New flexible double-lumen catheter for broncho-spirometry.
Journal of Thoracic Surgery; 18, 742746 [from Maltby 2002]
Press, Menlo Park, California, USA).
Hammond and Wright (1984). Comparison of the resistances of double-lumen
endo-bronchial tubes. Br. J. Anaesth.; 56, 299301.
Head H (1889). On the regulation of respiration. Journal of Physiology, 10, 170.
Hillard EK and Thompson PW (1963). Instruments used in thoracic anaesthesia. In:
Thoracic Anaesthesia (2nd edn) (Ed. by WW Mushin), p. 267. (Blackwell Scientific
Publications, Oxford, UK). [from Pappin 1979]
Hooke R (1666). An account of an experiment made by Mr. Hook, of preserving animals alive by blowing through their lungs with bellows. Philosophical
Transactions of the Royal Society; 16651678; vol 2, vol 2 1666-1667. [http:
//www.journals.royalsoc.ac.uk/]
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Maltby RJ (Ed.) (2002). Carlens catheter: Eric Carlens (19081990). In: Notable
names in anaesthesia. (Royal Society of Medicine Press, London). [ISBN 1853-155128].
Pappin JC (1979). The current practice of endobronchial intubation Anaesthesia;
34, 5764. [includes good history of double-lumen tubes]
Robertshaw FL (1962). Low resistance double-lumen endo-bronchial tube. Br. J.
Anaesth.; 34, 576579.
Rushman GB, Davies NJH and Atkinson RS (1996). A short history of anaesthesia:
the first 150 years. (Butterworth-Heinemann, Oxford, UK) ISBN 0-7506-3066-3.
Slinger PD (1990). Anaesthesia for lung resection. Can. J. Anaesth.; 37, SxvSxxiv.
[106 refs; part of the refresher course outline]
White GMJ (1960a). A new double-lumen tube. Br. J. Anaesth.; 32, 232.
White GMJ (1960b). Evolution of endotracheal and endobronchial intubation. Br. J.
Anaesth.; 32, 325.
6.4.2
The BronchoCath
[Mallinckrodt Medical (UK) Ltd, 11 North Portway Close, Round Spinney, Northampton,
NN3-8RQ, UK.]
The BronchoCath (Mallinckrodt Medical, 1983) is a disposable polyvinylchloride
(PVC) low resistance double-lumen endobronchial tube. Angular deviation of the endobronchial part from the midline is 15 on the right and 30 on the left. Five sizes for the
left, four sizes for the right (see Table 6.1).
Table 6.1:
BronchoCath
41 Fr
39 Fr
37 Fr
35 Fr
32 Fr
28 Fr
Body of tube
OD mm
1415
1314
1314
1213
L endobronchial
OD mm
106
101
100
95
The Mallinckrodt bronchial cuff was originally clear and transparent (just like the
tracheal cuff). It was subsequently changed to the current blue colour following complaints
that the cuff was difficult to visualise during fibreoptic bronchoscopy.
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Table 6.2:
BronchoCath
Large
Medium
Intermediate
Small
V. Small
Child
Size
41 Fr (L/R)
39 Fr (L/R)
37 Fr (L/R)
35 Fr (L/R)
32 Fr (L only)
28 Fr (L only)
Length to teeth
30 1 cm
28 1 cm
27 1 cm
26 1 cm
Table 6.3:
This Table is from Brodsky et al. 1996
Measured tracheal
width on chest x-ray
18 mm
16 mm
15 mm
14 mm
Predicted L
bronchus width
122 mm
109 mm
102 mm
95 mm
Size
41 Fr
39 Fr
37 Fr
35 Fr
Although Mallinckrodt recently made some improvements to their left-sided tube, in

my view these tubes still have serious design faults; for example (a) the left endobronchial
tip is bevelled medially (should be bevelled slightly laterally to face the subcarina), (b) the
right endobronchial tube should have a much larger right upper-lobe orifice.
Brodsky JB and Macario A (1995). Modified BronchoCath double-lumen tube.
J. Cardiothorac. Vasc. Anesth.; 9, 784785. [see also editorial pp. 117118]
6.4.3
The tube database (TEPID) 5
Several studies have tried to correlate both tube size and depth of tube insertion with a
single body parameter (e.g., height, weight or BMI), but none has proved particularly
useful (see references below). This suggests that using only a single parameter is probably
not a useful approachnot unexpected since tube distance from the teeth is markedly
influenced by both diaphragm position (& hence with the degree of abdominal obesity)
and height. Consequently my TEPID database uses three parameters (height, weight and
gender), and gives quite accurate predictions (560+ patients in the database).
The TEPID database of double-lumen tubes (DLT) can be useful for predicting both
tube size and length for a given patient. For example, the predicted double-lumen tube
lengths for an average supine male and female are given in Table 6.4.
5 Tube and EPIdural Database (TEPID). This is a collection of thoracic epidural and tube data accumulated
over many years. It is freely available from http://www.nickalls.org/dick/xenon/rwdnXenon.html
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The TEPID program also gives the position of the DLTs tracheal orifice, since this
can be used to estimate the likely carina position (by adding approximately 15 cm, as the
tracheal orifice of the double-lumen tube is typically 12 finger-breadths 6 from the carina)
Table 6.4:
TEPID data for length of double-lumen tube and tracheal orifice position (cm)
in an average supine male and female. In the UK the average male and female
heights are approximately 5ft 9in (176 cms) and 5ft 4in (164 cms) respectively.
See text regarding the value of the tracheal orifice measurement. The results are
given as: mean[range](n)
average male
average female
wt 76 75 kg
wt 67 75 kg
ht 176 75 cm
ht 165 75 cm
41L
30 [27532] (n=56)
39L
29 (n=1)
281 [2630] (n=15)
37L
273 [2629] (n=10)
35L
271 [26528] (n=8)
41R
291 [2830] (n=6)
39R
28 [275295] (n=4)
37R
266 [2529] (n=4)
35R
257 [2527] (n=4)
241 [21265] (n=67)
215 [18724] (n=41)
tracheal orifice
The TEPID database, together with a Perl program, is freely available. After entering
the patients height/weight/gender the program displays the relevant tube sizes and lengths
(single and double-lumen).
References
Bahk J-H (1999). Prediction of double-lumen tracheal tube depth. J. Cardiothoracic
Vasc. Anesth.; 13, 370371.
Benumof JL, Partridge BL, Salvatierra C and Keating J (1987). Margin of safety in
positioning modern double-lumen endotracheal tubes. Anesthesiology; 67, 729738.
Benumof JL (1988). Improving the design and function of double-lumen tubes. J.
Cardiothorac. Vasc. Anesth.; 2, 729733.
6 Measured
using a fibrescope.
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Brodsky JB, Benumof JL and Ehrenwerth J et al. (1991). Depth of placement of

double-lumen endobronchial tubes. Anesthesia and Analgesia; 73, 570572.
Brodsky JB, Macario A and Mark JBD (1996). Tracheal diameter predicts doublelumen tube size: a method for selecting left double-lumen tubes. Anesthesia and
Analgesia; 82, 861864.
Dyer RA, Heijke SAM, Russell WJ, Bloch MB and James MFM (2000). Can
insertion length for a double-lumen endobronchial tube be predicted? Anaesthesia
and Intensive Care; 28, 666668. [they compared (separately) height, weight, and
the external surface distance (sternal-angle to ear-lobe via mouth) and found no
useful correlation]
210214.
Kato H, Suzuki A, Nakajima Y, Makino H, Sanjo Y, Nakai T, Shiraishi Y, Katoh T
and Sato S (2009). A visual stethoscope to detect the position of the tracheal tube.
Anesthesia and Analgesia; 109, 18361842.
Slinger P (1995). Choosing the appropriate double-lumen tube; a glimmer of science
comes to a dark art [editorial]. J. Cardiothorac. Vasc. Anesth.; 9, 117118. [see also
article on pp. 7845]
Slinger PD (2007). Lung isolation review. (http://www.thoracic-anesthesia.
com/)
Yasumoto M, Higa K, Nitahara K, Shono S and Hamada T (2006). Optimal depth of
insertion of left-sided double-lumen endobronchial tubes cannot be predicted from
body height in below average-sized adult patients. European Journal of Anaesthesiology, 23, 4244. [Japanese subjects of height 155 cm]
7
now focus on the practical details of positioning double-lumen tubes and
the subsequent management of one-lung anaesthesia. The core skills are
(a) knowledge of the relevant anatomy, (b) some facility with the fibrescope,
and (c) a clear idea of what defines the optimum position of the tube or blocker. For
anaesthetic details regarding the standard range of thoracic operations/procedures see the
overviews by Sanders (2006) and by Pearce & Gould (2005). Thoracic anaesthesia was
the subject of an excellent recent issue of Anesthesiology Clinics (Slinger 2008).
Preoperatively it is important to look at both the chest X-ray and CT-scan for potential
problems not only with the operative side, but also with the dependent side and the trachea
for example, always check for a tracheal bronchus (see Ho et al., 2004). Listen to the
chest to identify, among other things, any silent areas; after intubation such areas might
otherwise mistakenly suggest tube malposition. In particular, note whether the upper lobes
sound clear or not. Always use a CVP line for a thoracotomy.
7.1
Right double-lumen tube
Owing to the hazard of obstructing the right upper-lobe bronchus, relatively few right-sided
tubes are usedprobably only when a left-sided tube or bronchus blocker cannot be used
(e.g., a sleeve resection of the left main bronchus).
7.2
Left double-lumen tube
For most left-lung surgery and all other thoracic surgery it is possible to use a left-sided
tube or a bronchus blocker. However, when planning to use a left-sided tube or blocker for
left lung surgery, it is a good idea to discuss this with the surgeons, just in case they are
100
CHAPTER 7. ONE-LUNG ANAESTHESIA
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expecting a right-sided tube to be used. For example, they might anticipate having to do a
sleeve resection for which you may not be able to use a left-sided tube.
Since a left sided tube is used for both left and right thoracic surgery the strategy while
on one-lung varies slightly depending on whether the endobronchial part of the tube is
in the top lung (operative side) or the bottom lung (dependent side). The position of the
patient (supine or lateral) also influences the strategy.
Top-side (left endobronchial tube): In this case the primary danger is that the bronchial
cuff may migrate back into the trachea and obstruct ventilation to the bottom lung. Consequently the strategy when on one-lung is to try and keep the bronchial cuff well below the
carina, and not to worry unduly if the tip of the tube gets fairly close to the left subcarina.
If when on one-lung, ventilation suddenly becomes obstructed, then this is almost
always because the bronchial cuff is obstructing the bottom lung, and so the solution is
(a) deflate the bronchial cuff temporarily, (b) push the tube further down the left main
bronchus, (c) re-inflate the cuff, and finally (d) check the cuff position with a fibrescope.
While you are on one-lung it is of no matter if the tip of the tube now obstructs the left
upper lobethe tube can be pulled back as necessary when returning to two-lungs, or
when the surgeon needs to staple a lobar bronchus.
Note that once the patient is in the lateral position, then the bulk of the cardiac output
is going to the bottom lung, and so inadvertently obstructing the upper-lobe prior to going
on to one-lung is not too problematicthe top lung will need to be collapsed anyway
once the surgeons open the chest. However, this is not the case while the patient is supine
(e.g., in the anaesthetic room) and significant desaturation may occur if the tube is pushed
too far down at this stage.
Bottom-side (left endobronchial tube): In this case the primary danger is that the tube
may migrate further down and obstruct ventilation to the left upper lobe. Consequently
the strategy when on one-lung is to try and keep the bronchial cuff close to the carina.
Sometimes the endobronchial part of the tube is slightly too long for the patient, such that
the tip is dangerously close to the left subcarina even when the cuff is at the carina, in
which case a smaller tube is necessary.
7.3
Placing double-lumen tubes
Is there an optimum method for placing a given double-lumen tube? If by optimum

we mean the most efficient sequence in the sense that information arising from each
manoeuvre builds logically on previous manoeuvres, then the answer would seem to
be yes. Prior to intubation it is important to exclude a supernumerary or displaced
tracheal bronchus (see Section 4.7) during bronchoscopy 1 . Once intubated, it makes
sense to start bronchoscopy with the tracheal side (view the carina via the tracheal lumen),
1 Typically this is performed by the surgeons; it is important to (a) check for a tracheal bronchus, (b) check the
position of the right upper lobe bronchus, and (c) suction any secretions, particularly in the bottom lung.
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and then progress to the endobronchial side, since information gathered by looking at
the tracheal side influences how one interprets findings on the endobronchial side. An
optimum sequence for positioning a double-lumen tube would seem to be something along
the following lines.
Listen to the chest preoperatively.
Bronchoscopy (to detect a tracheal bronchus, visualise the position of the RUL
orifice and configuration of its bronchopulmonary segments, suction secretions).
Insert double-lumen tube.
Stethoscope check (to detect upper-lobe obstruction by the tube),
Bronchoscope check:
tracheal side first (to see if the tube is down the correct side, and if there is any
bronchial cuff above the carina).
bronchial side second (fine-tune position of the end of the tube).
tracheal side again (check and fine-tune position of bronchial cuff).
Note that numerous studies have shown that double-lumen tubes are rarely optimumly
positioned without bronchoscopic fine tuning.
It is useful to consider the process of placing a double-lumen tube in several stages as
follows: (a) preparation, (b) intubation, (c) stethoscope check, (d) bronchoscopy check,
(e) final volume and pressure check, (g) turning the patient laterally. We now consider
these in order.
7.3.1
Preparation
Consider a secretion drying premed (e.g., hyoscine)

Hyoscine hydrobromide 2 (0204 mg IM 1 hour preop).
This greatly helps visualisation of the bronchial anatomy, and facilitates double-lumen
tube placement. I therefore routinely use a hyoscine premed when I intend to place
either a right-sided double-lumen tube or a bronchial blocker, as in these cases it helps
to have particularly good viewing conditions since correct placement is sometimes not
straight-forward.
Getting the timing/dose of hyoscine right is quite important, since the action of hyoscine
rarely lasts longer than about 90 mins in my experience.3 The doses I use are: average
adult female (0203 mg IM); average adult male (0304 mg IM).
2 Hyoscine hydrobromide (ampoules of 04 mg in 1 ml) Hyoscine is an anti-muscarinic agent; slightly sedating;
and sometimes results in a slowish heart rate. Important to use the full name on the prescription form to avoid
possible confusion with Buscopan (hyoscine butylbromide; 20 mg in 2 mls.)
3 It may therefore be better to use a longer acting agent like glycopyrollate instead, but I have not used it in
this setting.
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Check the tubes, cuffs and suction catheters

Double-lumen tubes.
Make sure you are familiar with the particular variety of double-lumen tube to
be used, and that all the appropriate sizes are available. Make sure the correct
connectors are available and that they all fit together. Check that the pilot balloons
connect to the correct cuffs (see Nystrom 2003) and that the cuffs are intact; tracheal
cuff (approx. 8 mls); bronchial cuff (approx. 34 mls).
Check the tube accommodates the intubating fibrescope.
If you are likely to need the small double-lumen tube (35 Fr), then check that the
fibrescope will pass through the tube. The Mallinckrodt BronchoCath sizes 4137 Fr
will always accept the 45 mm diam intubating fibrescope. However, sometimes the
35 Fr (small) tube will not accept the 45 mm fibrescope, so it is as well to check
this before (i.e., find a 35 Fr which will accept the fibresope). As regards lubrication,
consider using Xylocaine spray as this seems to be much better than KY-jelly.
Check the suction catheters are long enough (165 cms)
The suction catheters should be about 5 cm longer than the double-lumen tube.
Consider starting with a single-lumen tube
In potentially difficult patients, and those likely to be in the anaesthetic room for a long
time (e.g., oesophagectomy and other major cases), consider starting with a single-lumen
tube, and placing the double-lumen tube as the final anaesthetic-room procedure once all
the lines are in. This has the advantage of allowing you to place the CVP, arterial line,
NG-tube, bladder catheter etc. without worrying whether the double-lumen tube may have
moved in the meantime, possibly resulting in the upper-lobe becoming obstructed (see
Section 7.3.3). I therefore routinely adopt this approach in all cases needing a CVP line.
Anticipate the insertion distance of the double-lumen tube
The TEPID database of tubes is useful for predicting both tube size and length for a given
patient (see Section 6.4.3). In general the required size for an average male and female is
41 Fr and 39 Fr respectively. The distances are roughly as follows: 41 Fr (3031 cm), 39 Fr
(29 cm), 37 Fr (2728 cm), 35 Fr (2526 cm). A rough rule for the number of centimetres
is the French gauge minus 10.
7.3.2
Intubation
Apply gel lubrication to the tracheal cuff as it reduces leakage past the cuff (Sanjay et al.
2006). Use the stylette to give a suitable bend on the endobronchial part of the tube, and
insert with the curve facing upwards. Once the bronchial cuff is through the cords rotate
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the tube back into its anatomical position, and push gently into position. Since the trachea
has only a thin layer of muscle posteriorly, it is easily perforated. If there is any resistance
then consider trying a smaller tube.
Both cuffs are extremely delicate and are easily torn. Consequently take great care
not to let the cuffs touch the teeth; consider using a protective gauze/drape if necessary.
Always check that the cuffs are still intact following intubationit will be difficult to
change the tube once the patient is on the table.
Once the tube is in place, then inflate the tracheal cuff so you can ventilate both lungs
satisfactorily. Then inflate the bronchial cuff with a small amount of air (say, 23 mls) just
so that you will be able to see the cuff when viewing with the fibrescope. Its not important
to have the bronchial cuff fully inflated at this stage.
Railroading the tube
Sometimes intubation can be extremely difficult, and the only way is to railroad the tube
over a bougie. Check that the bougie is long enoughat least 60 cm long (i.e., 35 + 25 cm).
Railroading a double-lumen tube usually requires a fair bit of force, and so some care is
necessary in order not to damage the trachea or lung. The aim is to keep the end of the
bougie above the carina at all times.
Since the carina is approximately 2425 cms from the teeth (adult male), then in order
to keep the end of the bougie above the carina (to avoid damage from inadvertently pushing
it in too far) it is useful to make a clear mark on the bougie at about 24 cms, and maintain
this at or above the teeth when railroading the tube. Since all tubes are now transparent,
this mark will be easily visible through the tube wall.
If encountering problems, consider placing a single-lumen tube and checking the
anatomy with a fibrescope
If there are problems positioning the double-lumen tube then it is sometimes a good idea
simply to replace it with a single-lumen tube and check the anatomy carefully with the
fibrescope, rather than run the risk of making things worse (e.g., obstructing an upper lobe
and collapsing it).
Sometimes just checking you can identify the anatomy, or even measuring the distance
to the carina or left subcarina, will greatly help during the next attempt at placing the
double-lumen tube. Consider railroading the double-lumen tube over the fibrescope.
Consider using a single-lumen tube and a bronchus blocker. The TEPID database can be a
useful guide for tube size and length, especially in short patients (see Section 6.4.3).
The commonest initial problems are (a) the tube keeps going down the wrong side,
(b) the endobronchial part of the tube is too big and fails to go down the main bronchus,
(c) the tube is in too far, (d) sometimes the endobronchial part of a left-sided tube is slightly
too long for the patient, and a smaller tube is needed.
7.3.3
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Stethoscope check
Once the double-lumen tube is in place first check that there is good air entry
(i.e., with no added sounds) to both upper lobes by listening with a stethoscope just
inferior to (and touching) the clavicles. Air-entry here should sound exactly the
same as for the lower lobes (see Chapter 4 for surface markings). If there are any
added sounds in the upper-lobe zone (or if it is quiet) then gently withdraw the tube
about 1 cm at a time while listening until the air entry improves.
For example, if after placing a left double-lumen tube we hear added sounds over
the right upper lobe, then we can assume (providing it was clear before) that the tube
has gone down the wrong side. Conversely, if the left upper lobe is now quiet, then
we know the tube is down the correct side, and all we need to do is pull it back until
we have good air entry in the left upper lobe.
It is important to auscultate the upper lobes immediately and carefully after intubation
because an undetected obstructed upper-lobe will very quickly collapse (within about
5 minutes); the speed being hastened partly by the high inspired oxygen typically
used at this stage, and partly by the increased pressures generated by the ventilator.4
Once the lobe has collapsed, auscultation over the lobe may well seem quite normal,
since the remaining lung expands to fill this space.
If the collapsed lung is on the operation side (top side) then this will be revealed at
thoracotomy.5 However, if this occurs on what will be the dependent side (bottom
side) and goes un-noticed, then this could be disastrousmost probably resulting in
severe hypoxia when on one lung.
Next, check air-entry to the lower lobes by listening on the mid-axillary line below
the level of the nipples (see Figures 4.1 and 4.2 for surface markings).
Now check lung isolation. Clamp each side in turn and check (a) that there is no
air-entry on the clamped side (add air to the bronchial cuff as necessary), and (b) that
there is good air-entry on the opposite side. It should be easy to squeeze the bag
when on one lungany significant resistance at this stage is usually a sign that
the tube is not correctly positioned. If in doubt, let the bronchial cuff down and
then check further with the fibrescopethe bronchial cuff can be inflated later after
confirming that the tube is correctly positioned.
Mark the tube at the teeth (with a felt-tip pen) and then tie the tube in place using a
rolling-hitch, as described recently by Frank Aldridge (Aldridge 2006), making sure
the mark is visible above the knot and from the top side (so you can see it once
the patient is in the lateral position). This mark will be useful during the operation
4 Note that the pressures generated by the ventilator tend to keep a partially obstructed lobe open. Once a lobe
is totally obstructed it will experience a net compression from the lung surrounding it. This, plus a high FIO2 ,
results in rapid collapse of the lobe.
5 This may be associated with some desaturation, especially while supinesee Section 7.2
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(to indicate if the tube has moved), and also at the end of the operation when the
patient is supine again (the tube can be pulled back to its original anaesthetic-room
positionsee Section 7.6).
Make sure that the two pilot balloons are inside the tieif they remain outside there
is the danger that they may be damaged if the tube position has to be adjusted and
the knot moved along the tube.
Finally, suck out audible secretions at this stage (i.e., before using the fibrescope).
7.3.4
Bronchoscopy left-sided tube
The strategy underlying placement of a left-sided tube has two aims as follows.
1. To position the bronchial cuff at or below the carina.
2. To position the tip of the tube proximal to the left subcarina.
Bronchoscope checktracheal side
We proceed by asking three questions.
1. Is the tube down the correct side?
If not, then reposition the tube. If simple measures to reposition the tube fail
(withdrawing the tube, turning the head to the right 6 , advancing the tube again), then
consider railroading the tube into the left main bronchus under direct vision over the
fibrescope (place the fibrescope down the endobronchial (left) side; withdraw the
tube so the end is just above the carinausually at about 2324 cms at the teeth in
an average man; advance the fibrescope down the left main bronchus close to the
left subcarina, and railroad the tube down to a suitable position).
2. Is there any bronchial cuff above the carina?
If there is cuff above the carina, then push the tube down a bit further so the cuff is
just below the carina. If you cant see the cuff at all, then the tube may well be too
far down (we check this later when looking down the endobronchial side). However,
in view of the earlier stethoscope-check we should be confident at this stage that the
tube is not so far down that it is compromising the left upper-lobe.
3. Is the tracheal lumen of the tube very close to the carina?
If it is too close (less than one finger width) then the tube may well be too far down
(see Section 5.3 on how to measure this distance).
Armed with all this information, we now bronchoscope the endobronchial side.
6 Improves
the alignment of the trachea with the left main bronchus.
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Figure 7.1:
Left lung: medial supine view of the hilumenlarged from Figure 4.6 and
rotated into the supine position. Notice how in the supine position the bronchus
to the (yellow) apical segment of the lower lobe descends vertically down from
the first part of the left lower-lobe bronchuscompare with Figure 7.2 where the
orifice is denoted by the letter A (From Brock (1942-1944), with permission).
Bronchoscope checkendobronchial side

There are two stages.
1. Observe the carina and right main bronchus (dark circular shadow) through the
plastic wall of the tube (i.e., looking medially). Notice the position of the bronchial
cuff (blue) in relation to the carinai.e., check to see that the top of the bronchial
cuff is at or below the carina.
2. Position the end of the double-lumen tube optimumly in relation to the left subcarina,
by noting the position of the upper and lower-lobe bronchi in relation to the end of
the tube (see Figures 7.1 and 5.1). The closest the tube should be to the subcarina is
when the orifices of the two second-order bronchi either side of the left subcarina,
together just fit into the diameter of the end of the tube, as shown in the schematic
diagram in Figure 7.2. The tube can of course be further out than this, providing that
the bronchial cuff remains at or below the carina.
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Figure 7.2:
Left: This is a schematic showing the position of the orifice of the lingula
bronchus (Li) and the origin of the bronchus to the apical a segment (A) of the
left lower lobe in relation to the second-order bronchi and the end of the doublelumen tube (dashed circle), as viewed down the fibrescope from the head end in
a supine patient.
This schematic depicts the closest safe approach of the end of the tube to
the left subcarina. We can define this as being when the two diameters of the
orifices of the second-order bronchi bordering the left subcarina just fit into the
diameter of the end of the tube. Compare this with the bronchoscopic image
on the right which shows the view seen when the tube is slightly too far down.
Copyright RWD Nickalls 2005
Right: View of the entrance of the left lower-lobe bronchus (same orientation as
in the schematic on the left). If you see this view bordered by the end of the tube,
then the tube is slightly too far down. The shadow at the 11 oclock position is
the orifice of the left upper-lobe bronchus (partially hidden by the end of the
tube which is almost touching the left subcarina).
Since the endobronchial end of the left double-lumen tube is unfortunately
usually bevelled slightly medially b a tube in this position tends to look down
into the left lower lobe, as illustrated here. The orifice at the 6 oclock position
is the entrance of the bronchus to the apical a segment of the left lower lobe; the
remaining orifices are two basal bronchi c of the left lower lobecompare with
Figures 7.1, 4.6 and 5.2 (from the website of P Slinger d with permission).
a Sometimes
(wrongly) described as the superior segment.

tube should really be bevelled slightly laterally (i.e., to be facing the subcarina).
c Two of the three basal bronchi are visible at the 3 oclock position
d http://www.thoracic-anesthesia.com/
b The
7.3.5
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Bronchoscopy right-sided tube
The strategy underlying placement of a right-sided tube has two aims as follows.7
1. To align the side hole with the right upper-lobe bronchus.
2. To ensure there is an adequate gap between the endobronchial part of tube and the
wall of the upper part of the right main bronchus 8 (i.e., distal to the right upperlobe bronchus). This is a useful precaution, since if the side hole later becomes
mis-aligned (often the case once the patient has been turned into the lateral position)
then the gases can still get in and out of the right upper-lobe by passing between the
tube and the bronchial wall.
The commonest initial problem associated with placing a right double-lumen tube is to
inadvertently position it too far down; the top of the medial part of the bronchial cuff needs
to be extremely close to the carinaat least initially anyway.
Bronchoscopytracheal side
Since it is generally necessary to have the bronchial cuff very close to the carina in order to
align the side hole with the right-upper lobe bronchus, start by positioning the tube so that
the medial side of the top of the bronchial cuff lies at or just below the carina (i.e., as close
to the carina as possible). Note that the Mallinckrodt right-sided tube has a large amount
of blue plastic cuff-material stuck to the tube above the bronchial cuff on the medial side,
so look carefully to distinguish between the blue real cuff and the reflected blue plastic
on the tube proximal to the cuff.
Having positioned the cuff close to the carina, then mark the tube on the top side at the
teeth (with a felt-tip pen) making sure the mark is just visible above the knot.
Bronchoscopyendobronchial side
There are two stages.
1. Pass the fibrescope to the end of the tube and withdraw slowly looking towards
the right-hand side of the tube until the side hole comes into view. Advance the
fibrescope through the side hole and try and locate the right upper-lobe bronchus. If
the bronchus or edge of the orifice is visible, then move the tube slightly (rotating it
if necessary) in order to get maximum alignment. If the bronchus is not visible, then
move the tube in and out slightly, repeating after a small rotation if necessary, until
the right upper-lobe bronchus is found.
7 Note that the algorithm for placing a right-sided double-lumen tube is significantly different from that for
placing a left-sided tube.
8 This used to be called the bronchus intermediussee Section 4.4 for correct nomenclature.
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2. Now proceed to determine whether there is an adequate gap (distal to the side hole)
between the endobronchial part of the tube and the bronchial wall. Advance the
fibrescope through the side hole and try to look distally at the space between the tube
and the bronchial wall. If there is a gap then it is usually fairly easy to see. Even if
it seems quite small, this is usually acceptable since the gap will increase slightly
when on one-lung ventilation as the mean airway pressure will be increased then.
If there is no gap at all, then consider using a smaller tube, or perhaps a bronchus
blocker, unless you are confident you can maintain good alignment in the lateral
position. For a given patient, I therefore use a smaller right-sided tube (one size
smaller) than I would for a left-sided tube.
7.3.6
Final tidal volume and pressure check
Just before turning the patient into the lateral position it is useful to check while the
patient is still supine that the ventilator pressures and tidal volume generated by the theatre
ventilator are appropriate. Strange pressures at this stage may suggest that all is not well
with the tube position.
As a general rule, a normal tidal volume (TV) and respiratory rate (RR) will generate
a pressure on two lungs of about 20 cm H2 O (average male using a 41 Fr double-lumen
tube). Clamping the top side should then result in the peak pressure rising to no more
than 3035 cm H2 O, with a plateau of about 25 cm H2 O. If the pressures are much different
from these, then now is a good time to adjust the TV, flow and RR accordinglythe fine
tuning can be done later. Aim to use the same TV and RR for one-lung as for two-lungs.
7.4
Turning the patient laterally
The initial bronchoscopy after turning the patient into the lateral position commonly shows
some degree of tube malpositionsometimes major malpositionthe bronchial cuff
typically now appearing to be positioned slightly above the carina, even though it had been
perfectly positioned when supine. The tube position, however, is generally unchanged
relative to the teeth, since the tube is usually well tied in. The cause is therefore, not tube
movement, but movement of the carina.
The reality, therefore, is that turning patients from supine to the lateral position is often
associated with significant caudal movement of the carina. This is especially the case in
obese patients, and those with a pronounced abdominal paunch. Conversely, there is rarely
much movement of the carina in thin patients.
This caudal movement of the carina is most likely due the fact that the diaphragm
descends further once the patient is in the lateral position since the abdominal contents will
move caudally and outwards. Consequently the lungs also descend, resulting in the carina
being pulled downwards towards the bronchial cuff, with the effect that the bronchial
cuff may then come to lie in the trachea. If turning is also associated with some outward
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movement of the tube at the teeth, then catastrophic tube malposition can easily occur,
with the end of the tube coming to lie in the trachea, or even in the wrong bronchus.
Before turning first check that the patient is on two-lung ventilation. With a topside tube consider temporarily deflating the bronchial cuff (leave the 5-ml syringe
attached so you can easily inflate the cuff with the same volume afterwards).
In patients in whom the tube has been difficult to position, consider checking the
ventilation pressures and volumes just prior to turning; these can serve as a useful
guide after the patient has been turned (see Section 7.3.6).
Hold the tube at the mouth during turning, taking care to not to let the tube come out
any distance at all. In an obese patient push the tube in slightly during turning to the
lateral position (perhaps 1 cm) to compensate for the anticipated caudal movement
of the diaphragm and hence of the carina also.
Once the patient is in the lateral position, check that you have easy access to the two
pilot-cuff balloons. Reinflate the bronchial cuff if you deflated it prior to turning
(keeping the syringe attached serves as a useful reminder).
Finally, check the tube position bronchoscopically and adjust accordingly. Try to do
this before starting one-lung ventilation.
If the cuff is now in the trachea, then check first whether or not the tip is still in the
correct bronchus before pushing it further down. If already on one-lung ventilation,
then consider returning to two-lung ventilation before repositioning the tube, since
you can then deflate the bronchial cuff and see more clearly. You may be forced
to deflate the bronchial cuff anyway if ventilation becomes obstructed while on
one-lung. Deflate both cuffs before moving the tube in order to avoid damaging the
trachea and bronchus.9 After repositioning the tube you may well have to tie the
tube in again.
7.5
It is convenient to consider the following stages: (a) preparation, (b) going on to one-lung,
(c) management of one-lung anaesthesia, (d) returning to two-lungs, (e) turning supine,
(f) extubation.
9 A useful technique is to first attach an empty 5 and 10 ml syringe to the bronchial and tracheal cuffs
respectively. When you are ready to advance the tube under bronchoscopic control, ask someone to deflate the
cuffsbut to keep the syringes firmly attached. Once the tube is in the new position, the cuffs can be quickly
inflated with the same volume which was withdrawn originally.
7.5.1
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Preparation
Check the position of the tube with the fibrescope.

Check the tidal volume (TV) and pressures.
An average-sized man with a 41 Fr double-lumen tube and normal tidal volume
and respiratory rate (say, 10/min) will have a peak inspiratory pressure with twolung ventilation of approximately 20 cm H2 O. With one-lung ventilation the peak
inspiratory pressure typically increases to about 30 cm H2 O.
Two lungs: Check that the TV is reasonable and that the inspiratory pressure is
20 cm H2 O. Use a relatively slow rate (say, 10 /min).
One-lung: Clamp the top lung (at the end of expiration) just for a few breaths to
see what TV and pressures are generated. Check that the inspiratory pressure rises
smoothly and uniformly. Aim for a peak one-lung pressure of 30 cm H2 O, with a
plateau pressure of 27 cm H2 O (Slinger 2003). If the peak pressure remains high,
then exclude causes of increased resistance (e.g., secretions, bronchospasm, tube too
far in etc). If the plateau pressure remains high with a reasonable TV, then check the
tube position. If the tube position is fine, then consider reducing the TV slightly, and
adjusting the respiratory rate as necessary.
Check the end-tidal PCO2 .

If this is high, then try to bring this down to normal values before the surgeons need
one-lung ventilation.
Have a Jackson-Rees paediatric T-piece circuit available on a separate oxygen
flowmeter for use later with the top lung.
7.5.2
One-lung ventilation
For an excellent overview regarding the possible options for managing hypoxaemia during
one-lung ventilation see the recent article by Roze, Lafargue and Ouattara (2011)
Before going on to one-lung ventilation (a) note the tidal volume, end-tidal PCO2 ,
saturation and airway pressures (peak and plateau), and (b) increase the FIO2 to at
least 50%.
If using nitrous oxide and a volatile remember to increase the volatile concentration
when reducing the nitrous oxide concentration in order to maintain the same MAC
see Figures 9.1, 9.2, 9.3.
Go on to one-lung ventilation by clamping the top lung (proximal to the suction
orifice) at the end of expiration, and open the suction orifice to air (to allow the top
lung to collapse).
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Check that the tidal volume and airway pressures are appropriate on one-lung.
If there is an air-leak check that the bronchial cuff is adequately inflated. If the
airway pressures are too high coupled with a small TV consider going back on to
two lungs and reviewing the tube position.
Check to see if the top lung is deflating (ask the surgeons if necessary).
Check for auto-PEEP.
Listen to the bottom tube with a stethoscope (use the diaphragm) while watching the
airway-pressure dial, and check that (a) the inspiratory and expiratory breath sounds
are clear and uniform, and (b) no auto-PEEP is being generated (i.e., check there is
an end-expiratory pause).
If there is no end-expiratory pause then lengthen the expiratory phase by first
reducing the respiratory rate (see the excellent paper by Szegedi et al. 2002), and
adjust the TV as necessary to minimise rise in end-tidal PCO2 . Suck out any audible
secretions.
If everything is fine (and the lungs are visible 10 ) then connect the Jackson-Rees
T-piece (with 100% oxygen at about 12 L/min) to the top lung. It seems that even
when the lung has collapsed down there is significant entrainment of gas by the lung
(see articles by Pfitzner et al. 1999; 2001), and so the idea of the T-piece is to allow
oxygen to be entrained by the lung instead of air. Have the oxygen enter the T-piece
as close to the double-lumen tube as possible.
Check that the T-piece bag has a hole in it (note that some disposable T-piece circuits
use a valve and a closed reservoir bag).
Check that the pulse, blood pressure and end-tidal PCO2 are satisfactory.
Start monitoring the saturation more closely as this will usually begin to fall over
the next few minutes.
7.5.3
Management of one-lung anaesthesia
There are some general concepts worth bearing in mind.

Keep the saturation 90% by increasing the FIO2 as necessary.
In particular, avoid the combination of low saturation plus low cardiac output
(i.e., low oxygen delivery to the coronaries). To this end, avoid giving very much
down the epidural until the saturation and BP have stabilised at a reasonable level.
If necessary periodically squeeze oxygen into the top lung manually 11 in order to
10 This precaution lessens the risk of barotrauma should the hole in the T-piece bag become obstructed
providing the surgeons can see the lung they will alert you if the lung starts expanding.
11 E.g., using a paediatric T-piece circuit.
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maintain an adequate oxygenation (avoid applying PEEP to the bottom lungunless

the patient is obeseas this generally makes matters worse by shunting more blood
to the top lung). Once you know you can control the saturation at a reasonable level,
then gradually top-up the epidural as necessary.
Avoid excessive ventilator pressures.
Slinger (2003) highlights the association of postoperative acute lung injury with
plateau ventilatory pressures on one lung > 27 cm H2 O.
Try to keep the end-tidal PCO2 below 55 kPa.
The end-tidal to arterial PCO2 difference can be quite large on one-lung (Ip-Yam PC
et al. 1994), so it is best to try and keep the end-tidal level reasonably low to avoid a
respiratory acidosis. Do a blood-gas to check the PaCO2 if necessary.12 As a general
rule the end-tidal PCO2 is a poor guide to the arterial PCO2 if it does not plateau out,
in which case a blood gas is more useful.
Suction out the top lung periodically.
Periodically check the tube position with the fibrescope.
Avoid looking down the bottom lung unnecessarily at this stage in order to keep
the bottom lung well inflated, since there is always a leak when using the fibrescope.
Once you are happy the tube is correctly positioned, then top lung bronchoscopy
will serve as a guide to tube movement.
With a right-sided double-lumen tube check (a) the alignment of the side hole with
the right-upper lobe orifice, and (b) the position of the bronchial cuff in relation to
the carina.
When a left-sided tube is used in the bottom lung avoid having the end of the tube
too close to the subcarina (danger of the tube obstructing the upper-lobe of the
bottom lung). Conversely, when a left-sided tube is used in the top lung avoid having
the bronchial cuff too close to the carina (danger of the bronchial cuff herniating
above the carina and obstructing gas flow to the bottom lung).
Control hypotension with fluids and/or vasoconstrictors as necessary.
A thoracic epidural will usually make the hands vasodilate significantly, and this,
when it occurs, is a helpful sign. Metariminol (10 mg in 20 mls saline; dose 12 mls)
seems to be better and longer lasting than phenylephrine (1 mg in 20 mls saline; dose
12 mls). If having to give frequent boluses, then consider a noradrenaline infusion
(2 mg in 50 mls saline; rate 28 mls/hr)see also Section 8.1. Consider dopamine
(200 mg in 50 mls; rate 28 mls/hr) for bowel surgery (e.g., oesophagectomy).
12 Make
a note of the arterialend-tidal difference for use as a guide later.
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Avoid excessive IV fluids, especially crystalloids.

Slinger (2003) highlights the association of postoperative acute lung injury with
excessive IV fluids in the first 24 hours. Limit crystalloids to about 1 L, and then
use only Gelofusin or blood depending on the haematocrit. If the patient is clearly
vasodilated (perhaps from the epidural) then consider using a noradrenaline infusion
(Section 8.1). Aim to be more conservative with fluids for a pneumonectomy.
7.5.4
Returning to two-lungs
Always suction out the top lung before inflating it.

Following a lobectomy or pneumonectomy the surgeons will usually wish to test
the stump under water using inflation pressures of approximately 3040 cms water,
so remember to remove the tube clamp and close the suction orifice. If there is a
lung leak then you may need to return to one-lung for a while before testing the
stump again. Once the surgeons are happy with the stump then return to two-lung
ventilation (with smaller tidal volumes perhaps while the chest drains are inserted).
Sometimes going back on to two-lungs is associated with a fall in blood pressure, so
be prepared to infuse fluids or give vasoconstrictors at this stage.
Once the saturation is adequate, then the FIO2 can be reduced as necessary. Remember to reduce the volatile concentration (if adding nitrous oxide) in order to avoid an
unduly high total-MAC.
Check all parts of the lung are adequately inflated before the surgeons close the
chest completely.
Adjust the epidural rate/dose as necessary so as to have given an adequate amount
before the end of the operation (i.e., at least 1520 mls 025% bupivicaine before
the end).
Make sure the chest drains are attached to the under-water seal as soon as the chest
is air-tight.
Check that the chest-drain bottles are attached correctly (i.e., chest drains are attached
directly to the under-water seal tube) and that the under-water seal is working. Check
also that the air-exit hole is not obstructedremove the bung completely if in doubt.
Inflate the lungs manually a few times to remove as much of the residual air as
possible.
7.6
Turning the patient supine
Turning the patient from the lateral position (on the table) to supine onto the HDU bed is a
particularly hazardous moment (see Pearce and Gould 2005) with respect to cardiac arrest
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(the heart can get trapped in a pericardial windowcardiac herniation), exsanguination (a

vascular tie can slip or work loose) and tension pneumothorax (a chest drain can become
occluded).
Keep the saturation probe and the arterial line attached and running (monitoring)
until after extubation to safeguard against overlooking significant haemodynamic or
respiratory changes.
Increase the FIO2 to 100%.
The effect of changing posture back to the supine position will cause the carina
to move cranially (see Section 7.4), with the effect that the endobronchial part of
the tube may inadvertently occlude the upper lobe bronchus. Following a pneumonectomy, hypoxia at this stage may indicate an obstructed upper lobe. Such
problems can be avoided by (a) pulling the tube back out to the position it had in
the anaesthetic room (i.e. look for the mark on the tubesee Section 7.3.3), and
(b) sitting the patient up somewhat.
Check the chest drains for any significant blood loss or air leak.
If the patient is to be electively ventilated in ITU then change the tube to a single
lumen tube before going to ITU. Suction out both lungs before changing the tube.
7.7
Extubation
Position the patient sitting up at about 45 degrees.

Suction out both lungs before extubation.
If the operation is a pneumonectomy, then just prior to extubation remember to
inflate the lung well and clamp the chest drain (two clamps) while the pressure is
maintained (usually only one drain following a pneumonectomy).
7.8
7.8.1
Complications
Intraoperative
Most intraoperative complications are tube & airway related (e.g., damage to the trachea
or bronchus), obstruction from tracheal compression (thyroid surgery, big mediastinal
tumours), lung collapse secondary to failure to position the tube correctly. Other significant
problems are pneumothorax of the dependent lung (often difficult to diagnose for certain), hypotension, major blood loss, bradycardia/cardiac arrest (carcinoid tumourssee
Figure 8.1).
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An unusual but dramatic complication which is easily treated, is an acute unilateral

pulmonary oedema which arises from the operative side as a result of an inadvertent acute
incarceration or twisting of the exposed lung causing an obstruction of venous outflow of a
section of lung. Typically occurring after a period of one-lung anaesthesia, the oedema
arises from a piece of lung which the surgeon has pushed to one side away from the
operative field. Bronchoscopy demonstrates the oedema is associated with the operative
side. The surgeon should immediately and carefully check all the collapsed lung for any
twisting, which once straightened, will resolve the problem quite quickly.
Burton NA, Fall SM, Lyons T and Graeber GM (1983). Rupture of the left main-stem
bronchus with a polyvinylchloride double-lumen tube. Chest; 83, 928929.
Gilbert TB, Goodsell CW and Krasna MJ (1999). Bronchial rupture by a doublelumen endotracheal tube during staging thoracoscopy. Anesthesia and Analgesia;
88, 12521253.
Hannallah M and Gomes M (1989). Bronchial rupture associated with the use of a
double-lumen tube in a small adult. Anesthesiology; 67, 457459.
Mackie AM and Watson CB (1984). Anaesthesia and mediastinal masses; a case
report and review of the literature. Anaesthesia; 39, 899903. [30 refs]
Sakuragi T, Komano K, Yasumoto M and Dan K (1997). Rupture of the left mainstem bronchus by the tracheal portion of a double-lumen endobronchial tube. Acta
Anaesthesiol. Scand.; 41, 12181220.
Skobel E, Gehbauer G, Hanna P, Breuer C (2004). Bronchoscope observations after
conservatively postintubation tracheobronchial rupture. Chest Medicine on-line;
http://www.priory.com/cmol/skobel.htm
Smith BAC and Hopkinson RB (1984). Tracheal rupture during anaesthesia. Anaesthesia; 39, 894898. [19 refs + literature search]
Wagner DL, Gammage G and Wong ML (1985). Tracheal rupture following insertion
of a disposable double-lumen tube. Anesthesiology; 63, 698700.
7.8.2
Postoperative
Pulmonary complications are the leading cause of morbidity in the postoperative thoracic
patient; for example atelectasis, secretions, lower respiratory infection and ventilator
insufficiency. Postoperative bronchoscopy therefore has a major role in managing these
common and potentially life-threatening complications. All too often bronchoscopy is
unduly delayed; it should be seen as an adjunct to physiotherapy and other more routine
elements of postoperative care, and not viewed as a treatment of last resort. See the
excellent review and pointer to recent literature by Keith and Kernstein (2005). This is on
the CD.
RWD Nickalls
Sometimes a small/moderate bronchial tear is found at routine postoperative bronchoscopy; this will usually heal well if left alone (see Skobel et al. 2004 above).
Bolliger CT, Jordan P, Soler M, Stulz P, Tamm M, Wyser Ch, Gonon M and Perruchoud AP (1996). Pulmonary function and exercise capacity after lung resection.
Eur. Respir. J.; 9, 415421.
Duggan M and Kavanagh BP (2005). Pulmonary atelectasis. [review article]
Anesthesiology; 102, 838854.
Keith J and Kernstine K (2005). The role of bronchoscopy in the prevention of
common post-thoracotomy pulmonary complications: bronchoscopy in thoracic
patients: an emphasis on post-thoracotomy bronchoscopy. Virtual hospital; http:
//www.uihealthcare.com/vh/
Acute lung injury/pulmonary oedema
An excellent editorial by Slinger (2003) comments on the findings of Licker et al. (2003),
and highlights four factors thought to be significant independent risk factors for acute lung
injury following one-lung anaesthesia, namely (a) excessive intravascular volume, (b) high
intraoperative ventilatory pressures (> 27 cm H2 O), (c) pneumonectomy, (d) preoperative
alcohol abuse. Suggested guidelines for the management of one-lung anaesthesia are as
follows.
1. Avoid over inflation of the dependent lung. Consider using smaller (more physiological) tidal volumes if possible (say, 5 mls/kg) plus oxygen insufflation, and with
PEEP if necessary. Limit plateau inspiratory pressures to <25 cm H2 O.
2. Minimise pulmonary intravascular pressures. This is primarily by fluid restriction,
but also by minimising hypercarbia and hypoxia.
To this end a plot of the Datex AS/3 monitors plateau ventilatory pressure (P plateau ) was
added to our computer-generated anaesthetic record sheet, in order to have a record of this
parameter in the notes, as shown in Figure 8.1 (page 135).
Hayes JP, Williams EA, Goldstraw P and Evans TW (1995). Lung injury in patients
following thoracotomy. Thorax; 50, 990991. [7 refs; about incidence of ARDS
and pulmonary oedema postoperatively]
Licker M, de Perrot M, Spiliopoulos A, Robert J, Diaper J, Chevalley C and Tschopp
J-M (2003). Risk factors for acute lung injury after thoracic surgery for lung cancer.
Anesthesia and Analgesia; 97, 15581565. [49 refs; see also editorial by Slinger
(2003)]
Mathru M, Blakeman B, Dries D, Kleinman B and Kumar P (1990). Permeability
pulmonary oedema following lung resection. Chest; 98, 12161218.
RWD Nickalls
Peters RM (1989). Post-pneumonectomy pulmonary oedema. Appl. Cardiopulmon.

Pathophysiol.; 3, 4351.
puzzle. Anesthesia and Analgesia; 97, 15551557. [editorial relating to article by
Licker et al. (2003)]
Williams EA, Evans TW and Goldstraw P (1996). Acute lung injury following lung
resection: is one-lung anaesthesia to blame? Thorax; 51, 114116. [41 refs]
Wittnich C, Trudel J, Zidulka A and Chiu RC (1986). Misleading pulmonary wedge
pressure after pneumonectomy: its importance in postoperative fluid therapy. Ann.
Thoracic Surg.; 42, 192196.
Pneumonectomy
The recent UK pneumonectomy outcome study (Powell et al. 2009) showed that
The major complication incidence was: 30-day mortality 5.4%; treated cardiac arrhythmia 19.9%; unplanned intensive care unit admission 9.3%; further surgery 4.8%; inotrope usage 3.5%. Age, ASA physical status P3,
pre-operative diffusing capacity for carbon monoxide (DLCO) and epidural
analgesia were collectively the strongest risk factors for major complications.
7.9
General references
Aldridge F (2006). Get a grip! A knotty problem solved Anaesthesia, 61, 822.
[An insightful new approach to tying the tube in securely.] See also:
Knots on the web (http://www.earlham.edu/~peters/knotlink.htm);
Rolling Hitch (http://en.wikipedia.org/wiki/Rolling_hitch);
Rolling Hitch (http://www.apparent-wind.com/knots/rolling-hitch/)
Alliaume B, Coddens J and Deloof T (1992). Reliability of auscultation in positioning of double-lumen endobronchial tubes. Can. J. Anaesth., 39, 689690.
Bahk J-H (1999). Prediction of double-lumen tracheal tube depth. J. Cardiothoracic
Vasc. Anesth.; 13, 370371.
Benumof JL, Partridge BL, Salvatierra C and Keating J (1987). Margin of safety in
positioning modern double-lumen endotracheal tubes. Anesthesiology; 67, 729738.
Benumof JL (1988). Improving the design and function of double-lumen tubes. J.
Cardiothorac. Vasc. Anesth.; 2, 729733.
RWD Nickalls
Boucek CD, Landreneau R, Freeman JA, Strollo D and Bircher HG (1998). A

comparison of techniques for placement of double-lumen endo-bronchial tubes.
Journal of Clinical Anesthesia, 10, 557560. [from Cheong & Koh 1999]
Brodsky JB (2000). Placement of double lumen tubestime to shed light on an old
problem. Br. J. Anaesth., 85, 166167 [reply to Pennefather/Russell editorial above;
16 refs].
Brodsky JB (1988). Con: proper positioning of a double-lumen tube can only
be accomplished with the use of endoscopy. J, Cardiothoracic Vasc, Anesth.; 2,
105109.
Brodsky JB, Benumof JL and Ehrenwerth J et al. (1991). Depth of placement of
double-lumen endobronchial tubes. Anesthesia and Analgesia; 73, 570572.
Brodsky JB, Macario A and Mark JBD (1996). Tracheal diameter predicts doublelumen tube size: a method for selecting left double-lumen tubes. Anesthesia and
Brodsky JB, Macario A, Cannon WB and Mark JBD (1995). Blind placement of
plastic left double-lumen tubes. Anesth. Intensive Care; 23, 583586.
Brodsky JB and Mark JBD (1983). A simple technique for accurate placement of
double-lumen endobronchial tubes. Anesthesiol. Rev.; 10, 2630.
Brodsky JB, Shulman MS and Mark JBD (1985). Malposition of the left sided
double-lumen endobronchial tubes. Anesthesiology; 62, 667669.
Campos JH, Massa and Kernstine KH (2000). The incidence of right upper-lobe
collapse when comparing a right-sided double-lumen tube versus a modified left
double-lumen tube for left-sided thoracic surgery. Anesthesia and Analgesia; 90,
535540.
Cheong KF and Koh KF (1999). Placement of left-sided double-lumen endobronchial tubes: comparison of clinical and fibreoptic-guided placement. Br. J.
Anaesth.; 82, 920921.
[compared blind intubation with intubation with the the fibrescope already in the
tracheal lumen watching the tip and bronchial cuff as you approach the carina and
left main bronchus. They preferred the second method as easy and more reliable in
awkward cases.]
Chow MYH and Ip-Yam PC (2000). Placement of double-lumen tubes. Br. J.
Anaesth.; 85, 332 [reply to Pennefather/Russell editorial above; 11 refs].
Dyer RA, Heijke SAM, Russell WJ, Bloch MB and James MFM (2000). Can
insertion length for a double-lumen endobronchial tube be predicted? Anaesthesia
RWD Nickalls
and Intensive Care; 28, 666668. [they compared (separately) height, weight, and
the external surface distance (sternal-angle to ear-lobe via mouth) and found no
useful correlation]
Ehrenwerth J (1988). Pro: proper positioning of a double-lumen tube can only be
accomplished with endoscopy. J. Cardiothoracic Vasc. Anesth.; 2, 101104.
Fortier G, Cote D, Bergeron C and Bussieres JS (2001). New landmarks improve
the positioning of the left Broncho-Cath double-lumen tubecomparison with the
classic technique. Can. J. Anaesth.; 48, 790794.
Inoue S, Nishimine N, Kitaguchi K, Furuya H and Taniguchi S (2004). Doublelumen tube location predicts tube malposition and hypoxaemia during one lung
ventilation. Br. J. Anaesth.; 92, 195201.
210214.
Nystrom PG (2003). Reverse assembly of a double-lumen tube. Anesthesia and
Press).
Pennefather SH and Russell GN (2000). Placement of double lumen tubestime to
shed light on an old problem. Br. J. Anaesth.; 84, 308310 [editorialsee several
replies below].
Pfitzner J (2000). One-lung anaesthesia: the need for renewed respect. Br. J.
Anaesth.; 85, 331 [reply to Pennefather/Russell editorial above; 2 refs].
Powell ES et al. 2009. UK pneumonectomy outcome study (UKPOS): a prospective
observational cohort study of pneumonectomy outcome. Journal of Cardiothoracic
Surgery; 4, 41
Russell WJ (1996). Further reflections on a blind guided technique for placing
double-lumen endo-bronchial intubation. Anaesthesia and Intensive Care; 24, 123.
Russell WJ (1992). A blind guided technique for placing double-lumen endobronchial tubes. Anaesthesia and Intensive Care; 20, 7174.
RWD Nickalls
Sanders D (2006). Thoracic surgery. In: Allman KG and Wilson IH (Eds.) Oxford
Handbook of Anaesthesia, 2nd. ed., pp. 351383 (Oxford University Press).
Sanjay PS, Miller SA, Corry PR, Russell GN and Pennefather SH (2006). The effect
of gel lubrication on cuff leakage of double lumen tubes during thoracic surgery.
Anaesthesia, 61, 133-137. [gel lubrication of the tracheal cuff significantly reduced
leakage past the cuff]
Slinger P [Ed.] (2008). Thoracic anesthesia. Anesthesiology Clinics; 26 (June),
241398 (Elsevier, Inc)
[chapters: Evidence-based management of one-lung ventilation / Oxygen toxicity
during one-lung ventilation: is it time to re-evaluate our practice? / Anesthetic considerations for airway stenting in adult patients / Perioperative anesthetic management
for esophagectomy / Anesthetic considerations for patients with anterior mediastinal
masses / The emerging role of minimally invasive surgical techniques for the treatment of lung malignancy in the elderly / Prevention and management of perioperative
arrhythmias in the thoracic surgical population / Pulmonary vasodilatorstreating
the right ventricle / Post thoracotomy pain management problems / Postthoracotomy paravertebral analgesia: will it replace epidural analgesia? / Advances in
extracorporeal ventilation ]
Slinger P (2001). Lung isolation in thoracic anesthesia: state of the art. Can. J.
Anaesth.; 48, R3-3
Slinger P (1995). Choosing the appropriate double-lumen tube; a glimmer of science
comes to a dark art [editorial]. J. Cardiothorac. Vasc. Anesth.; 9, 117118. [see also
article on pp. 7845]
Slinger PD (1989). Fibreoptic bronchoscopic positioning of double-lumen tubes. J.
Cardiothoracic Vasc. Anesth.; 3, 48696.
Yasumoto M, Higa K, Nitahara K, Shono S and Hamada T (2006). Optimal depth of
insertion of left-sided double-lumen endobronchial tubes cannot be predicted from
body height in below average-sized adult patients. European Journal of Anaesthesiology, 23, 4244. [Japanese subjects of height 155 cm]
7.9.1
Tracheostomy and one-lung ventilation

Tobias JD (2001). Variations on one-lung ventilation. J. Clin. Anesth.; 13, 3539.
Uzuki M, Kanaya N, Mizuguchi A et al. (2003). One-lung ventilation using a new
bronchial blocker in a patient with tracheostomy stoma. Anesthesia and Analgesia;
96, 15381539.
7.9.2
RWD Nickalls
Bassi A, Milani WRO, El Dib R and Matos D (2009). Intravenous versus inhalation
anaesthesia for one-lung ventilation (Review). The Cochrane Library; 2009, issue 3.
(pp. 23) (http://www.thecochranelibrary.com/)
Levin AI and Coetzee JF (2005). Arterial oxygenation during one-lung anesthesia.
Anesth. Analg.; 100, 1214.
Levin AI, Coetzee JF and Coetzee A (2008). Arterial oxygenation and one-lung
anesthesia. Current Opinion in Anaesthesiology; 21, 2836. [107 refs]
Licker M, de Perrot M, Spiliopoulos A, Robert J, Diaper J, Chevalley C and Tschopp
J-M (2003). Risk factors for acute lung injury after thoracic surgery for lung cancer.
Anesthesia and Analgesia; 97, 15581565. [49 refs; see also editorial by Slinger
(2003)]
Press).
Pfitzner J, Peacock MJ and Daniels BW (2001). Administering ambient pressure
oxygenation to the non-ventilated lung during thoracoscopic surgery. Anaesthesia;
56, 281282.
Pfitzner J, Peacock MJ and Daniels BW (1999). Ambient pressure oxygen reservoir
apparatus for use during one-lung anaesthesia. Anaesthesia; 54, 454458.
Pfitzner J, Peacock MJ and McAleer PT (1999). Gas movement in the nonventilated lung at the onset of single-lung ventilation for video-assisted thoracoscopy.
Roze H, Lafargue M and Ouattara A (2011). Case scenario: management of intraoperative hypoxemia during one-lung ventilation. Anesthesiology; 114, 167174.
[55 refs]
Slinger PD (1989). Fibreoptic bronchoptic positioning of double-lumen tubes. J.
Cardiothoracic Anesthesia; 3, 486496.
Slinger PD (1990). Anaesthesia for lung resection. Can. J. Anaesth.; 37, SxvSxxiv.
[106 refs; part of the refresher course outline]
Slinger PD (1995). New trends in anaesthesia for thoracic surgery including thoracoscopy. Can. J. Anaesth.; 42, R77R84. [part of the refresher course outline]
puzzle. Anesthesia and Analgesia; 97, 15551557. [editorial relating to article by
Licker et al. (2003)]
RWD Nickalls
Slinger PD (2005). Management of one-lung anesthesia. Anesthesia and Analgesia;

(Supplement: IARS 2005 Review Course Lectures; pp. 8994) [52 refs]
Slinger PD (2007). Lung isolation review. (http://www.thoracic-anesthesia.
com/)
Strachan L (2006). One-lung ventilation. Update in Anaesthesia (June 2006),
p. 2023. http://update.anaesthesiologists.org/2006/
Szegedi LL, Bardoczky GI, Engelman EE and dHollander AA (1997). Airway
pressure changes during one-lung ventilation. Anesthesia and Analgesia, 84, 1034
1037.
Szegedi LL, Barvais L, Sokolow Y, Yernault JC and dHollander AA (2002).
Intrinsic positive end-expiratory pressure during one-lung ventilation of patients
with pulmonary hyperinflation. Influence of low respiratory rate with unchanged
minute volume. Br. J. Anaesth.; 88, 5660. [decreasing RR while maintaining MV
decreases PEEPi while maintaining PCO2 . ]
7.9.3
Tracheal bronchus
See article by Ho et al. (2004) for a brief review of the recent literature
Conacher ID (2000). Implications of a tracheal bronchus for adult anaesthetic
practice. Br. J. Anaesth.; 85, 317321.
Ho AM-H, Karmakar MK, Lam WW, Lam FO, Lee TW, Ng SK and Chung DC
(2004). Does the presence of a tracheal bronchus affect the margin of safety of
double-lumen tube placement? Anesthesia and Analgesia; 99, 293295. [reviews
the recent literature on tracheal bronchus nearly all are on the right-hand side and
within 2 cm of the carina; 10 refs]
Ikeno S, Mitsuhata M, Saito K, Hirabayashi Y, Akazawa S, Kasuda H and Shimizu
R (1996). Airway management for patients with a tracheal bronchus. Br. J. Anaesth.;
76, 573575.
7.9.4
Physiology & pathology
Abe K et al. (1998). The effects of propofol, isoflurane and sevoflurane on oxygenation and shunt fraction during one-lung anaesthesia. Anaesthesia & Analgesia, 87,
11641169. [propofol was best]
Burwell DR and Jones JG (1996). The airways and anaesthesia; I: anatomy, physiology and fluid mechanics. Anaesthesia; 51, 849857. (September issue) II:
pathophysiology. Anaesthesia; 51, 943955. (October issue)
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Cohen E (1997). Anesthesia. Physiology of the lateral position and one-lung

ventilation. Chest Surgery Clinics of North America; 7(4) (November), 753771.
(WB Saunders Company)
Eisenkraft JB (1994). Anaesthesia and hypoxic pulmonary vasoconstriction. In:
Recent advances in anaesthesia and analgesia 18 ; Chapter 7, pp. 103122. [86 refs]
Ip-Yam PC, Innes PA, Jackson M et al. (1994). Variation in the arterial to end-tidal
PCO2 difference during one-lung thoracic anaesthesia. Br. J. Anaesth.; 72, 2124.
Peltola K (1983). Central haemodynamics and oxygenation during thoracic anaesthesia. Acta Anaesthesiol. Scand.; 275, 142.
Portch D and McCormick B (2009). Pulmonary function tests and assessment for
lung resection. Update in Anaesthesia (June 2009), p. 1321. http://update.
anaesthesiologists.org/2009/
Ross AF and Ueda K (2010). Pulmonary hypertension in thoracic surgical patients.
Staub NC (1985). Site of hypoxic vasoconstriction. Chest; 88 (Suppl), 24S45S.
Sykes K (1999). Pulmonary physiology during one-lung ventilation. In: Ghosh
S and Latimer RD [Eds] Thoracic anaesthesia: principles and practice, Chapter 2,
pp. 2441. (ButterworthHeinemann, Oxford, UK).
7.9.5
Flow/pressure/volume loops
Bardoczky GI, Vries J de, Merilainen P, Schofield J and Tuomaala L (2006). Appliguide: patient spirometrymonitoring of patient ventilation during anesthesia. (GE
Healthcare, Finland). pp. 46 [excellentavailable as a PDF from GE Healthcare,
Technical Department]
Fernandez-Perez ER and Hubmayr RD (2006). Interpretation of airway pressure
waveforms. Intensive Care Med.; 32, 658659.
Kryger et al. (1976). Diagnosis of obstruction of the upper and central airways. Ann.
J. Med.; 61, 8593.
8
Drugs
8.1
Cardiovascular drugs
The key to using these drugs effectively is knowing the likely side effects, appropriate
dilutions and safe bolus doses. Learn how to bolus the drugs listed in Table 8.2 (see
Section 8.1.2) using a 1 ml syringevery useful when the pumps/power fail.
Use dedicated CVP portsone drug per port. Avoid piggy-backing several drugs
together, especially when titrating a new drug infusion. Always reduce infusions slowly
and review the effectavoid stopping these infusions suddenly as blood pressure may fall
rapidly. Check infusions will not run out during transfer to and from ITU.
Table 8.1:
Commonly used drugs for rapid bolus control of hypotension in adults (70 kg).
Drug
Dilution (in saline)
Bolus dose
30 mg / 5 ml
051 ml
Metaraminol (Aramine)
10 mg / 1 ml ampoule
10 mg / 20 mls
051 ml
Phenylephrine
1 mg / 20 mls
051 ml
Methoxamine (Vasoxine)
20 mg / 20 mls
051 ml
Ephedrine
126
CHAPTER 8. DRUGS
RWD Nickalls
Adrenaline has both and effects.

Dobutamine has a predominant 1 effect (inotropic & chronotropic), with minimal effect on peripheral vascular resistance (due to its modest 2 and effects).
Dobutamine is the only catecholamine administered as a racemic mixture. It is this
mixture which results in its characteristic 1 selectivity, since the ve isomer is an
agonist, while the +ve isomer is an antagonist (Zaritsky and Chernow 1988).
Dobutamine may cause hypokalaemia.
Ephedrine is a so-called indirect agonist, as it causes release of catecholamines
( + ) at the terminal, and hence tachyphylaxis occurs with frequent use. It causes
a moderate increase in BP and HR. If ephedrine fails to have much effect,1 then
consider using a pure -agonist (e.g., metaraminol, phenylephrine, noradrenaline).
Avoid using ephedrine if HR > 100. For useful references regarding ephedrine and
phenylephrine see Cooper (2005), Gambling DR and McLaughin KR (2010). See
editorial by Smiley (2009) regarding use in Cesarean section.
Isoprenaline has almost pure effects. Used almost exclusively to increase the
heart rate in patients with acute complete heart block.
Metaraminol is a pure -agonist. An IV bolus lasts about 510 minutes and
commonly elicits a small reflex bradycardia (therefore avoid using if bradycardia
exists). Metaraminol is slightly longer acting than than phenylephrine, and is
therefore better for bolus use. If you need to give multiple metaraminol boluses then
consider using a noradrenaline infusion via a CVP line (see below). If no CVP line
then metaraminol can be used as a 5 mg IM dose, or as a temporary slow infusion
(510 mg in 1 litre).
Noradrenaline is an almost pure -agonist. It does actually have a very small
effect on heart rate, and, unlike metaraminol, does not cause a reflex bradycardia with
bolus doses. Contrary to popular opinion, a noradrenaline infusion for supporting
a normal blood pressure is generally beneficial to the kidney and renal function in
sepsis (Lee et al. 2004; Bellomo and Giantomasso 2001). Noradrenaline is often of
value both operatively and postoperatively in patients with a history of hypertension,
to counteract the vasodilatory effects of anaesthesia (general and epidural) and
maintain their normal preoperative blood pressure and renal function.
Phenylephrine is a pure -agonist. It seems to have a slightly shorter duration of
action compared to metaraminol, but otherwise its action is essentially similar to
metaraminol. See related references cited for Ephedrine above.
Terlipressin (triglycyl-lysine-vasopressin) is a pro-drug which breaks down to the
active lysine-vasopressin (Kam, Williams and Yoong 2004). Terlipressin is often
1 If initial doses of ephedrine fail to have much effect, then this is usually a sign of sepsis and that noradrenaline
should be used instead.
CHAPTER 8. DRUGS
RWD Nickalls
used in ITU to supplement a noradrenaline infusion in septic shock (better blood

pressure control, less tachycardia, better renal and gut perfusion). The adult dose is
12 mg IV (repeat 4-hourly initially); effect half-life is 6 hrs.
Vasopressin (ADH) is increasingly being used in septic shock to supplement a
noradrenaline infusion (see Roth 2006; Kam, Williams and Yoong 2004, Sun et al.
2003). Vasopressin (American Pharmaceuticals) is available in ampoules of 20 U/ml.
8.1.1
Infusions: dilutions and use
An important but commonly overlooked aspect of practical drug delivery is the dilution.
In my view the hallmark of a well chosen dilution is that, in addition to satisfying the
necessary pharmaceutical requirements, it facilitates both the mental calculation and the
means of infusion and safe effective bolus delivery, particularly in urgent/emergency
situations.
The dilutions listed in Table 8.2 approach this ideal; they are practical and easy to
remember, dosage is easy to determine without reliance on calculators or charts. Indeed, an
awareness of Table 8.2 would easily have avoided the calculation error described recently
by de Wildt et al. (2007), associated with setting up a noradrenaline infusion.
Table 8.2:
Single strength dilutions (adults, 70 kg): start infusion at 5 mls / hr and titrate in
increments of 2 mls / hr. When bolusing adrenaline, noradrenaline or isoprenaline
start with 0102 mls, titrating amount to effect (approximate bolus dose is
12 mins worth of current infusion).
Drug
Dopamine
Dobutamine

3 kg
mg in 50 mls
1
Bolus
GTN
SNP
3 kg
mg in 50 mls
10
0102 ml
Adrenaline
Noradrenaline
Isoprenaline
3 kg
mg in 50 mls
100
011 ml
0102 ml
Infusion
110 mls / hr
(110 g / kg / min)
110 mls / hr
(011 g / kg / min)
140 mls / hr
(00104 g / kg / min)
The entries in Table 8.2 are based on the following rule, which is a simplified and
more practical form of that described by Sellick (1985), namely: for a patient weighing
W kg, then diluting 3 W mg of any drug in 50 mls yields a solution for which 1 ml/hr is
equivalent to 1 g / kg / min.
When initiating an infusion, use the single strength concentration listed in Table 8.2
(adults), and start at a rate of approximately 5 ml/hr, using boluses (see Section 8.1.2)
as necessary. If the patients condition later requires increasingly large infusion rates,
CHAPTER 8. DRUGS
RWD Nickalls
then higher concentrations (e.g., double strength, quadruple strength etc) can be used
instead to avoid volume overload. If the patient is obviously septic then start with a
double-strength dilution. A useful rule-of-thumb is to increase the infusion rate in steps
of about 20%, but to decrease it in smaller steps (e.g., 10%).
Although 50 ml syringe-drivers are generally used in the operating theatres, in an
ITU however, where the infusions often run for long periods of time, it is generally more
convenient to use larger volumes (e.g., 100 ml or 250 ml bags) in conjunction with the
usual ITU infusion-delivery systems.
Example 1
A 70 kg patient requires a dobutamine infusion. The dobutamine entry in Table 8.2, shows
that diluting 210 mg (3 70) in 50 ml 5% dextrose gives a concentration for which 1 ml/hr
is equivalent to 1 g / kg / min. Start the infusion at 5 mls/hr.
Example 2
A 30 kg patient requires a GTN infusion. The GTN entry in Table 8.2, shows that diluting
9 mg (3 30/10) in 50 ml 5% dextrose gives a concentration for which 1 ml/hr is equivalent
to 01 g / kg / min. Start the infusion at 5 mls/hr.
8.1.2
Bolus dosage
In emergency situations it is sometimes necessary to give IV bolus doses of these drugs

(typically for GTN, adrenaline, noradrenaline). Consequently, it is very important that the
dilution of the maintenance infusion used should simplify this, i.e., allow an IV bolus to be
given manually and quickly using a syringe, so as not to be dependent on the electronic
delivery system which can sometimes fail. An important feature of the single strength
dilutions shown in Table 8.2 is that they facilitate the manual administration of appropriate
bolus doses, quickly, safely and easily, typically using a 1 ml syringe (see examples below).
I have found empirically that an appropriate initial bolus dose is a volume roughly
equivalent to 12 minutes worth of the current maintenance infusion (depending on the
severity of the problem). In practice the 1-minute bolus volume is easily calculated since an
infusion rate of 6 ml/hr is equivalent to 01 ml/min; a maintenance infusion rate of R ml/hr
is therefore equivalent to 01 R/6 ml in one minute. For example, a 1-minute bolus
volume for an infusion running at 12 mls/hr is 01 12/6 = 02 ml. In general the bolus
volume can be easily and conveniently delivered using a 1 ml syringealways readily
available on any ward. If the effect of the initial bolus is inadequate, sequentially double
the bolus volume until a therapeutic bolus volume is found.
CHAPTER 8. DRUGS
8.1.3
RWD Nickalls
Noradrenaline
Example 1
Consider a 70 kg routine surgical patient requiring a noradrenaline infusion to counteract
the effects of an epidural (typical requirement: single strength noradrenaline running at
28 mls/hr).
Step 1: Dilute 370
100 mg noradrenaline into 50 mls saline, (i.e., approximately 2 mg in
50 mls), and start the infusion at 5 mls / hr (equivalent to 005 g / kg / min). Remember to
include a three-way tap and a filled labelled 1 ml syringe, and connect the infusion to the
central-line port as a separate dedicated infusion.
Step 2: Now fill the central-line deadspace cautiously, using 0102 ml increments,
until a bolus results in a transient rise in blood pressure. Then titrate the infusion using
increments of about 24 mls/hr to obtain a suitable blood pressure, using small boluses
via a 1 ml syringe as necessary to gain control. If the patient is significantly septic then
the infusion rate may well need to be increased, up to 50 mls / hr as necessary.2 A useful
rule-of-thumb is to increase the infusion rate in steps of 20%, but to decrease it in steps of
only 10%.
Notes: If there is occasion to rescue a low BP of, say, 6070 mm Hg, then a bolus of
approximately 12 mins worth of the infusion will be an appropriate first choice test dose.
For example, if the current infusion rate is 6 mls/hr then consider a test bolus of about
0102 mls (since an infusion of 6 mls/hr is equivalent to 01 ml/min).
Example 2
Consider a 70 kg septic ITU patient on double-strength noradrenaline at 12 mls/hr, and
suppose you are now called because the infusion has suddenly stopped, and the blood
pressure is falling.
This amount of noradrenaline is not unusual in the ITUeven the use of quad
strength is not uncommon. However, what is not widely appreciated is that if a high-dose
noradrenaline infusion stops suddenly (e.g., battery failure; line occlusion; bag/syringe
empty etc.) the blood pressure fall will be rapid and profoundfor example, falling to
about 4050 mmHg within 1 minute or soand so this problem constitutes a significant
emergency and must be addressed immediately. The essence of the problem, therefore, is
how to administer 2 minutes worth of noradrenaline to the patient within less than 1 minute
from a standing start.
Step 1: Note the infusion rate: 12 mls/hr in this case.
Step 2: Divide the current infusion rate by 6 to determine the number of 01 ml units
the patient would normally be receiving per minute 3 (this is the minimum bolus volume).
2 If large infusion flow rates become necessary, then consider using twice the concentration (or more) with
an appropriately reduced rate (one can happily use a single strength dilution up to 50 mls/hr or so in a theatre
setting).
3 An infusion of 6 mls/hr is equivalent to 01 mls/min.
CHAPTER 8. DRUGS
RWD Nickalls
Thus, in this example we have 12/6 = 2, and so the 1-minute bolus volume is 2 01 mls
= 02 mls.
Step 3: Fill a 1 ml syringe directly from the infusion bag/reservoir/pump and inject
2 mins worth of noradrenaline infusion as a bolus04 ml in this case (2 02)down
a separate 4 CVP/IV line and flush it in with 10 mls saline. If there is already significant
bradycardia, then atropine and temporary cardiac massage may also be necessary to help
the drug get around. Titrate against the blood pressure, approximately 02 mls/min, as
necessary, until the original infusion problem is fixed and up and running again.
Notes: In this particular setting, since the bolus volume is so small and a rapid response
is required, the bolus must be flushed in with, say, 1020 mls saline, in order to guarantee
that the bolus is delivered into the circulation (i.e., so the drug cannot inadvertently remain
within the CVP line). Consequently, a drug-free CVP-line must be used, and if any
uncertainty exists, then give the bolus (initially at least) into a peripheral vein.
This scenario occurs not infrequently, particularly in patients returning from theatre
with their noradrenaline syringe driver on empty. You then have to sort out the severe
hypotension and maintain an adequate blood pressure manually for about 5 mins or so
while the nurses set up a new noradrenaline infusion. Fortunately, when a syringe driver
alarms and stops there are usually several mls left in the syringe/system which can be used
to fill your 1 ml syringe.
Example 3
Postoperative use of noradrenaline in patients with a history of hypertension. A patient
with a long history of hypertension requiring quadruple drug antihypertensive therapy,
was admitted postoperatively to ITU (following a nephrectomy; preop creatinine 150),
with a blood pressure of 110120 mmHg and poor urine output. From the notes it was
clear that her usual blood pressure was approximately 160170 mmHg, and so a CVP line
was inserted and noradrenaline used to push the blood pressure up to 160 mmHg, with
the effect that her urine output increased significantly and her creatinine stabilised out
at 160170. The noradrenaline was weaned down over about 4 days (during which her
pre-op antihypertensive drugs wore off) by which time her blood pressure stabilised at
about 160 mmHg and she was returned to the ward. Her normal antihypertensive therapy
was then gradually re-introduced.
8.1.4
References
Aantaa R and Jalonen J (2006). Perioperative use of 2 -adrenoceptor agonists and

the cardiac patient. European Journal of Anaesthesiology; 23, 361372. [clonidine
and dexmedetomidate]
4 Avoid using the existing noradrenaline CVP line, since you need to guarantee that (a) only the bolus dose
is given, and (b) it is delivered into the circulationyou can not flush the bolus with saline down the existing
noradrenaline infusion line. Much safer to give it initially via a separate line, until you have control of the blood
pressure.
CHAPTER 8. DRUGS
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Bellomo R and Giantomasso Di (2001). Noradrenaline and the kidney; friends or

foes? Critical Care; 5, 294298.
Cooper DW (2005). Ephedrine, phenylephrine and fetal acidosis. Anaesthesia; 60,
12371238. [10 refs]
de Wildt SM, Verzijden R, van den Anker JN and de Hoog M (2007). Information
technology cannot guarantee patient safety. British Medical Journal ; 334, 851852.
[highlights a recent drug-infusion calculation error generated by a palm-computer
medical drug program]
Gambling DR and McLaughin KR (2010). Ephedrine and phenylephrine use during
Cesarean delivery. Anesthesiology; 112, 12871288.
Kam PCA, Williams S and Yoong FFY (2004). Vasopressin and terlipressin: pharmacology and its clinical relevance. Anaesthesia; 59, 9931001 [Review article]
Lee R, Giantomasso Di, May E and Bellomo R (2004). Vasoactive drugs and the
kidney. Best Practice & Research Clinical Anaesthesia; 18, 5374.
ODonnell A (2006). Drug formulary. In: Allman KG, Wilson IH (Eds.) Oxford
Handbook of Anaesthesia. 2nd. ed. pp. 11051165.
Roth JV (2006). The use of vasopressin bolus to treat refractory hypotension
secondary to reperfusion during orthotopic liver transplantation. Anesthesia &
Analgesia; 103 (July), 261. [6 refs]
[Used an infusion of vasopressin 4 U/h, plus two boluses of 04 U, in a 83 Kg man
relatively refractory to noradrenaline (20 mls/hr of single-strength noradrenaline).]
Sellick BC (1985). The calculation of infusion rates. Anaesthesia; 40, 599.
Smiley RM (2009). Burden of proof. Anesthesiology; 111, 470472. [Editorial
regarding ephedrine and phenylephrine in Cesarean section]
Sun Q et al. (2003). Low-dose vasopressin in the treatment of septic shock in
the sheep. Am. J. Respir. Crit. Care Med.; 168, 481486. [used 12 U/hr; good
introduction and discussion; 44 refs]
Zaritsky AL and Chernow B (1988). Catecholamines and other inotropes. In:
Chernow B (Ed.) The pharmacologic approach to the critically ill patient, Chapter 31,
(pp. 584602).
CHAPTER 8. DRUGS
8.2
RWD Nickalls
Somatostatin analogues & carcinoid
An good overview with useful references is presented by Mason (2001).
8.2.1
Octreotide
Sandostatin: 1ml ampoule; three concentrations available: 50/100/200 g/ml
Octreotide is a synthetic analogue of the hypothalamic release-inhibiting hormone

somatostatin (BNF), and is a key drug in the management of patients with carcinoid
syndrome (Farling and Durairaju 2004; Vaughan and Brunner 1997; Battershill PE and
Clissold SP 1989). It is used to counteract serotonin (5HT) and kinin activity and to gain
full control of symptoms (subcutaneously (adults): initially 50 g 12 times/day increasing
to 200 g 3 times/day). Octreotide is increasingly being used in the treatment of congenital
and postoperative chylothorax (Roehr CC, Jung A, Proquitte H et al. 2006).
8.2.2
Ketanserin
Ketanserin is a selective antagonist of anti-5HT2 , the 1 -adrenoreceptor, and the H1 histamine receptor (Koopmans et al. 2005; Hughes and Hodkinson 1989). Ketanserin
reduces portal pressure in animals (Chernow 1988). A 10 mg bolus IV (adults) has been
used successfully in carcinoid crisis to block mediators (Koopmans et al. 2005, Hughes
and Hodkinson 1989). Alternatively (adults), ketanserin 10 mg given over 3 mins followed
by an infusion of 3 mg/hr is suggested by Mason (2001), Fischler et al. (1983), Hughes
and Hodkinson (1989).
8.2.3
Carcinoid tumours
Carcinoid (neuroendocrine) tumours have their origin in the endocrine argentaffine cells of
the small bowel mucosa, which are part of the so-called APUD family (Amine content,
Precursor Uptake, and Decarboxylation). Carcinoid is characterised biochemically by an
increased urinary excretion of 5-hydroxyindole-acetic acid (5-HIAA; Mol wt 191), the
normal range being 1047 Mol/24 hrs (1989 mg/24 hrs).
A range of peptides, kinins and prostaglandins can be secreted, including kallikrein,
bradykinin, serotonin (5HT), histamine, and substance-P. Less commonly secreted are
insulin, ACTH, MSH, gastrin and glucagon. The carcinoid syndrome symptoms of
diarrhoea, sedation, hypertension are thought to be due to serotonin; flushing, hypotension
and bronchospasm are thought to be due to bradykinin (Mason and Steane 1976).
8.2.4
Anaesthesia for bronchial carcinoid resection
The anaesthetic management of such patients consists primarily of (a) using the drug
octreotide for preoperative symptom control (2 days2 weeks) and also as part of the
premedication regimen, (b) avoiding drugs which liberate histamine (e.g., atracurium,
CHAPTER 8. DRUGS
RWD Nickalls
morphine), (c) using small boluses of octreotide (adults: 1020 g) as necessary to counteract symptomatic episodes (flushing, hypotension, bronchospasm). Ketanserin (adults:
10 mg bolus IV) 5 has been used successfully in carcinoid crisis to block mediators (Koopmans et al. 2005, Hughes and Hodkinson 1989). Steroids are often used perioperatively.
Bradykinin may be the key mediator of hypotension in carcinoid syndrome (Veall et al.
1994).
Preoperative control of symptoms: Octreotide is typically given subcutaneously in
doses (adults) of 50200 g 8-hrly.
Premedication: Octreotide 50100 g subcutaneously 1 hr preoperatively (adults).
Induction: Insert the arterial line under local prior to induction. Try to avoid the use of
rigid bronchoscopy by the surgeons on induction in order to minimise airway stimulation
suggest they consider flexible bronchoscopy via a single-lumen tube if necessary.
Intra-operatively (adults): Use octreotide intravenously as required to control exacerbations of bronchospasm, hypotension with flushing, and bradycardia (100 g diluted in
1020 mls saline). Titrate using small boluses of approximately 1020 g. Bradycardia
associated with heart-block has been reported following a 100 g bolus (Dilger et al. 2004).
Acute hypertension may be due to serotonin (5HT) (blocked by ketanserin), while
acute hypotension may be due to bradykinin (blocked by octreotide). Have a syringe of
adrenaline (1/10,000) 6 immediately available to treat episodes of profound bradycardia or
asystolic arrest
Consider ondansetron (give slowly 7 ) for its anti-5HT activity (Wilde and Markham
1996). Consider using chlorpheniramine (anti-H1 ) and ranitidine (anti-H2 ) (Vaughan,
Howard and Brunner 2000, Mason and Steane 1976). Monitor blood glucose (carcinoid
tumours may secrete insulin or glucagon). Epidural bupivicaine + fentanyl is fine.
The vasopressors of choice in carcinoid surgery are most probably phenylephrine,
metaraminol, and also methoxamine (not currently available), since they are not catecholamines 8 (Koopmans et al. 2005). However, I have used a noradrenaline infusion in
carcinoid cases on several occasions uneventfully.
Example of intraoperative hypotension
Figure 8.1 shows an episode of extreme hypotension during a thoracic carcinoid resection.
During this operation there were two such episodes (one cardiac standstill) which responded
rapidly to open cardiac massage, adrenaline (2 ml of 1/10,000) and 20 g octreotide via the
CVP line. Although a noradrenaline infusion was being used at the time (to counteract
the epidural), each of these episodes appeared to be related to surgical manipulation; no
noradrenaline boluses were given at any stage.
5 Alternatively
ketanserin 10 mg over 3 mins followed by an infusion of 3 mg/hr (Mason 2001).

in 10 mls saline.
7 See letter by Cherian and Maguire 2005.
8 Since odihydroxybenzine is called catechol, sympathomimetic amines having the same OH-substitutions
in the benzine ring (i.e., in both the 3- and 4- positions) are termed catecholamines (e.g., dopamine, dobutamine,
noradrenaline, adrenaline, isoprenaline).
6 1 mg
CHAPTER 8. DRUGS
ANSTHESIA RECORD
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EMAIL :dick@nickalls.org
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ANSTHESIA RECORD SYSTEM
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Linux
[www.nickalls.org]
Figure 8.1: Anaesthetic record during a thoracic carcinoid resection in an adult, showing an
episode of bradycardia and extreme hypotension which responded to cardiac massage, bolus of
adrenaline (2 ml 1/10,000) and 20 g octreotidesee text. Notice the transient reduction in ETCO2
due to low cardiac output associated with the period of hypotension. The patient made a full and
uneventful recovery. Datex AS/3 monitor; data points at 5 sec intervals; BP, NIBP, CVP mmHg;
P plateau cm H2 O; TV mls; SAT, FIO2 , ETCO2 , FIN2 O , MACage , VAP (sevoflurane) %.
CHAPTER 8. DRUGS
8.2.5
RWD Nickalls
References
Allman KG and Wilson IH (Eds.) (2006). Oxford Handbook of Anaesthesia.

2nd. ed., [APUDomas and anaesthesia for carcinoid (pp. 172174)]
Battershill PE and Clissold SP (1989). Octreotide: a review of its pharmacodynamic
and pharmacokinetic properties, and therapeutic potential in conditions associated
with excessive peptide secretion. Drugs; 38, 658702.
Carcinoid Cancer Foundation (http://www.carcinoid.org/): This web site is
mainly for patients and has lots of general information. However, it also has a good
medical section (http://www.carcinoid.org/content/medical-reviews/)
which has several useful articles.
Cherian A and Maguire M (2005). Transient blindness following intravenous
ondansetron. Anaesthesia; 60, 938939. [advise slow IV injection; 5HT3 and
5HT3A receptors are involved in modulation of retinal signals]
Chernow B [Ed.] (1988). The pharmacologic approach to the critically ill patient,
2nd ed. (Williams & Wilkins, Baltimore, USA). 336337.
Cortinez LI (2000). Refractory hypotension during carcinoid resection. Anaesthesia;
55, 505506. [see also: Vaughan DJ, Howard JM and Brunner MD 2000]
Dery R (1971). Theoretical and clinical considerations in anaesthesia for secreting
carcinoid tumours. Can. Anaesth. Soc. J.; 18, 245263. [cited from Vaughan DJ,
Howard JM and Brunner MD 2000]
Dilger JA, Rho EH, Que FG, Sprung J (2004). Octreotide-induced bradycardia and
heart block during surgical resection of a bronchial carcinoid tumor. Anaesthesia
and Analgesia; 98, 318320. [this event followed a 100 g bolus]
Farling PA and Durairaju AK (2004). Remifentanil and anaesthesia for carcinoid
syndrome. Br. J. Anaesth.; 92, 893895. [excellent review]
Fischler M, Dentan M, Westernam MN et al. (1983). Prophylactic use of ketanserin
in a patient with carcinoid syndrome. Br. J. Anaesth.; 55, 920. [cited from Mason
2001]
Hughes EW and Hodkinson BP (1989). Carcinoid syndrome: the combined use of
ketanserin and octreotide in the management of an acute crisis during anaesthesia.
Anaesthesia and Intensive Care; 17, 367370. [cited from Koopmans et al., 2005]
Keens SJ, Desmond NJ and Utting JE (1986). Carcinoid syndrome with myasthenia
gravis. Anaesthesia, 41, 404407.
CHAPTER 8. DRUGS
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Kema IP, de Vries EG and Muskiet FA (2000). Clinical chemistry of serotonin and
metabolites. J. Chromatogr. Biomed. Sci. Appl.; 747, 3348. [cited from Koopmans
et al., 2005]
Kinney MA, Warner ME, Nagorney DM et al. (2001). Perianaesthetic risks and
outcomes of abdominal surgery for metastatic carcinoid tumours. Br. J. Anaesth.;
87, 447452.
Koopmans KP, Brouwers AH, De Hooge MN et al.(2005). Carcinoid crisis after
injection of 6-18 F-Fluorodihydroxyphenylalanine [18 F-DOPA] in a patient with
metastatic carcinoid. The Journal of Nuclear Medicine; 46, 12401243.
Kvols LK, Martin JK, Marsh HM et al. (1985). Rapid reversal of carcinoid crisis
with a somatostatin analogue [letter]. N. Engl. J. Med.; 313, 12291230. [cited from
Koopmans et al., 2005]
Mason R (2001). Anaesthesia databook: a perioperative and peripartum manual. 3rd
ed. (see section on Carcinoid syndrome).
Mason RA and Steane PA (1976). Carcinoid syndrome: its relevance to the anaesthetist. Anaesthesia, 31, 228242.
Roehr CC, Jung A, Proquitte H et al. (2006). Somatostatin or octreotide as treatment
options for chylothorax in young children: a systematic review. Intensive Care Med.;
32, 650657. [56 refs]
Vaughan DJ and Brunner MD (1997). Anesthesia for patients with carcinoid syndrome. Int. Anesthesiol. Clin.; 35, 129142. [excellent]
Vaughan DJ, Howard JM and Brunner MD (2000). Refractory hypotension during
carcinoid resection. Anaesthesia; 55, 927 [letter] [see also: Cortinez 2000].
Veall G, Peacock J, Bax N and Reilly C (1994). Review of the anaesthetic management of 21 patients undergoing laparotomy for carcinoid syndrome. Br. J. Anaesth.;
72, 335341. [cited from Cortinez 2000]
Wilde IM and Markham A (1996). Ondansetron. A review of its pharmacology and
preliminary clinical findings in novel applications. Drugs; 52, 773794.
CHAPTER 8. DRUGS
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8.3
Haemostatic drugs
Note that the hospital has a major haemorrhage guideline. See also review by Mahdy
and Webster (2004) discussing the role of agents for reducing perioperative blood loss and
transfusion requirements. Consider the cell-saver.
Bombeli T and Spahn DR (2004). Updates in perioperative coagulation: physiology
and management of thromboembolism and haemorrhage Br. J. Anaesth.; 93, 275
287. [excellent review article]
Mahdy AM and Webster NR (2004). Perioperative systemic haemostatic agents. Br.
J. Anaesth.; 93, 842858.
Recombinant factor VIIa

The hospital has a Guideline for use of Factor VIIa for use in massive haemorrhage.
Ahonen J and Jokela R (2005). Recombinant factor VIIa for life-threatening postpartum haemorrhage. Br. J. Anaesth.; 94, 592595.
Spahn DR and Makris M (2005). Is recombinant FVIIa the magic bullet in the
treatment of major bleeding? Br. J. Anaesth.; 94, 553555. [editorial]
Welsby IJ, Monroe DM, Lawson JH and Hoffmann M (2005). Recombinant activated
factor VII and the anaesthetist. [review article] Anaesthesia; 60, 12031212.
8.4
Remifentanil
Remifentanil (Ultiva) is an ultra short-acting narcotic, used either as a bolus or as an

infusion. Remifentanil pharmacokinetics are not modified by hepatic or renal failure
(Absalom and Struys 2006). Duration of action when given as a bolus is approximately
10 mins. See the excellent review by Scott and Perry (2005).
8.4.1
Bolus
Drug
Remifentanil (Ultiva)
1 mg ampoule

1 mg / 20 mls
(50 g / ml)
Bolus dose (adults)

0515 g / kg
CHAPTER 8. DRUGS
RWD Nickalls
Induction of anaesthesia
Remifentanil is an extremely useful co-induction agent for intubation and for bronchoscopy.
It is very cardio-stable and reduces the propofol induction dose by about 50%. Typical
co-induction dose for 70 kg adult: 70100 g (in 2550 g increments over 2 mins). Use
approximately half the dose in the elderly. Watch out for (a) respiratory depression, especially in the elderly (only give during pre-oxygenation), (b) bradycardia (have atropine
handy), (c) hypotension.
During anaesthesia
Bradycardia seems to be most pronounced during anaesthesia with volatiles, so once
anaesthesia has been established then titrate initially with 1020 g boluses (70 kg adult)
in order to determine the effective dose.
8.4.2
Infusion
For sedation and analgesia in ventilated patients in an ITU setting, the recommendation is
to start at about 01 g / kg / min and titrate by 20% depending on the response, as shown
in the following Table.
Drug
Remifentanil
(Ultiva)
Dilution (5% Dex or saline)

3 kg
mg in 50 mls
100
Infusion (adults)
start at 10 mls / hr
(01 g / kg / min)
For anaesthesia, any recommendation of specific ranges of MAC to supplement a

remifentanil infusion should really be based on a review of the growing literature of
observed MAC reductions (see: Breslin et al. 2001, Lang et al. 1996, van Delden et al.
2002).
For TCI techniques see Absalom and Struys (2007). The Minto 3-compartment model
(Minto, Schnider, Egan et al. 1997; Minto, Schnider and Shafer 1997) most commonly
used for remifentanil, uses age and lean body mass (LBM) as co-variables, and so requires
entry of weight, height and gender as well (Absalom and Struys 2007, p. 16).
8.4.3
References
Absalom AR and Struys MMRF (2007). Overview of target controlled infusions

and total intravenous anaesthesia. 108 pp. (Academia Press, Ghent, Belgium;
http://www.academiapress.be) ISBN 978-90-382-11077 [excellent small book
sponsored by the marketing department of Carefusion, Basingstoke, RG22-4BS,
Hampshire, UK; tel: +44(0)1256-388462]
CHAPTER 8. DRUGS
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Breslin D, Reid JE, Mirakhur RK, Hayes AK and McBrien ME (2001). Sevofluranenitrous oxide anaesthesia supplemented with remifentanil: effect on recovery and
cognitive function. Anaesthesia; 56, 114119.
This article attempts to determine the appropriate remifentanil infusion rate associated with sevoflurane at 15, 10 and 05 MAC. They found that a remifentanil
infusion of 034 (range 020049 g/kg/min) requires a MAC of 05 in a population
of mean age 30 years and mean BMI 251 for operations of mean duration 57 mins.
Lang E, Kapila A, Shlugman D, Hoke JF, Sebel PS and Glass PSA (1996). Reduction
of isoflurane minimal alveolar concentration by remifentanil. Anesthesiology; 85,
721728.
Their conclusion (majority of patients in the age-range 3155) was that isoflurane (in
oxygen only) concentrations of 0405 % (i.e., 04 MAC40 approx from my charts)
required a remifentanil infusion rate of 01503 g/kg/min for adequate anaesthesia
(plasma level of 48 ng/ml).
Minto, CF, Schnider TW, Egan TD et al. (1997). Influence of age and gender on the
pharmacokinetics and pharmacodynamics of remifentanil. I. Model development.
Anaesthesiology; 86, 1023.
Minto, CF, Schnider TW and Shafer SL (1997). Pharmacokinetics and pharmacodynamics of remifentanil. II. Model application. Anaesthesiology; 86, 2433.
Purugganan RV (2008). Intravenous anesthesia for thoracic procedures. Current
Opinion in Anaesthesiology; 21, 17.
Scott LJ and Perry CM (2005). Remifentanil. A review of its use during the induction
and maintenance of general anaesthesia. Drugs; 65, 17931823. [excellent]
van Delden PG, Houweling PL, Bencini AF, Ephraim EP, Frietman RC, van Niekert
J, van Stolk MA, Verheijen R, Wajer OJ, Mulder PGH (2002). Remifentanil
sevoflurane anaesthesia for laparoscopic cholecystectomy: comparison of three dose
regimens. Anaesthesia; 57, 2127.
This article determined the appropriate remifentanil infusion rate associated with
sevoflurane (with no nitrous oxide) at 12, 08 and 04 MAC. They found that a
remifentanil infusion of 023 (range 012073 g/kg/min) requires a MAC of 08
in a population of mean age 47 years. Their conclusion was that the optimum
combination (for anaesthesia quality and recovery rate) was sevoflurane ET 124 %
(i.e., MAC47 = 07 approx from my charts 9 ) and remifentanil 023 g/kg/min (I
have converted their g/kg/hr to g/kg/min).
9 See
Figures 9.1, 9.2, 9.3.
9
Supporting technologies
we address some of the supporting technologies associated with thoracic
anaesthesia. The motivation is historicalto highlight some of the key references
and see how discoveries were made.1 Since our subject is thoracic anaesthesia
the recent historical overview by Brodsky 2 (2005) is an excellent starting point.
Unfortunately the historical background of medical discoveries tends to be insufficiently
emphasised, but time spent reading original papers and early documentation is usually
well rewarded, often revealing not only scientists with extreme focus and mental tenacity
but also the occasional hand of serendipity.3
Two insights are commonly cited as influencing discovery and subsequent innovative
development. The first is awareness of the problem, immortalised by Louis Pasteur (1822
1895) in the succinct but misquoted phrase Chance favours the prepared mind.4 The second
is appreciating the significance of a discovery. For example, although Crawford Long
(18151878) was apparently the first person to use ether for a surgical operation, we really
owe the initial development of clinical anaesthesia to William Morton 5 6 (18191868) who
appreciated its value to humanity, and to John Snow (18131858) who laid the scientific
foundations of inhalational anaesthesia.7
ERE
1 See the memorable September 2002 issue of the ASA Newsletter (http://www.asahq.org/) on the
history of monitoring.
2 Brodsky JB (2005). The evolution of thoracic anesthesia. Thoracic Surgery Clinics; 15, 110.
3 See accounts by Comroe (1977), Swazey and Reeds (1978) and Watson (1968) in Section 1.2 (History).
4 The full sentence actually used by Pasteur in his inaugural address (1854) as the professor of chemistry at
the Faculte des Sciences at Lille, was In the field of observation, chance only favours those minds which have
been prepared. (Mackay A (1977). The harvest of a quiet eye; a selection of scientific quotations. Institute of
Physics, London; ISBN 0-85498-031-8. page 116.)
5 MacQuitty B (1969). The battle for oblivion: the discovery of anaesthesia. (GG Harrap & Co. Ltd., London).
6 It now appears that there were in fact several other people experimenting with ether at that time (see
[Section 9.4.5] Stone, Meyer and Alston 2010).
7 See more on John Snow in Section 9.4.1.
141
CHAPTER 9. SUPPORTING TECHNOLOGIES
9.1
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Serendipity
The word serendipity is often used in the context of discovery and innovation; its original
usage was very specificdiscovering, quite by accident, something that you were not
looking for (Remer 1965). The word is ascribed to Horace Walpole (17171797), who used
it in 1754 in a letter 8 to Horace Mann, then living in Florence (Toynbee 1903; Remer 1965,
Boyle 2000).
This discovery indeed is almost of that kind I call serendipity, a very expressive word,
which as I have nothing better to tell you, I shall endeavour to explain to you: you will
understand it better by the derivation than by the definition. I once read a silly fairy
tale, called The three princes of serendip:9 as their highnesses travelled, they were
always making discoveries, by accidents and sagacity, of things which they were not
in quest of: for instance, one of them discovered that a mule 10 blind of the right eye
had travelled the same road lately, because the grass was eaten only on the left side,
where it was worse than on the rightnow do you understand serendipity? One of
the most remarkable instances of this accidental sagacity (for you must observe that
no discovery of a thing you are looking for, comes under this description) was of my
Lord Shaftsbury, who happening to dine at Lord Chancellor Clarendons, found out
the marriage of the Duke of York and Mrs Hyde, by the respect with which her mother
treated her at table.
Horace Walpole January 28, 1754
From: Toynbee (1903)
The animal in the original story was actually a camel. The relevant extract from the 1964
English translation of the 1557 Italian version (Boyle 2000), runs as follows.
Misfortune befalls the princes when a camel driver stops them on the road and asks
them if they have seen one of his camels. Although they have not, they have noticed
signs that suggest a camel has passed along the road. Ever ready to dazzle with their
wit and sagacity, the princes mystify the camel driver by asking him if the lost camel
is blind in one eye, missing a tooth and lame. The camel driver, impressed by the
accuracy of the description, immediately hurries off in pursuit of the animal.
After a fruitless search, and feeling deceived, he returns to the princes, who reassure
him by supplying further information. The camel, they say, carried a load of butter on
one side and honey on the other, and was ridden by a pregnant woman. Concluding
that the princes have stolen the camel, the driver has them imprisoned. It is only after
the drivers neighbour finds the camel that they are released.
The princes are brought before the Emperor Beramo, who asks them how they could
give such an accurate description of a camel they have never seen. It is clear from the
princes reply that they had brilliantly interpreted the scant evidence observed along
the road.
8 Letter
dated 28 January, 1754see Toynbee (1903).

Lanka.
10 A camel in the English version.
9 Sri
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As the grass had been eaten on one side of the road where it was less verdant, the
princes deduced that the camel was blind on the other side. Because there were lumps
of chewed grass on the road the size of a camels tooth, presumably they had fallen
through the gap left by a missing tooth. The tracks showed the prints of only three
feet, the fourth being dragged, indicating that the animal was lame. That butter was
carried on one side of the camel and honey on the other was clear because ants had
been attracted to melted butter on one side of the road and flies to spilled honey on the
other.
Boyle (2000)
Boyle R (2000). The three princes of Serendip. http://livingheritage.org/

three_princes.htm
Remer TG (1965). Serendipity and the three princes: from the PEREGRINAGGIO
of 1557 (University of Oklahoma Press, Norman, Oaklahoma, USA). [includes an
English translation of the 1557 Peregrinaggio edition]
Toynbee P (1903). Letters of Horace Walpole; arranged by Mrs. Paget Toynbee.
(The Clarenden Press, Oxford, UK). See letter dated: 28 January, 1754.
Walpoles letters (Ed. P Cunningham, 4 vols) are available on the Project Gutenberg
website (http://www.gutenberg.org/). For the letter of 28 January 1754 (to
Horace Mann) see letter 90, Volume 2 (17491759), pages 203205:
9.2
Tuohy needle with Huber point and Lee markings
Not only is the modern epidural needle a fusion of three primary ideas, but it actually
started life as spinal needle. Of the many designs which have been developed few have
endured (see the excellent review by Frolich et al. 2001).
Edward Boyce Tuohy (19081959) was an anaesthetist at the Mayo Clinic (Rochester,
Minnesota, USA), interested in continuous spinal anaesthesia (Maltby 2002). Although this
technique was first described by Henry Dean in 1906, it was mainly developed during the
1940s by William Lemmon (Maltby, 2002). However Lemmons technique was far from
ideal since it required the needle to remain in position (tip in the CSF) during anaesthesia
in order to allow intermittent top-ups as required.
Tuohys idea was to develop a method of introducing a catheter into the lumbar CSF
space via a spinal needle to facilitate continuous spinal anaesthesiathe needle itself
could then be removed once the catheter was in place. Continuous caudal anaesthesia via a
caudal catheter was already fairly widely used, and lumbar subarachnoid catheters were
also sometimes used for drainage in meningitis.
In 1944 Tuohy described this technique using an ordinary 15-gauge spinal needle
(Maltby 2002), and only later, in 1945, did he decide to incorporate the Huber point
(designed by Ralph L Huber (18901953) and made by Becton Dickinson) taking advantage of its lateral opening which allowed the catheter to be directed sideways into the
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space (Tuohy 1945). In 1949, both MM Curbelo and Charles Flowers described using the
Tuohy needle for epidural anaesthesia. Tuohy was later appointed professor of anaesthesia
at the Georgetown Medical Centre in Washington, DC.
Finally, we owe the 1 cm markings on the standard Tuohy needle to the English
anaesthetist John Alfred Lee (19061989). He added them so that anaesthetists would
know fairly accurately the depth of the needle tip, and hoped that this small refinement
might reduce the number of dural taps (Lee 1960; Maltby 2002).
Eldor J (1995). Huber needle and Tuohy catheter. Regional Anesthesia; 20, 252253
[cited from Maltby 2002]
Frolich MA and Caton D (2001). Pioneers in epidural needle design. Anesthesia
Lee JA (1960). Specially marked needle to facilitate epidural block. Anaesthesia;
15, 186. [cited from Maltby 2002]
Maltby JR (2002). Notable names in anaesthesia. (The Royal Society of Medicine
Press Limited, London). [JA Lee (pp. 114116); EB Tuohy (pp. 216218)]
Schorr MR (1966). Needles: some points to think about Part II. Anesthesia and
Analgesia; 45, 514519 [cited from Maltby 2002]
Tuohy EB (1945). Continuous spinal anesthesia: a new method utilizing a ureteral
catheter. Surgical Clinics of North America; 25, 834840 [cited from Maltby 2002]
9.3
Pulse oximetry
For a detailed review of the long and and fascinating history of blood gases, oximetry and
pulse oximetry see Severinghaus (2002; 1986) and Severinghaus and Astrup (1987).
The first practical oximeter was the eight-wavelength ear-oximeter developed in 1964
by Robert Shaw and subsequently marketed by Hewlett-Packard in 1970 (Moyle 1994).
In 1971 Takuo Aoyagi (1936), a Japanese biomedical engineer at the Nihon Kohden
Corporation (Tokyo), used the pulsatility of the absorption signal to separate arterial and
tissue absorption and determine arterial saturation. Severinghaus describes it thus:
Takuo Aoyagi . . . attempted to eliminate arterial pulsatile noise in his earpiece dye
dilution curves by subtracting infra-red signals. He observed that the compensated
noise varied with oxygen saturation and realised that it might be used to compute the
arterial oxygen saturation.
Severinghaus (1989)
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The first commercial pulse oximeter appeared in 1970 (Moyle 1994), and in 1982 the
Stanford anaesthetist William New (1942), with Jack Lloyd and engineer Jim Corenham, founded Nellcor 11 Incorporated to mass-produce clinically useful pulse-oximeters
(Rendall-Baker and Bause 2002).
If a finger pulse-oximeter fails owing to significant peripheral vasoconstriction, then
an ear-probe will usually be satisfactory. Alternatively, a digital nerve block may help
(Erasmus 2003).
Astrup PB and Severinghaus JW (1986). History of blood gases, acids and bases.
(Munksgaard, Copenhagen). [from Severinghaus 1989]
Breathnach CS (1972). The development of blood gas analysis. Medical History; 16,
5162. (available from http://www.ncbi.nlm.nih.gov/pmc/journals/228/)
Erasmus PD (2003). Digital block improves pulse oximetry signal in vasoconstricted
patients. Anaesthesia; 58, 10331034.
Kofke WA (2003). An interview with John W. Severinghaus. Association of
University Anesthesiologists (AUA) Update; Fall 2003 issue. http://www.auahq.
org/fall03aua.pdf [an interesting 4 page article in which Severinghaus describes
how he became involved in MAC, blood gases and oximetry]
Moyle JTB (1994). Pulse oximetry. (BMJ Publishing Group, London).
Pole Y (1999). Evolution of the pulse-oximeter. The History of Anaesthesia Society
Proceedings; 26, 2122.
Rendell-Baker L and Bause GS (2002). Cardiorespiratory monitoring: a pictorial
sampler. ASA Newsletter; 66, No. 9 (September) (http://www.asahq.org/)
Severinghaus JW (2002). The history of clinical oxygen monitoring. In: Eds.
Diz JC, Franco A, Bacon DR, Rupreht J and Alvarez J. The History of Anesthesia.
Proceedings of the Fifth International Symposium on the History of Anesthesia;
Santiago, Spain, 1923 September 2001. Excerpta Medica, International Congress
Series 1242. ISBN 0-444-51293-4 (Elsevier Science). pp. 115120.
Severinghaus JW and Astrup PB. (1987). History of blood gas analysis. International
Anesthesiology Clinics; 25, no. 4, (Little, Brown & Co.., Boston, USA). [first
published as a series of articles in Journal of Clinical Monitoring in 1986]
Severinghaus JW (1986). Historical development of oxygenation monitoring. In:
Pulse Oximetry. Eds. Payne JP & Severinghaus JW, (Springer-Verlag), pp. 118
[covers spectroscopy, oximetry and blood gas electrodes]
11 The name Nellcor was derived from a synthesis of the surnames NEw, LLoyd, CORenham (Rendall-Baker
and Bause 2002).
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Severinghaus JW and Astrup PB. (1986). History of blood gas analysis. VI. Oximetry. Journal of Clinical Monitoring; 2, 270288.
Severinghaus JW and Honda Y. (1987). History of blood gas analysis. VII. Pulse
oximetry. Journal of Clinical Monitoring; 3, 135138.
West JB (1998). High life; a history of high-altitude physiology and medicine.
(Oxford University Press).
Yoshiya I, Shimada Y and Tanaka K (1980). Spectrophotometric monitoring of
arterial oxygen saturation in the fingertip. Med. Biol. Eng. Comput.; 18, 2732.
[excellent]
9.4
MAC
Ether contributes other benefits besides preventing the pain.

It keeps patients still, who otherwise would not be.
John Snow
From: Eger (1974),12 p. 1
9.4.1
History
John Snow
John Snow (18131858) appears to have been the first person to appreciate the importance
of controlling the inspired concentration of volatile anaesthetics, and within five years of
William Mortons ether demonstration 13 he had single-handedly established the scientific
foundations underpinning the pharmacokinetics of volatile anaesthetics.
Snow was a London-based GP with hospital connections, and had been interested for a
long time in the use of inhalation agents on respiration. He initially investigated the use of
carbon dioxide, and had been experimenting with inhaled ether since 1843 believing it to
be a useful medicine for improving circulation. In 1846 he published an article entitled
Pathological effects of atmospheres (Maltby 2002; Vinten-Johansen et al. 2003).
Consequently, following Mortons ether demonstration (October 16, 1846) at the
Massachusetts General Hospital (Boston, USA), and the subsequent demonstration in
London in December 1846, Snow found himself in the right place at the right time.
Furthermore, with his interest in chemistry and recent researches into inhaled ether he
also found himself to be just the right person to get involved in this new anaesthesia
phenomenon. Since his GP work was not very profitable, Snow decided to take up
anaesthesia.
Snow was extraordinarily industrious and productive. By mid 1847 he had (a) defined
and published the temperature characteristics of ether vapour (January 1947), (b) designed
12 This
quotation, which heads Egers own chapter on MAC, is from: Snow 1847 (part 4).
Morton (18191868) gave his demonstration on October 16, 1846. For an excellent account of the
history and background see MacQuitty (1969).
13 William
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an ether inhaler, (c) defined a range of clinical stages of anaesthesia (his five degrees of
narcotism), and (d) performed many animal experiments with a view to determining the
effects of different inspired concentrations of both ether and chloroform. Snow appreciated
the significance of knowing the saturated vapour pressure, and went on to show that
the amount of volatile agent required to produce anaesthesia was inversely related to its
solubility in the blood.
Snow published his findings in an eighteen-part series of articles in the journal London
Medical Gazette during the period 1848 to 1851, entitled On narcotism by the inhalation
of vapours. In the following extracts (all from PartI of the series) Snow describes the
effects on a mouse of a sequence of step increases in the inspired concentration of ether
(from approximately 12 % to 47 %).14 Notice the detail of his observations, and how
he pays particular attention to how well the mouse breathes (I have added a calculated
concentration in MAC ether
mouse at each stage to make it easier to follow his experiments).
I consider, however, that I have found a plan of determining more exactly the [required]
proportion of ether and of other volatile substances present in the blood in the different
degrees of narcotism. It consists of ascertaining the most diluted mixture of vapour and
of air that will suffice to produce any particular amount of narcotism; and is founded
on the following considerations, and corroborated by its agreeing with the comparative
physiological strength of the various substances.
. . . The plan which I adopted to ascertain the smallest quantity of vapour, in proportion
to the air, that would produce a given effect, was to weigh a small quantity of the
volatile liquid in a little bottle, and introduce it into a large glass jar covered with a
plate of glass; and having taken care that the resulting vapour was equally diffused
through the air, to introduce an animal so small, that the jar would represent a capacious
apartment for it, and wait for that period when the effects of the vapour no longer
increased. . . .
Exp. 17. Two grains of ether were put into a jar holding 200 cubic inches [116 %,
036 MAC], and the vapour diffused equally, when a tame mouse was introduced, and
allowed to remain a quarter of an hour, but it was not appreciably affected.
Exp. 18. Another mouse was placed in the same jar, with three grains of ether, being
a grain and a half to each 100 cubic inches [175 %, 055 MAC]. In a minute and a
half it was unable to stand, but continued to move its limbs occasionally. It remained
eight minutes without becoming further affected. When taken out it was sensible to
pinching, but fell over on its side in attempting to walk. In a minute and a half the
effect of the ether appeared to have gone off entirely.
Exp. 19. A white mouse in the same jar, with four grains of ether [233 %, 072 MAC],
was unable to stand at the end of a minute, and at the end of another minute ceased to
move, but continued to breath naturally, and was taken out at the end of five minutes.
It moved on being pinched, began to attempt to walk at the end of a minute, and in two
minutes more seemed quite recovered.
14 MAC ether
mouse
= 32 % (Eger 1974, p. 5).
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Exp. 20. Five grains of ether, being two and a half grains to each 100 cubic inches
[292 %, 091 MAC], were diffused throughout the same jar, and a mouse put in. It
became rather more quickly insensible than the one in the last experiment. It was
allowed to remain eight minutes. It moved its foot a very little when pinched, and
recovered in the course of four minutes.
Exp. 21. A white mouse was placed in the same jar with six grains of ether [35 %,
11 MAC]. In a minute and a half it was lying insensible. At the end of three minutes
the breathing became laborious, and accompanied by a kind of stertor. It continued in
this state till taken out, at the end of seven minutes, when it was found to be totally
insensible to pinching. The breathing improved at the end of a minute; it began to
move at the end of three minutes; and five minutes after its removal it had recovered.
Exp. 22. The same mouse was put into this jar on the following day, with seven
grains of ether, being 35 grs to the 100 cubic inches [408 %, 128 MAC]. Stertorous
breathing came on sooner than before; it seemed at the point of death when four
minutes had elapsed; and being then taken out, was longer in recovering than after the
last experiment.
Exp. 23. Two or three days afterwards the same mouse was placed in the jar, with
eight grains of ether, being 4 grains to the 100 cubic inches [466 %, 146 MAC]. It
became insensible in half a minute. In two minutes and a half the breathing became
difficult, and at a little more than three minutes it appeared that the breathing was about
to cease, and the mouse was taken out. In a minute or two the breathing improved, and
in the course of five minutes from its removal it had recovered.
. . . We find from the eighteenth experiment, that a grain and a half of ether for each
100 cubic inches of air, is sufficient to induce the second degree of narcotism in the
mouse; and a grain and a half of ether make 19 cubic inches of vapour, of sp. gr. 2586.
Now the ether I employed boiled at 96 [F].15 At this temperature, consequently, its
vapour would exclude the air entirely; and the ether vapour in contact with the liquid
giving it off, could only be raised to 100 by such a pressure as would cause the
boiling point of the ether to rise to that temperature. That pressure would be equal
to 324 inches of mercury [1082 Atm.], or 24 inches above the usual barometrical
pressure; and the vapour would be condensed somewhat, so that the space of 100 cubic
inches [at 1082 Atm.] would contain 108 cubic inches at the usual pressure [1 Atm.].
This is the quantity, then, with which we have to compare 19 cubic inches, in order to
ascertain the degree of saturation of the space in the air-cells of the lungs, and also of
the blood; and by calculation, as when treating of chloroform,
19 is to 108 as 00175 is to 1
So that we find 00175 [175 %], or 1/57th, to be the amount of saturation of the blood
by ether necessary to produce the second degree of narcotism;
Snow (1848a)
15 96 F = 355 C. ( F32
9
1972).
= C5 ). Pure diethyl-ether boils at 3451 C (CRC Handbook of chemistry and physics;
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Notice the interesting way in which Snow calculates the vapour concentration resulting
from 15 grains 16 of liquid diethyl-ether 17 in 100 cubic inches 18 of air at 100 F 19 as
175 %. My own calculation runs as follows. Since the molecular weight of diethyl-ether
is 7412, the volume of pure ether vapour at STP occupied by 9675 mg liquid ether
(15 grains) is given by 20
9675
224
= 2924 cc
7412
If we now correct this volume for a temperature of 100 F 21 (377 C) we obtain 2924
3107/273 = 333 cc. Adding this volume of pure vapour to 100 cubic inches of air 22
(also at 377 C) gives a concentration of
333
= 001754 175 %
333 + (100 2543 3107/273)
However, we have made some simplifying assumptions (e.g., constant pressure and complete mixing), and since Snow only used a glass jar with a simple lid, it is likely that some
of the mixture escaped from the jar before mixing was complete.23
It is clear from these extracts from Snows publications, that Snow was seeking the
inspired concentration associated with each of his five degrees of narcotism, and that
he was guided by two key principles, namely (a) to determine the most diluted mixture
which gave these effects (i.e., the minimum concentration), and (b) waiting until the effect
no longer increased (i.e., at equilibrium).
Snows pharmacological approach of linking particular inspired concentrations of
vapour to particular states or depths of anaesthesia, and then using this information to try
and deliver a safer form of anaesthesia by controlling the inspired vapour concentration
was, therefore, strikingly similar to our modern use of MAC.24 His experiments were
carefully performed, observed, and well documentedin fact so much so that they even
allow us to make a reasonably accurate estimate of MAC for the mouse. For example,
Snows experiments 20 and 21 suggest that the inspired concentration of ether associated
with 50 % movement was between 29 % and 35 %, giving an estimate close to the modern
25 of 32 %.
value of MAC ether
mouse for the mouse
16 1
grain = 645 mg.
17CH CH OCH CH ; molecular weight

3
2
2
3
18 1 cubic inch = 2543 = 1638 cc.
19 100 F
= 7412; BP = 3451 C
= 377 C.
mol of vapour occupies 224 L at STP.
21 Note that this is roughly mouse body temperature.
22 We keep the pressure constant and assume complete mixing.
23 Please email me if you improve on this analysis.
24 The first paper on MAC was by Merkel and Eger (1963). The definition of MAC is as follows: the minimum
alveolar concentration, at equilibrium, and at 1 atmosphere pressure, which prevents movement in 50 % of
patients to a standard surgical incision. For an excellent early overview of MAC see Chapter 1 in the timeless
classic book by Eger (1974).
25 Eger (1974), p. 5.
20 1 gm
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100 years or so later in the early 1960s Eger and Severinghaus embodied Snows
concepts in the form of MAC (Merkel and Eger 1963; Saidman and Eger 1964; Eger,
Saidman, and Brandstater 1965a).
Edmond Eger
In 1960 Edmond Eger joined the San Francisco Department of Anaesthesia, and became
a Research Fellow to John Severinghaus (Eger 2002, Maltby 2002). Eger and Dr Giles
Merkel (Research Fellow) were given the task of defining the properties of a new volatile
anaesthetic agent called halopropane. Eger describes the early steps as follows.
From studies John [Severinghaus] and others had performed with carbon dioxide, we
knew that measuring the end-tidal concentration of a gas gave us a handle on the
arterial partial pressure for that gas. Also, the work of Kety and Schmidt indicated
that the cerebral partial pressure of an inert gas should rapidly equilibrate with the
partial pressure in arterial blood. So, if we measured the end-tidal concentration of
halopropane and held it stable for a sufficient period of time, the end-tidal concentration
would give us a measure of the anesthetic partial pressure at its site of action. With
that, we had the first part of MAC.
The second part was not hard to come by. . . . Movement. A categorical response,
seemed just the thing . . . So we married the end-tidal concentration with movementno
movement as an index of anesthesia, and MAC was born.
Everything except the name. Johns group met every Monday morning to discuss
the previous weeks work and what might be done in the coming week . . . At one of
these Giles and I told of our technique for determining the minimal alveolar anesthetic
concentration, and John connected this to the ratio of the speed of an airplane relative
to the speed of sound (a MAAC ratio). John now says it never was clear why we chose
MAC rather than MAAC. I dont remember either, except that we wanted to emphasise
the word alveolar. Besides, voicing MAAC might make us sound like bleating
sheep rather than anesthesiologists.
The next step was to determine MAC in humans. . . . The result was the series of
articles that were published in 1965 (Eger, Saidman and Brandstater 1965a, 1965b;
Eger et al. 1965).
Eger (2002)
John Severinghaus
Severinghaus (Severinghaus 2009, Maltby 2002) recalled this episode in a recent journal
interview as follows (Kofke 2003).
Dr. Eger was interested in the relative potency of anesthetics. He wanted a way to
compare them numerically in terms of their alveolar concentrations at the time of
establishment of a minimal level of anesthesia to permit surgery. It was clear to all
that for each patient or animal, there was a critical alveolar (and thus arterial and
ultimately brain) pressure of an agent that just prevented a motor response to pain. He
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believed this would be a relatively invariant number between patients This would be
the minimal alveolar anesthetic concentration. I recalled that in aviation, a similar
index, Mach, was the ratio of an aircrafts speed to the speed of sound.26 A hypersonic
flight was defined, for example, as Mach 2, twice the speed of sound. I suggested the
same symbol be used for the ratio of concentration of the anesthetic in the alveoli (as
determined in the airway at end expiration) to that critical no-movement level, which
would be defined as 1 MAC, originally MAAC. It still should be MAAC since we cant
agree on whether the single A refers to alveolar or anesthetic or both.
Kofke (2003)
William Mapleson
In 1979, a far-sighted William Mapleson anticipated the increasingly central role of MAC
with respect to how anaesthetists delivered a given depth of anaesthesia, as follows (see
also Maltby 2002).
. . . To this end, the anaesthetist will be invited to set his flows of oxygen and nitrous
oxide in the normal way and then to set the brain tension of anaesthetic he requires,
not in kPa or mmHg, but in total MAC units.
Mapleson (1979).
More recently the clinical utility of MAC has been extended by establishing its variation
with age (Mapleson, 1996), temperature (Eger 2001) and hair colour (Liem et al. 2004).
9.4.2
Age-corrected MAC
Although several factors are known to be associated with altered anaesthetic requirements,27 age is the most important owing to the increasingly large age-range met with in
clinical practice.
While age has long been known to influence anaesthetic requirement (Gregory, Eger
and Munson 1969), the exact variation of MAC with age was formalised only recently
by Mapleson (1996), following a meta-analysis of the available data (see Table 9.1). In
particular, Mapleson showed that semi-log plots of MAC against age (age 1 year) for all
inhalational agents are linear and parallel, and hence it is probable that all the inhalational
agents achieve their effects by a similar mechanism. On this basis, therefore, Mapleson
derived the following relationship between age and MAC from the pooled data,
MAC age
= MAC40 10000269(age40)
which expresses MAC for a given age as a function of that at 40 years (MAC40 ).
The computed real-time MAC as displayed by the Datex AS/3 and S/5 anaesthesia
monitors relates to normothermic patients aged approximately 35 years-old. However,
26 Severinghaus
worked on radar technology during World War II (Kofke 2003).

key factors are narcotics (see section on remifentanil in the appendix), age, temperature, pregnancy, and
hair colour (Liem et al. 2004, showed that patients with red hair had a 19 % increased MAC requirement).
27 The
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Table 9.1:
MAC data based on age 1 year. The 95 % confidence limits (CL) for ages 1
and 80 years are up to 1 % greater than at MAC40 (from Mapleson 1996). For
the CO2 value see Eisele and Eger (1967).
Agent
Halothane
Isoflurane
Enflurane
Sevoflurane
Desflurane
Carbon dioxide
Xenon
Nitrous oxide
1 year
095
149
208
229
83
92
133
40 years
075
117
163
180
66
30
72
104
80 years
058
091
127
140
51
57
81
95 % CL ( % MAC40 )
6
6
17
6
10
16
8
since many of the thoracic patients are quite elderly it is more appropriate clinically to
use an age-corrected MAC. A real-time software version which incorporates nitrous oxide
is shown in Figure 9.5 (page 159). Print versions 28 in the form of graphs which allow
for nitrous oxide use have been designed (Nickalls and Mapleson 2003), a separate chart
being used for each volatile agent as shown in Figures 9.19.3. The use of nitrous oxide
is accommodated in the charts by offsetting the right-hand N2 O scales vertically by the
amount given by
F E0N2 O
MAC age, volatile

MAC age, N2 O
The print versions are available for download 29 and also in Allman and Wilson (2006).
A nomogram by Lerou (2004) also gives age-corrected MAC.
Software
The iso-MAC information is also available for some hand-held devices, for example, as
the software MACpalm and ACTc.
MACpalm: The MACpalm program is available from http://www.medicaldownload.
com/medicalsoftware/macpalm.html. The installation is described in the MACpalm
manual.
ACTc: The Anesthesia Clinical Tutor and Calculator (ACTc) program is available from
http://www.gasshead.com/. A manual is available at http://www.gasshead.com/
content/TutorACTc.pdf
28 These allow anyone to confidently use the common volatile agents with patients of any age without any
guesswork or the need for superhuman memory. The motivation for developing a convenient graphic version
arose from my wanting a paper-equivalent for use when working at another hospital, since I then had no access to
my own real-time computer version based in the thoracic theatre at the City Hospital.
29 http://www.nickalls.org/dick/xenon/rwdnXenon.html#workstation-mac
ISOFLURANE
MAC
End-tidal (%) in 100 % oxygen/air
24
22
20
18
16
14
12
10
08
06
16 ......
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End-expired (%) in
67%
50%
N2 O
N2 O
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16
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14 ........
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12 .......
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c RWD Nickalls 2003

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14
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14
10
12
08
10
06
08
04
06
02
04
02
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0 10 20 30 40 50 60 70 80 90 100
Age (years)
Figure 9.1:
Age-related iso-MAC curves drawn using the data of Mapleson (1996), The
dots on the iso-MAC curves are to help alignment. The left-hand ordinate scale
indicates the end-expired isoflurane concentration when using an oxygen/air
mixture. The two right-hand ordinate scales indicate the end-expired isoflurane
concentration when using nitrous oxide 50 % and 67 % in oxygen. The vertical
shifts for the nitrous oxide 50 % and 67 % scales are 056 and 075 respectively.
For a given age and MAC the associated end-expired isoflurane concentration
is read from the appropriate ordinate scale. For example, a MAC of 12 for a
60-year old patient using isoflurane and nitrous oxide 67 % in oxygen requires
an end-expired isoflurane concentration of approximately 05 %.
RWD Nickalls
SEVOFLURANE
38
36
34
32
30
28
26
24
22
20
18
16
14
12
10
08
End-expired (%) in
67%
50%
MAC
N2 O
N2 O
16 ......
24
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20
14 ...................
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22
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08
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0 10 20 30 40 50 60 70 80 90 100
Age (years)
Figure 9.2:
DESFLURANE
140
130
120
110
100
90
80
70
60
50
40
30
MAC
16 ......
.....
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End-expired (%) in
67%
50%
N2 O
N2 O
90
100
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c RWD Nickalls 2003

0 10 20 30 40 50 60 70 80 90 100
Age (years)
Figure 9.3:
80
90
70
80
60
70
50
60
40
50
30
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Figure 9.4:
An example of one of the new age and temperature-corrected MAC charts (see
Section 9.4.3 for details). A Perl program prompts the user for agent name and
patient age and then prints the chart out in the operating theatre.
9.4.3
RWD Nickalls
Temperature corrected MAC
It is well established that MAC decreases as body temperature decreases. In fact even John
Snow was aware of the influence of temperature, as the following extract shows.30
As the narcotism of frogs, by vapour too much diluted to affect animals of warm blood,
depends merely on their temperature, it follows that by warming them, they ought to
be put into the same condition, in this respect, as the higher classes of animals; and
although I have not raised their temperature to the same degree, I have found that as it
is increased, they cease to be affected by dilute vapour that would narcotise them at a
lower temperature.
Snow (1848a)
However, it is less well known that (a) MAC decreases linearly with core temperature fall
(approximately 25 % reduction in MAC per degree centigrade from 37 C), and (b) the
rate of MAC decrease with temperature fall is considerably more for vapours than for
gases; for example the change in MAC / C for halothane and cyclopropane in dogs is
53 % and 2 % respectively (Eger, Saidman, and Brandstater 1965b; Eger 1974). In humans
the linear rate of fall of MAC with temperature in the clinical range is approximately 5 %
per degree centigrade for isoflurane, sevoflurane and desflurane, while that for nitrous
oxide shows essentially no change (Eger 2001).
These findings can be used to combine both age and temperature correction for MAC
in a single chartmost easily done by creating a separate chart for each year of ageas
shown in Figure 9.4. The additional functionality of such a chart is particularly useful,
since the end-tidal agent requirement is most likely to be underestimated in young patients
with a pyrexia. In practice, it is a simple matter to create and print this combined age and
temperature-corrected iso-MAC chart for a specific patient on demand in the operating
theatre.31
For example, suppose we wish to deliver 12 MAC to a 15 year-old patient with
a temperature of 39 C. The Datex AS/3 and S/5 monitors show a value of 12 MAC
for an end-tidal sevoflurane concentration (in air) of approximately 22 %, whereas the
age/temperature correction chart (see Figure 9.4) indicates that to achieve the same MAC
value in this patient (age 15 yrs; temp 39 C) actually requires an end-tidal value of 28 %
(i.e., a 27 % increase compared with the Datex displayed value).
9.4.4
Dosage and MAC correction
Awareness
The problem of awareness and the need for research in this area is often highlighted
(Bergman et al. 2002, Guidry 2005, Leslie and Davidson 2010) and, as one might expect,
data gathered by automatic anaesthesia management systems (AIMS) has been particularly
30 This
temperature work relates to chloroformsee his Experiment 16 (Snow 1848a).

have written a Perl program for this which is freely available. This program and separate charts for the ages
0120 yrs are available on the thoracic CD - ROM in PDF format.
31 I
RWD Nickalls
useful in this regard. For example, using archived AIMS data, Driscoll et al. (2007) were
not only able to establish volatile agent underdosing as the cause of awareness in three
cases, but were also able to show that the clinicians manual component of the relevant
parts of the anaesthesia records were unreliable and failed to reflect events accurately.
More recently, the role of underdosing as a cause of awareness during anaesthesia has
been highlighted in two large studies (Ghoneim et al. 2009, Xu et al. 2009), both of which
found that awareness was associated with reduced drug dosage, being younger, and with
non-volatile anaesthetic techniques. Similarly, Kent (2010) found that the two main causes
of awareness in the Closed Claims database were light anaesthesia and anaesthetic delivery
problems.
Unfortunately EEG depth of consciousness monitoring techniques (e.g., BIS) are
still problematic and unreliable (Mychaskiw et al. 2001, Rampersad and Mulroy 2005).
Furthermore, in spite of several well publicised large neuromonitoring trials and surveys
(Ekman et al. 2004, Myles et al. 2004; Sebel et al. 1997; Sebel et al. 2004; Avidan et al.
2008) there are still no data to suggest, in those cases where volatile agents are used,
that neuromonitoring offers any advantage with regard to preventing awareness, over the
rigorous implementation of corrected MAC monitoring. Indeed, it is significant that the
study of 20,000 patients by Sebel et al. (2004) actually showed that the BIS-monitored
cohort had a higher incidence of awareness (018%) than the control cohort 32 (01%)
(McCulloch 2005). In the BIS/MAC study by Avidan et al. (2008) the authors concluded
that ...Our findings do not support routine BIS monitoring as part of standard practice.
Indeed, the associated editorial by Orser (2008) expressed concern regarding BIS-like
devices, as follows.
. . . the delegation of critical elements of patient care to a black box approach, in
which decisive factors are under proprietary control, must be avoided.
Since the MAC paradime has been so successful (White, 2003), and because there
are no known convincingly documented cases of awareness which are not associated with
possible underdosing, it was recently suggested (Nickalls and Mahajan 2010)
. . . that the time has come to reformulate the concept and adopt a new and pragmatic
working premis, namely, that all cases of awareness are due to underdosing unless
there is convincing verifiable information to the contrary. . . . We . . . must confront the
problem of underdosing by putting in place systems which we can have confidence in
to deliver an adequate dose, implementing the latest alarms (Umesh 2009), algorithms
(Mashour, Esaki Vandervest et al. 2009), and corrections for age (Mapleson 1996,
Nickalls and Mapleson 2003, Eger 2001), temperature (Eger 2001), and so forth as
they come available.
In practice, however, there are studies showing a very low incidence of awareness even
without using brain function monitoring (Pollard et al. 2007), and when volatile agents are
used the end-tidal MAC approach is still the most reliable method for avoiding awareness,
32 See
letter by McCulloch (2005).
RWD Nickalls
and is recommended by the Royal College of Anaesthetists (see RCOA 2006). Indeed,
anaesthetists can easily be made even more aware of the current MAC status simply by
using use a real-time colour-coded dial-display of corrected MAC (see Figure 9.5).
Figure 9.5:
Left: Example of the real-time age-corrected MAC-widget displayed by the
authors open-source anaesthesia workstation software a interfaced to the Datex
S/5 monitor. If the corrected MAC is too low (as shown in this casetotal
MAC 07) then, in addition to sounding an audible alarm, the dial of the
MAC-widget turns red.
Right: Screenshot showing the MAC widget displaying a white dial (corrected
MAC in the normal range). The MAC-widget software can easily be run on a
laptop interfaced to an anaesthesia monitor.
a
Nickalls RWD, Dales S and Nice AK (19962011).
What is the minimum MAC multiple which avoids awareness? 1 MAC has long been
regarded as a significant boundary since isoflurane at 1 MAC was shown to prevent implicit
memory during surgery (Dwyer et al. 1992). More recently this problem was addressed
by Hardman and Aitkenhead (2005), who stated that a stable end-tidal value greater than
1 MAC makes awareness extremely unlikely, as follows.
Risk of awareness correlates with depth of anaesthesia. . . . Fortunately, clinical
investigations have shown a reasonably reliable association between recall and MAC;
patients exhaling more than 08 MAC are unlikely to recall intraoperative events, and
spontaneous recall is virtually eliminated if > 1 MAC is exhaled, except after a sudden
increase in inspired concentration.
Hardman and Aitkenhead (2005)
That the end-tidal agent concentration should be maintained 1 MACage in order to reliably
avoid awareness is consistent with a recent fMRI finding by Kerssens et al. (2005), namely
that while auditory activation in a group of 6 subjects (mean age 23 years) was detected
RWD Nickalls
when breathing 1% end-tidal sevoflurane in oxygen/air (05 MACage ), such activation

was absent when breathing 2% end-tidal sevoflurane (i.e., when breathing 1 MAC, since
MACsevo
23 = 2%).
It is significant, therefore, that in the BIS/MAC study by Avidan et al. (2008) the
end-tidal agent concentration was less than 07 MAC in three of the four cases of definite
awareness, and in seven of of the nine cases of possible awareness. Thus the lower
acceptable limit of 05 MAC suggested by Eger and Sonner (2005), Myles (2007) would
seem to be far too low to reliably prevent awareness. Consequently the values suggested
by Hardman and Aitkenhead (2005)see aboveparticularly when age and temperature
corrected, would seem to be the best current advice.
Note that the MAC value displayed by monitors having no age and temperature
correction is most likely to underestimate the true MAC requirement in young patients with
a high temperature (Section 9.4.3) and (possibly) with red hair (Liem et al. 2004). Indeed,
it may be significant, therefore, that the two patients with documented awareness during
BIS monitoring with sevoflurane reported by Ekman et al. (2004) were quite young (aged
16 and 22 years). Unfortunately the details of the aware patients who received volatile
agents in the non-BIS group were not given.
Research
In all work relating to depth of anaesthesia or awareness, it is essential to collect accurate
real-time end-tidal anaesthetic gas (ETAG) concentrations and core temperatures using
automated anaesthesia record keeping (AARK) equipment, drugs and doses used, as well as
patient age, height, gender and hair-colour. The presented awareness-related data must be
sufficient to enable readers to calculate the corrected MAC for each patient; consequently
the observed ETAG concentrations for each patient should always be presented. Where
MAC corrections have been applied, the literature source of the corrections used must be
indicated. Furthermore, mean age-corrected values need to be correctly determined; for
example, the age correction for MAC is non-linear and hence the mean MAC value for a
group must be derived from the corrected MAC of each individual subject/patient.
In view of the importance of determining minimum MAC values for reliably preventing
awareness, journal editors should ensure that awareness-related MAC data presented in
journal articles are sufficient to allow readers to determine the corrected MAC values for
each patient (Nickalls and Mahajan 2010).
Data sharing
Ideally all cases of inadvertent awareness should be documented, and archived, together
with all the anaesthesia data associated with such cases (including all machine-automated
end-tidal data) and placed in the public domain. Such a database could then form the
basis of research, and may therefore, help . . . recognise those few cases which may
suggest either that the accepted dosage threshold should be raised or, perhaps, a significant
pharmacogenetic difference (Nickalls and Mahajan 2010).
RWD Nickalls
However, although original data documented in journals is still often difficult to access from the authors or organisation (Wicherts et al. 2006, Anon 2006, Kaiser 2008),
fortunately the climate of opinion is now strongly in favour of data-sharing, with funding
organisations increasingly stipulating that authors place their data in open-access repositories within a set period after publication in peer-reviewed journals (Short 2007, Wadman
2009). Nevertheless, we should continue to press for even more safeguards; for example,
the adoption by anesthesia journals of an authorship policy specifying the preservation and
sharing of original data (Anon 2009a). Authors and researchers need to embrace the new
culture of integrity, access and stewardship (Anon 2009b)not only making the data
available, but safe-guarding it as well.
9.4.5
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depth of anesthesia as indicated by a bispectral index monitor. Anesth. Analg.; 100,
13631364.
RCOA (2006). Loss of consciousness monitoring. A statement by the Royal College
of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland.
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Sandin RH, Enlund G, Samuelsson P and Lenmarken C (2000). Awareness during

anaesthesia: a prospective case study. Lancet; 355, 707711.
Sebel PS, Lang E, Rampi IL et al. (1997). A multicenter study of bispectral electroencephalogram analysis for monitoring anaesthetic effect. Anaesthesia and Analgesia;
84, 891899.
Sebel PS, Bowdle TA, Ghoneim MM et al. (2004). The incidence of awareness
during anesthesia: a multicenter United States study. Anesthesia and Analgesia; 99,
833839.
Severinghaus JW (2009). Gadgeteering for health care: [The JW Severinghaus
lecture on translational science] Anesthesiology; 110, 721728.
Short R (2007). Open access will mean peer review becomes the job of the many,
not the select few. British Medical Journal ; 334 (17 February), 330.
Snow J (1847). On the inhalation of the vapour of ether in surgical operations.
Reprinted in Br. J. Anaesth. (1953); 25, pp. 5367 (part 1), 162169 (part 2),
253262 (part 3), 349382 (part 4). Also available from UCLA Department of
Epidemiology website: http://www.ph.ucla.edu/epi/snow.html
Snow J (1848a). On narcotism by the inhalation of vapours (Part I). London Medical
Gazette; 6NS 33 , 850854 [included in Snow 1848b]
Snow J (1848b). On narcotism by the inhalation of vapours (parts IVII). (Wilson
and Ogilvy, London). A facsimile edition with an introductory essay by RH Ellis
(Royal Society of Medicine Services Ltd., London, 1991) ISBN 1-85315-158-0
Soto R, Nguyen TC and Smith RA (2005). A comparison of Bispectral Index and
Entropy, or how to misinterpret both. Anesthesia and Analgesia; 100, 10591061.
Stone ME, Meyer MR and Alston TA (2010). Elton Romeo Smilie, the not-quite
discoverer of ether anesthesia. Anesthesia & Analgesia; 110, 195197.
Umesh G, Jasvinder K and Shetty N (2009). Low minimum alveolar concentration
alarms: a standard for preventing awareness during general anaesthesia. J. Clin.
Monit. Comput.; 23, 185186.
Vinten-Johansen P, Brody H, Paneth N, Rachman S and Rip M (2003). Cholera,
chloroform and the science of medicine: a life of John Snow. (Oxford University
Press, UK)
Wadman M (2009). Open-access policy flourishes at NIH. Nature; 458, 690691
(9th April).
33 6NS
indicates New Series No 6.
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White D (2003). Uses of MAC. Br. J. Anaesth.; 91, 167169. [editorial]

Wicherts JM, Borsboom D, Kats J and Molenaar D (2006). The poor availability of
psychological research data for reanalysis. American Psychologist; 61, 726728.
[cited in Anon 2006]
Xu L, Wu AS, Yue Y (2009). The incidence of intra-operative awareness during general anesthesia in China: a multicenter observational study. Acta Anaesthesiologica
Scandinavica; 53, 873882.
9.5
9.5.1
Arterial line
History
The first direct measurement of arterial blood pressure is generally said to have been in
1733 by Stephen Hales (16771761) using a glass tube 9 feet long connected flexibly
(using the trachea of a goose) to the femoral and carotid arteries of horses (Comroe 1977,
pp. 1517). Some eight years earlier the physician and mathematician Daniel Bernoulli
(17001782) was measuring fluid pressure in pipes using a narrow tube (Quinney 1997). In
1828 Jean-Louis Poiseuille (17991869) developed this technique further (see also: Zuck
1997) using a U-tube filled with mercury to determine the pressure at various points along
the aorta (his later researches into flow in small tubes led to his famous Poiseuilles Law).
The first clinically useful placement of an arterial catheter for this purpose was developed by Peterson et al. (1949). They described their method as follows.
A small plastic catheter, inserted into an artery through a needle, is left in the artery
when the needle is withdrawn. Attached to a capacitance manometer, this technique
permits recording for long periods of time without discomfort and allows relatively
free mobility of the subject.
Comroe (1977), p. 36
Use of the strain-gauge (Tomlinson, 1876) for transducing arterial pressure was first
described a few years earlier by Lambert and Wood (1947). See letter by Kannan (2005)
for recent use of ultrasound to facilitate arterial line placement.
Barr PO (1961). Percutaneous puncture of the radial artery with a multipurpose
Teflon cannula for indwelling use. Acta Physiol. Scand ; 51, 643.
El-Hamamsy I, Duurrleman N, Stevens L-M, Leung TK, Theoret S, Carrier M and
Perrault LP (2003). Incidence and outcome of radial artery infections following
cardiac surgery. Annals of Thoracic Surgery; 76, 801804. [strict systematic
changing of arterial lines on a timely basis is unwarranted]
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Hales S (1733). Statical essays: Containing haemastatics. vol 2. (Innys and Manby,
London). 361 pp.
Kannan S (2005). Another use for ultrasound in the ICU. Anaesthesia; 60, 944.
[used a 7 MHz ultrasound probe; useful in oedematous patients; 7 refs]
Peterson LH, Dripps RD and Risman G (1949). A method for recording the arterial
pressure pulse and blood pressure in man. Am. Heart J.; 37, 771782.
Poiseuille JLM (1828). Recherches sur la Force du Coeur Aortique; Thèse No. 166
(Didot, Paris).
Quinney DA (1997). Daniel Bernoulli and the making of the fluid equation.
http://plus.maths.org.uk/issue1/bern/
Tomlinson H (1876). On the increase in resistance to the passage of an electric
current produced on wires by stretching. Proc. Soc. Exp. Biol. Med.; 64, 186190.
Wong AYC and ORegan AM (2003). Gangrene of digits associated with radial
artery cannulation. Anaesthesia; 58, 10341035. [overview of rare complications,
and discusses use of the modified Allen test]
Zuck D (1997). Anaesthesia and physiology: the first twenty years. The History of
Anaesthesia Society Proceedings; 20, 7590.
9.5.2
Anatomy
An extensive collateral network of superficial and deep palmar arches normally connects
the radial and ulna arteries in the hand. However, in 58 % of patients the palmar arches
are incomplete, and of these incomplete cases approximately 4 % will suffer significant
vascular insufficiency if the radial artery is removed or occluded (Cable, Mullany & Schaff
1999; Lippert H and Pabst R 1985) see Allen test below.
Brzezinski M, Luisetti T and London MJ (2009). Radial Artery Cannulation: A Comprehensive Review of Recent Anatomic and Physiologic Investigations. Anesthesia
and Analgesia, 109, 17631781.
Coleman SS and Anson BJ (1961). Arterial patterns in the hand based upon a study
of 650 specimens. Surg. Gynecol. Obstet.; 113, 409.
Husum B and Palm T (1978). Arterial dominance in the hand. Br. J. Anaesth.; 50,
913.
Lippert H and Pabst R (1985). Arterial variations in man: classification and frequency. (JF Bergmann Verlag, Munich, Germany). [cited by Cable, Mullany &
Schaff 1999]
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Riekkinen HV, Karkola KO and Kankainen A (2003). The radial artery is larger
than the ulna. Annals of Thoracic Surgery, 75, 882884. [mean internal diameter is
31 mm (range: 24 mm)]
9.5.3
Allen test
Edgar V Allen (19001961) was a physician at the Mayo Clinic, and co-author of a
textbook on vascular medicine (Allen, Barker and Hines 1946). He described a simple test
(the so-called Allen test) to reveal ulnar or radial artery occlusion at the wrist (Allen 1929).
His description with respect to the ulnar artery is as follows.
If obstruction of the ulnar artery is suspected, the radial arteries are located by their
pulsations; the examiner places one thumb lightly over each radial, with the four
fingers of each hand behind the patients wrist, thus holding the wrist lightly between
the thumb and fingers. The patient closes his hands as tightly as possible for a period
of 1 minute in order to squeeze the blood out of the hand; the examiner compresses
each wrist between the thumb and fingers, thus occluding the radial arteries; the
patient quickly extends his fingers partially while compression of the radial arteries
is maintained by the examiner. The return of color to the hand and fingers is noted.
In individuals with an intact arterial tree the pallor is quickly replaced by rubor of a
degree higher than normal.
Cable, Mullany & Schaff (1999)
Before harvesting34 or even cannulating the radial or ulnar artery, the adequacy of
collateral vessels should be assessed by an Allen test (after EV Allen 1929), to determine
if they alone can adequately supply the hand. If a vessel fails the Allen test, then the other
vessel certainly should not be harvested, and probably ought not to be cannulated either.
Modified Allen test
Erroneous results can arise if the test is not performed correctly (Greenhow 1972). Note
that the wrist must not be hyperextended as this can cause vessel occlusion and invalidate
the test (Fuhrman et al. 1992). The slightly more controlled so-called modified Allen test
(Vaghadia et al. 1988) is now generally used (compressing both arteries simultaneously),
in conjunction with the following pass or fail times.
[both] the ulnar and radial arteries are compressed at the wrist for 30 secs to induce
hand ischaemia, while the hand is drained of blood by tight clenching. The test vessel
is then released and the time to adequate perfusion of the tips of the fingers and thumb
noted. The vessel is said to pass or fail the test as follows: pass (< 5 secs); equivocal
(610 secs); fail (> 10 secs)
Royse et al. (1999)
34 The
radial artery is sometimes removed (known as harvesting) for use in coronary-artery or temporal-artery
bypass proceduressee Royse et al. (1999).
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Note that the vessels should actually be compressed just proximal to the point where the
tip of the cannula is expected to lie, in order to detect essential collateral branches distal
to the likely cannula tip position (Gandhi and Reynolds 1983). Plethysmography is more
sensitive than either the Allen test or pulse-oximetry (Fuhrman et al. 1992).
Allen, EV (1929). Thrombo-angiitis obliterans:35 methods of diagnosis of chronic
occlusive arterial lesions distal to the wrist, with illustrative cases. American Journal
of Medical Sciences; 178 (August), 237244.
Allen, EV, Barker NW and Hines EA (1946). Peripheral vascular diseases. (WB
Saunders Company, Philadelphia, USA). [from Wright 1952]
Cable DG, Mullany CJ and Schaff HV (1999). The Allen test. Annals of Thoracic
Surgery; 67, 876877. [excellent includes a photograph of Allen]
Fuhrman TM, Pippin WD, Talmage LA and Reilley TE (1992). Evaluation of
collateral circulation of the hand. J. Clinical Monitoring and Computing; 8, 2832.
Gandhi SK and Reynolds AC (1983). A modification of Allens test to detect
aberrant ulna collateral circulation. Anesthesiology; 59, 147148.
Glavin RJ and Jones HM (1989). Assessing collateral circulation in the hand four
methods compared. Anaesthesia; 44, 594595.
Greenhow DE (1972). Incorrect performance of Allens testulnar-artery flow
erroneously presumed inadequate. Anesthesiology; 37, 356357.
Paul BZS and Feeney CM (2003). Combining the modified Allens test and pulse
oximetry for evaluating ulna collateral circulation to the hand for radial artery
catheterization of the ED 36 patient. The California Journal of Emergency Medicine;
4, 8991.
Royse et al. (1999). Radial artery harvest technique, use and functional outcome.
European J. of Cardio-thoracic Surgery; 15, 186193. [available for download at:
http://www.heartweb.com.au/]
Sinton I (2003). Digital ischaemia after ulnar artery cannulation. Br. J. Anaesth.; 91,
302303. [letter]
Vaghadia H, Schechter MT, Sheps SB and Jenkins LC (1988). Evaluation of a
postocclusive reactive circulatory hyperaemia (PORCH) test for the assessment of
ulna collateral circulation. Can. J. Anaesth.; 35, 5918. [a modified Allen test]
35 Buergers
disease.
Department
36 Emergency
9.5.4
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Systolic pressure variation
Real-time measurement of systolic-diastolic pressure variation with respect to spontaneous

ventilation or with IPPV may be useful as an index of hypovolaemia, either via pulse
oximetry waveform variation or via direct arterial measurement.
Fujita Y and Sari A (2003). On-line monitoring of systolic pressure variation.
Reuter DA, Felbinger TW, Kilger E et al. (2002). Optimizing fluid therapy in
mechanically ventilated patients after cardiac surgery by an on-line monitoring of
left ventricular stroke volume variations: comparison with aortic systolic pressure
variations. Br. J. Anaesth.; 88, 124126.
9.5.5
Complications
Complications from arterial cannulation are rare, but therapeutic vasodilation in the form
of stellate ganglion block (Gyanendra et al. 1998), or use of intra-arterial phentolamine
(Burrell 1977) or papaverine is sometimes required.
Burrell AR (1977). Treatment of ischaemia following radial artery cannulation.
Anaesthesia and Intensive Care; 5, 388. [used intra-arterial phentolamine (diluted to
05 mg/ml) and gave a 3 ml bolus, followed a while later by a 5 ml bolus.].
Gyanendra U and Kashyap L (1998). Accidental single brachial artery puncture
leading to reversible ischaemia of the upper limb. Intensive Care Medicine; 24,
197. [severe spasm following 16-G needle puncture treated using repeated stellate
ganglion block]
Leroy O, Billiau V, Beuscart C, Santre C, Chidiac C, Ramage C and Mouton Y
(1989). Nosocomial infections associated with long-term radial artery cannulation.
Intensive Care Med.; 15, 241246.
Lindsay SL, Kerridge R and Collett BJ (1987). Abscess following cannulation of
the radial artery. Anaesthesia; 42, 654657.
Mastan M and Van Oldenbeek C (2003). Digital ischaemia after ulnar artery cannulation. Br. J. Anaesth.; 90, 111. [letter]. [see reply: Sinton I (2003); 91, 302303;
uses a modified Allen test]
Ryan DW (1989). Limitations of invasive intravascular monitoring. Intensive
Therapy and Clinical Monitoring; 10, 216220.
Slogoff S, Keats AS and Arlund C (1983). On the safety of radial artery cannulation.
Anesthesiology; 59, 4247.
Wilkins RG (1985). Radial artery cannulation and ischaemic damagea review.
9.6
9.6.1
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Central venous catheter
History
The development of intravascular catheters and the techniques for inserting them has
resulted in important advances both diagnostically (angiography) and therapeutically (CVP
& Hickman lines; angioplasty).
Werner Forssmann
In the 1920s Werner Forssmann (19041979), then a surgical resident, was looking for
safer ways of delivering cardio-active drugs to the heart (i.e., other than via direct needle
injection), and eventually he hit upon the idea of using a long IV catheter. In 1929, when
he was only 26, Forssmann tested this idea in a Berlin hospital, by inserting a long urinary
catheter via the antecubital fossa into his own right atrium and confirmed its intra-cardiac
position radiologically. He went on to use this method for injecting intra-cardiac contrast
in animals, paving the way for diagnostic cardiac angiography, for which he was awarded
the Nobel Prize in 1956, together with Cournand (18951988) & Richards (18951973).
The following translation of part of Fossmanns original article (Forssmann, 1929) is by
Luft (1994).
In cases of shock, such as those engendered by sudden cardiac standstill, or during
anesthetic emergencies and poisonings, it may be desirable to deliver medications
directly to the heart itself. . . . Nevertheless intracardiac puncture is a dangerous
procedure for several reasons, including injury to the coronary arteries and its branches,
pericardial tamponade, injury to the diaphragm, and pneumothorax. . . . For these
reasons I considered a new method to approach the heart in a less dangerous fashion,
namely the catheterisation of the right heart from the venous system.
Experiments on a cadaver were productive. I was able to catheterize any vein in
the antecubital fossa and was able to regularly reach the right ventricle. . . . I next
undertook experiments on a living subject, namely on myself. I first convinced a
colleague to puncture a vein in my right antecubital fossa with a large needle. I next
advanced a well-oiled ureteral catheter size 4 Charriere in diameter through the needle
into the vein. The catheter allowed itself to be advanced with trivial ease to 35 cm.
Because my friend objected to our proceeding with these experiments further, we
broke them off even though I felt perfectly well. One week later I tried again alone.
I anesthetized my own left antecubital fossa and because I was not able to manipulate
the needle by myself I constructed a cut-down and advanced the catheter along its
full 65 cm length. From surface estimates, I reasoned that the catheter tip would be at
the level of the heart.
I documented the position of the catheter with roentgenograms that I obtained by
standing in front of the fluoroscope while observing the catheter in a mirror held by a
nurse. In conclusion, I would like to point out the utility of this technique in providing
new opportunities to research the metabolic activities and actions of the heart.
Forssemann (1929) [From: Luft (1994)]
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Andre Cournand and Dickinson Richards

Cournand and Richards extended Forssmanns intravascular catheter concept and developed
long single and double-lumen catheters which allowed them to sample blood and pressures
from the right heart and pulmonary artery (c. 1940s). They also determined approximate
left atrial pressures by wedging the catheters by pushing them as far as they would
go (i.e., not balloon-occlusion wedge pressures as determined by Swan and Ganz in
1967). They studied cardio-pulmonary physiology and patho-physiology, and showed
that hypoxia, sufficient to make the arterial oxygen saturation less than 80 %, resulted in
significant pulmonary vasoconstriction and a rise in pulmonary artery pressure (Cournand
1956; Richards 1956). Interestingly, they also showed that an infusion of acetylcholine
(05 mg/min) into the pulmonary artery reversed the pulmonary vasoconstriction while not
affecting the systemic blood pressure (Harris et al. 1956; Cournand 1956).
Sven-Ivar Seldinger
Radiologists often need to insert long large-diameter catheters into arteries in order to
inject contrast into distant vessels. In the early 1950s, however, the two existing techniques
had significant shortcomings. For example, the catheter-through-needle technique was
associated with a significant leak at the vessel entry point (catheter smaller than needle),
and the long narrow catheters made it difficult to inject contrast fast enough to be effective.
The catheter-over-needle technique was only feasible with quite short catheters (since the
needle did not bend, and long needles were difficult to manipulate safely).
In 1952 Sven-Ivar Seldinger (19211998) a Swedish radiologist at the Karolinska
Hospital, Stockholm overcame these difficulties by developing his catheter-over-guidewire
technique (Seldinger 1953; Seldinger 1987; Higgs et al. 2005; Greitz 1999). He actually
used a guidewire with a straight flexible tip. Seldinger described the process of development
as follows.
However, rightly or not, some people considered the procedure [translumbar aortography] hazardous and searched for a technique where a catheter could be inserted via a
peripheral artery. Surgical cut down methods had been reported . . . and Bierman et al.
(1951) . . . suggested a percutaneous technique in which a catheter was inserted through
a puncture instrument into the femoral artery and advanced to the aorta. The catheter
had to be wide enough to permit a very rapid injection. If not, the contrast medium
would be so diluted by the voluminous aortic bloodflow that diagnostic angiographs
would not be obtained. In turn a very wide-bore puncture instrument, with consequent
risk of trauma, was required.
Thus there was obviously a need for an improved percutaneous method for aortography,
and one of the requirements to the solution was an increased bore of the catheter. . . .
There existed a puncture equipment named after Cournand, consisting of an inner
sharp needle in an outer blunt cannula, the edge exceeding the cannula by one or two
mm. One alternative was to use a flexible catheter instead of the cannula, but it would
certainly be tricky to handle an inner needle, half a meter or more long. I avoided this
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trouble by cutting a side hole on a polythene catheter at such a level that a cutting
needle of convenient length, when inserted through it, exceeded the tip of the catheter
by one or two mm. After some moulding of the catheter and a minute incision in the
skin, this instrument could be inserted into the artery by percutaneous puncture.
Some obvious disadvantages were inherent in this technique. For instance, the thinwalled catheters were so flexible that, sometimes it was impossible to advance them
further into the vessel. This difficulty could often be overcome. When intravascular
position was obtained, the needle could be withdrawn from the side hole and replaced
by a semi-flexible metal wire which was introduced through the entire length of the
catheter to support it.
Now! After an unsuccessful attempt to use this technique I found myself, disappointed
and sad, with three objects in my handa needle, a wire and a catheterand, in a
split second, I realised in what sequence I should use them: needle inwire inneedle
offcatheter on wirecatheter incatheter advancewire off.
I have been asked how this idea turned up and I can quote Phokion,37 the Greek: I
had a severe attack of common sense.
The tools could not be less complicated; they could be found among the instruments
of any hospital and, if necessary, could be completed at the nearest ironmongers. Any
handy person could use them.
With the beginners luck the first angiography performed with this technique was
a success: a subclavian arteriography, with one single exposure, the catheter introduced through the brachial artery after puncture at the cubital level, which revealed a
parathyroid adenoma, unsuccessfully searched for by the surgeon in the mediastinum,
With my permission, the Head of the Department, Knut Lindblom, reported on the
technique at the Radiological Congress of Northern Europe which took place in
Helsinki one week later, in June 1952.
Seldinger (1987)
The January 1984 issue of the American Journal of Roentgenology 38 (volume 142)
celebrated the 30th anniversary of the Seldinger Technique with a series of articles on
Seldinger 39 . The article by Doby (1984) gives an excellent historical overview, and
includes some detailed sketches by Seldinger himself relating to his development of the
technique.
Stanley Baum and Herbert Abrams
A not uncommon problem associated with the straight guidewire, particularly when
cannulating the femoral artery, was failure to advance easily. This problem was largely
overcome in 1964 by Baum and Abrams development of the J-tipped catheter which
is threaded over the guidewire (Baum and Abrams 1964). Once the catheter has been
37 Phocion
(402317 B . C .): Athenian statesman, general, and pupil of Plato.

their web site at http://www.ajronline.org/
39 The main articles are listed in the references.
38 See
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positioned above the obstruction then the catheter is changed (by reinserting the guidewire)
for a special angiography catheter.
Charles Dotter
At approximately the same time the American radiologist Charles Dotter (19201985),
widely regarded as the father of interventional radiology, was beginning to lay the foundations of this new speciality at the Oregon Health State University,40 in conjunction with
his student Melvin Judkins.
In 1963 Dotter inadvertently unblocked an occluded right iliac artery while passing a
catheter through it in order to reach the aorta for an abdominal aortogram, and realised
that intravascular catheterisation can be used therapeutically as well as diagnostically. On
16 January 1964, Dotter, together with Judkins, performed the first deliberate dilation
of an arterial obstruction, and thereafter developed the tools and techniques for what is
now known as transluminal angioplasty (Payne 2001). Dotter also developed the first
safety J-tipped guidewire (Judkins et al. 1967), flow-guided catheter, an intravascular
biopsy catheter, and intravascular coils which were the forerunner of expandable stents
(http://www.ohsu.edu/dotter/ctdotter.htm).
PICC cathetersBroviac JW and Hickman
With the advent of intensive care, intravenous nutrition and chemotherapy central catheters
were increasingly used for long periods of time, leading to significant catheter-related
infections. This prompted engineers to address design and materials issues, leading to new
long-term so-called PICC catheters,41 first by Broviac et al. (1973) and later by Hickman
et al. (1979). Special valved catheters (Croshong catheter) were developed by Bard Access
Systems.
9.6.2
References
Baum S and Abrams HL (1964). A J-shaped catheter for retrograde catheterization

of tortuous vessels. Radiology; 83, 436437. [first description/use of the J-catheter]
Broviac JW, Cole JJ and Scribner BH (1973). A silicone rubber atrial catheter for
prolonged parenteral alimentation. Surg. Gynaecol. Obstet.; 136, 602606.
Cournand AF (1956). Control of the pulmonary circulation in man with some
remarks on methodology. (Nobel Lecture)
Doby T (1984). A tribute to Sven-Ivar Seldinger. American Journal of Roentgenology; 142 (Jan), 13. [http://www.ajronline.org/cgi/reprint/142/1/1.
pdf]
40 see
http://www.ptca.org/nv/history.html, and also http://www.ohsu.edu/dotter/

Peripherally Inserted Central Catheter.
41 PICC
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Forssmann W (1929). Catheterization of the right heart. Klinische Wochenschrift;

8 (No. 45), 20852087. [from Luft 1994]
Greitz T (1999). Sven-Ivar Seldinger. Am. J. Neuroradiol.; 20 (June/July), 1180
1181. [http://www.ajnr.org/cgi/reprint/20/6/1180]
Harris P, Fritts HW, Clauss RH, Odell JE and Cournand A (1956). Influence of
acetylcholine on human pulmonary circulation under normal and hypoxic conditions.
Proc. Soc. Exptl. Biol. Med.; 93, 77.
Higgs ZCJ, Macafee DAL, Braithwaite BD and Maxwell-Armstrong CA (2005).
The Seldinger technique: 50 years on. Lancet, 366, 14071409.
Judkins M, Kidd HJ et al. (1967). Lumen-following J-guide for catheterization of
tortuous vessels. Radiology; 88, 1127.
Luft FC (1994). The birth of a common procedure. Annals of Internal Medicine;
120, 974.
Payne MM (2001). Charles Theodore Dotter, the father of intervention. Texas Heart
Institute Journal ; 28, 2838. http://www.ncbi.nlm.nih.gov/pmc/journals/
92/.
Richards DW (1956). The contribution of right heart catheterization to physiology
and medicine, with some observations on the pathophysiology of pulmonary heart
disease. (Nobel Lecture)
Seldinger SI (1953). Catheter replacement of the needle in percutaneous arteriography: a new technique. Acta Radiologica Scandinavica; 39, 368376.
Seldinger SI (1987). A leaf out of the history of angiography.
In: Silvestre ME, Abecasis F and Veiga-Pires JA (1987); Radiology: Faculty Proceedings of the 6th European Congress of Radiology, Lisbon, Portugal, 31 May6
June 1987. (Excerpta Medica, International Congress Series No. 749; Elsevier Science Publishers BV [Biomedical Division], Amsterdam, The Netherlands.) ISBN:
0-444-80947-3. p. 36. [from Greitz (1999)]
(1984) special Seldinger issue of the American Journal of Roentgenology;
142 (Jan):
Sven-Ivar Seldinger: a biography and bibliography. American Journal of
Roentgenology; 142 (Jan), 4.
The Seldinger technique. American Journal of Roentgenology; 142 (Jan), 57.
[a reproduction of Seldingers original article]
Testimonials to Seldinger. American Journal of Roentgenology; 142 (Jan),
811. [reflections by Dotter CT, Grainger RG, Nordenstrom B, Abrams HL,
and Athanasoulis CA]
9.6.3
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Optimum position
The current view regarding the optimum location of the tip of a CVP-catheter is driven
by the need to avoid the possibility of the catheter migrating into the pericardium. Consequently the tip should be above the pericardial reflection on to the SVC (Chalkiadis and
Goucke 1998), which is generally held to be at the level of the carina (T4T5; sternal
angle)i.e., above the left and right atria. Ryu et al. (2007) give a simple landmark-based
method for safely positioning the tip of the CVP line in relation to the carina. Several
articles have appeared recently describing the use of ultrasound to facilitate CVP-line
placement, including a good editorial by Scott (2004).
Techniques for correcting/relocating subclavian and internal-jugular catheters which
have taken an aberrant course are addressed by Pattnaik and Bodra (1999); they highlight
an article by Kayal et al. (1989) who used ultrasound while flushing with saline to detect
when the tip of the catheter is in the correct vessel. Pattnaik and Bodra (1999) suggest
listening with a stethoscope is useful. An alternative approach to the aberrant catheter
problem, might be to consider placing a new J-wire into the same vein via the proximal
lumen 42 (hopefully in the internal jugular vein), removing the misplaced CVP line and
then railroading a new onewith luck the new wire will be in a better location (one could
check the new wire position with an x-ray first perhaps).
Occasionally a CVP line inserted via the left IJ vein will go down the left internal
mammary vein; quite how this happens is not clear since the curved tip of the J-wire
should prevent the wire from going down a small vessel. The distal lumen in such cases is
typically associated with difficult aspiration and poor CVP waveform. Since redirecting
a misplaced CVP line can be difficult, consider monitoring the CVP via one of the more
proximal lumenswithdrawing the line slightly if necessaryuntil you see a good CVP
waveform. Consequently, always X-ray a left IJ line before considering railroading a
Swan-sheath over it. For information and video clips relating to CVP insertion technique
see the Clinical Cases web-site (http://clinicalcases.org/).
9.6.4
Anatomy
Albrecht K et al. (2004). Applied anatomy of the superior vena cavathe carina as
a landmark to guide central venous catheter placement. Br. J. Anaesth.; 92, 7577.
Davidson A, Blumgard C, Paes ML and Enever G (1993). Posture and internal
jugular vein size studied with the Siterite ultrasound device. Br. J. Anaesth.; 71,
771P. [November issue]
[gives a useful table of depth and diameter of the vein for various amounts of head
tilt. My own working of their data gives the mean depth of the middle of the vein as
164 cm, which is equivalent to a distance of 23 cm at 45 degrees to the skin]
42 I
have not tried this as yet, but it seems as though it ought to work.
RWD Nickalls
Daseler EH and Anson BJ (1959). Surgical anatomy of the subclavian artery and its
branches.Surg. Gynecol. Obstet.; 108, 149174.
Galloway S and Bodenham A (2003). Ultrasound imaging of the axillary vein
anatomical basis for central venous access. Br. J. Anaesth., 90, 589595.
Mathers LH, Smith DW and Frankel L (1992). Anatomic considerations in placement of central venous catheters. Clinical Anatomy; 5, 89106.
Pahwa R and Kumar A (2003). Persistent left superior vena cava: an intensivists
experience and review of the literature. Southern Medical Journal ; 96, 528529. [see
example CXR on the http://www.learningradiology.com/ website (search
for persistent left superior vena cava)]
Latto IP, Ng WS, Jones PL and Jenkins BJ [Eds.] (2000). Percutaneous central
venous and arterial catheterisation; 3rd ed, (W. B. Saunders Company Ltd., London,
UK).
Schummer W, Schummer C and Frober R (2003). Internal jugular vein and anatomic
relationship at the root of the neck. Anesthesia and Analgesia; 96, 1540.
Schummer W, Schummer C and Geold M (2002). Persistent left superior vena cava:
clinical implications for central venous cannulation. American Society for Parenteral
and Enteral Nutrition; 17, 304308.
Sulek CA, Gravenstein N, Blackshear RH and Weis L (1996). Head rotation during
internal jugular vein cannulation and the risk of carotid artery puncture. Anesthesia
and Analgesia; 82, 125128. [keeping the head in the midline position reduces the
incidence of carotid artery puncture]
9.6.5
Position of CVP tip
Albrecht K et al. (2004). Applied anatomy of the superior vena cavathe carina as
a landmark to guide central venous catheter placement. Br. J. Anaesth.; 92, 7577.
Chalkiadis GA and Goucke CR (1998). Depth of central venous catheter insertion in
adults: an audit and assessment of a technique to improve tip position. Anaesthesia
and Intensive Care; 26, 6166. [they used the subclavian methodtheir tailored
technique (8 cm distal from the tip of needle) gave a mean distance from the skin of
132 cm (range: 11515 cms; n=73)]
Rath GP, Bithal PK, Toshniwal GR, Prabhakar H and Dash HH (2009). Saline flush
test for bedside detection of misplaced subclavian catheter into ipsilateral internal
jugular vein. Br. J. Anaesth., 102, 499502.
Ryu H-G, Bahk J-H, Kim J-T and Lee J-H (2007). Bedside prediction of the central
venous-catheter insertion depth. Br. J. Anaesth., 98, 225227.
9.6.6
RWD Nickalls
General
Chalkiadis GA and Goucke CR (1998). Depth of central venous catheter insertion in

adults: an audit and assessment of a technique to improve tip position. Anaesthesia
and Intensive Care; 26, 6166. [they used the subclavian methodtheir tailored
technique (8 cm distal from the tip of needle) gave a mean distance from the skin of
132 cm (range: 11515 cms; n=73)]
Fukazawa K, Aguina L and Pretto E (2010). IMAGES IN ANESTHESIOLOGY:
Internal jugular valve and central placement. Anesthesiology; 112, 979.
Kayal RD, Salloum LJ, Snyder AB and Barone JE (1989). A simple method
of repositioning the wayward central catheter. Journal of Parenteral and Enteral
Nutrition; 13, 438439.
Kitagawa N et al. (2004). Proper shoulder position for subclavian venepuncture.
Anesthesiology; 101, 13061312. [evidence from CT studies suggests that best
position is with the shoulder pushed inferiorly]
Messahel FM and Al-Mazroa AA (1992). Cannulation of the internal jugular vein;
the very high approach. Anaesthesia; 47, 842844.
Nandwani N, Fairfield MC, Krarup K and Thompson J (1997). The effect of laryngeal mask airway insertion on the position of the internal jugular vein. Anesthesia;
52, 7783. [no lateral movement, but perhaps some slight anterior movement
0611 cm, mean 08 cm]
Ng PK, Ault MJ and Maldonaldo LS (1996). Peripherally inserted central catheters
in the intensive care unit [review]. J. Intensive Care Medicine; 11, 4954.
Oropello JM, Leibowitz AB, Manasia A, Guidice RD and Benjamin E (1996). Dilator associated complications of central vein catheter insertion: possible mechanisms
of injury and suggestions for prevention. Journal of Cardiothoracic and Vascular
Anesthesia; 10, 634637.
Pattnaik SK and Bodra R (1999). Another whoosh test. Anaesthesia; 54, 1224
1225. [they describe gradually withdrawing the the malpositioned central line while
listening for the disappearance of the distal whoosh sound (caused by flushing it
with saline) with a stethoscope over the vein. Also list other useful references on
this theme (6 refs)].
Latto IP, Ng WS, Jones PL and Jenkins BJ [Eds.] (2000). Percutaneous central
venous and arterial catheterisation; 3rd ed, (W. B. Saunders Company Ltd., London,
UK).
Sha K et al. (1998). Use of transoesophageal echocardiography probe imaging to
guide internal jugular vein cannulation. Anesthesia & Analgesia, 87, 10321033.
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Stickle BR and McFarlane H (1997). Prediction of a small internal jugular vein by

external jugular vein diameter. Anaesthesia, 52, 220222.
[if the external jugular vein is greater than 7 mm diam, then the internal jugular vein
is likely to have a diameter less than 7 mm, and so may be difficult to find]
Tripathi M, Dubey PK and Ambesh SP (2005). Direction of the J-tip of the guidewire
in Seldinger technique is a significant factor in misplacement of subclavian vein
catheter: a randomised controlled study. Anesthesia and Analgesia; 100, 2124.
Tripathi M and Tripathi M (1996). Subclavian vein cannulation: an approach with
definite landmarks. Ann. Thoracic Surgery; 61, 238240.
Willeford KL and Reitan JA (1994). Neutral head position for placement of internal
jugular vein catheters. Anaesthesia; 49, 202204.
Williamson RM and Werstler E (2006). Central line in patients with AV fistula.
Anaesthesia; 61 (August), 819-820. [describes confusion with the sampled blood
gases in a renal patient with a left-arm dialysis fistula]
9.6.7
Ultrasound guided
Chapman GA, Johnson D and Bodenham AR (2006). Visualisation of needle

position using ultrasonography. Anaesthesia; 61, 148158.
Fukazawa K, Aguina L and Pretto E (2010). IMAGES IN ANESTHESIOLOGY:
Internal jugular valve and central placement. Anesthesiology; 112, 979.
Habib FA and McKenney MG (2004). Surgeon-performed ultrasound in the ICU
setting. Surgical Clinics of North America; 84, 11511179. [see section on CVP
line placement 11651166, with screen images]
Hall AP and Russell WC (2005). Towards safer central venous access: ultrasound
guidance and sound advice. Anaesthesia; 60, 14. [see also correspondence from
Reavley P (2005)]
Hatfield A and Bodenham A (2005). Ultrasound for central venous access. Continuing Education in Anaesthesia, Critical Care & Pain; 5, 187190.
National Institute for Clinical Excellence (NICE) (2002). Guidance on the use
of ultrasound locating devices for placing central venous catheters. Technology
Appraisal Guidance No. 49 (September 2002); 24 pp. http://guidance.nice.
org.uk/TA49/Guidance/pdf/English
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Riopelle JM, Ruiz DP, Hunt JP et al. (2005). Circumferential adjustment of ultrasound probe position to determine the optimal approach to the internal jugular vein:
a noninvasive geometric study in adults. Anesth. Analg.; 100, 512519.
Scott DHT (2004). The king of the blind extends his frontiers. Br. J. Anaesth.; 93,
175177. [editorial on ultrasound-guided techniques]
9.6.8
External jugular vein
If the external jugular vein distends on head-down position, then a Venflon in this site
adequately reflects CVP providing the chest is not open. Placing a central catheter via this
route has a high failure rate.
Blitt CD, Wright WA, Petty WC and Webster TA (1974). Central venous catheterisation via the external jugular vein. A technique employing the J-wire. JAMA ; 229,
817.
Briscoe CE (1973). A comparison of jugular [external] and central venous pressure
measurement during anaesthesia. Br. J. Anaesth.; 45, 173.
Dailey RH (1988). External jugular vein cannulation and its use for CVP monitoring.
Journal of Emergency Medicine; 6, 133.
Shah MV, Swai EA and Latto IP (1986). Comparison between pressures measured
from the proximal external jugular vein and a central vein. Br. J. Anaesth.; 58, 1384.
9.6.9
Axillary vein
Andel H, Rab M, Felfernig M et al. (1999). The axillary vein central venous catheter
in severely burned patients. Burns; 25, 753756.
Levine E and Budzikowski AS (2009). Catheterisation, axillary vein.
http://emedicine.medscape.com/article/1348912-overview
http://emedicine.medscape.com/article/1348912-media
http://emedicine.medscape.com/article/1348912-treatment
(other related procedures are at: >clinical procedures>vascular)
Accessed May 2010.
Nickalls RWD (1987). A new percutaneous infra-clavicular approach to the axillary
vein. Anaesthesia; 42, 151154. http://www.nickalls.org/dick/papers/
anes/axillaryvein1987.pdf
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Restrepo Valencia CA (2008). Axillary catheter for hemodialysis, an alternative

vascular access. Nefrologia;, 28, 7781.
Sandhu NS (2004). Transpectoral ultrasound-guided catheterization of the axillary
vein: an alternative to standard catheterization of the subclavian vein. Anesthesia
Sharma A, Bodenham AR and Mallick A (2004). Ultrasound-guided infraclavicular
axillary vein cannulation for central venous access. Br. J. Anaesth.; 93, 188192.
Taylor BL and Yellowlees I (1990). Central venous cannulation using the infraclavicular axillary vein. Anesthesiology; 72, 55.
9.6.10
Femoral vein
There are many papers in the literature showing that CVP is accurately reflected by inferior
vena cava and common iliac venous pressure measurements in supine patients (both adult
and paediatric), providing the transducer is zeroed at the usual right-atrial level on the
mid-axillary line. Measurements of inferior vena cava pressures seem to be approximately
05 mm Hg lower than superior vena cava pressures on average, and rarely more than
3 mm Hg different, even in patients with high PEEP or raised mean airway pressures
(Desmond 2003). Femoral CVP results may be less accurate in patients with significantly
raised intra-abdominal pressure [the references below are from Desmond (2003)].43
Chait HI, Kuhn MA, Baum VC (1994). Inferior vena caval pressure reliably predicts
right atrial pressure in pediatric cardiac surgical patients. Crit. Care Med.; 22,
21924.
Desmond J (2003). Is the central venous pressure reading equally reliable if the
central line is inserted via the femoral vein? http://www.bestbets.org/ (search
under author)
Ho KM, Joynt GM, Tan P. (1998). A comparison of central venous pressure and
common iliac venous pressure in critically ill mechanically ventilated patients. Crit.
Care Med.; 26, 4614.
Nahum E, Dagan O, Sulkes J, et al. (1996). A comparison between continuous
central venous pressure measurement from right atrium and abdominal vena cava or
common iliac vein. Intensive Care Med.; 22, 5714.
Joynt GM, Gomersall CD, Buckley TA, et al. (1996). Comparison of intrathoracic
and intra-abdominal measurements of central venous pressure. Lancet; 347, 11557.
Walsh JT, Hildick-Smith DJ, Newell SA, et al. (2000). Comparison of central venous
and inferior vena caval pressures. Am. J. Cardiol.; 85, 51820.
43 I
thank Dr Mofolashade Enebeli-Cliffe for drawing my attention to many of these references.
9.6.11
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Complications
These are mostly related to air embolism, vessel damage from needle or dilator or kinked
guide-wire, introducing the guide-wire outside the vessel, catheter knotting, dysrhythmias,
pneumothorax and cardiac tamponade. Unusual anatomy 44 and failure to use ultrasound
visualisation appear to be prominent factors in many complications (see Section 9.6.4).
Guide-wire problems
The guide-wire is easily kinked, and once kinked it can not be straightened and can easily
damage/tear the vein if introduced into it. A simple test to check for such kinking while
trying to advance the dilator (over the wire) is to intermittently check that you can slide
the wire back and forth (say, 1 cm or so) inside the introducer. Any difficulty in sliding
the wire back and forth is a good sign that the wire may have become kinkedin which
case withdraw the guide-wire carefully to bring the kink to the skin for inspection.
In my experience, the guide-wire is most easily damaged/kinked when using the
femoral approach in fat patients, since in these cases one often has to press the Sonosite
probe down quite firmly (and hence distort the subcutaneous tissue) in order to see the
vein clearly. The kinking of the guide-wire usually occurs while trying to introduce the
dilator through the subcutaneous tissue, since in fat patients the path of the guide-wire
here becomes quite curved into a sigmoid shape once the Sonosite probe is removed.45 In
my experience in this setting, it is best to have an assistant replace the Sonosite probe and
press down as before (i.e., to straighten the subcutaneous path of the guide-wire) while
introducing the dilator.
If a dialysis catheter guide-wire does become kinked in a difficult case, it is often
possible to rescue the situation and exchange it safely, since the guidewire will generally
still be in the vein even when pulled back slightly to bring the kink to the skin 46 . The
idea is to first railroad an ordinary CVP line over the wire and into the vein (ie., with the
kink still showing just above the skin), replace the damaged guide-wire with a new dialysis
catheter guide-wire, then remove the CVP line, and then continue with the dialysis line as
before.
Dhanani J, Senthuran S, Olivotto R, Boots RJ and Lipman J (2007). The entrapped
central venous catheter. Br. J. Anaesth.; 98, 8992. [a new catheter pierced an
existing catheter in the same vein; interventional radiology used for diagnosis and
determination of a removal strategy; the literature is reviewed; 11 refs]
Lobato EB, Gravenstein N and Paige GB. (1997). Dilator-associated complications
44 Persistence of the left superior vena cava (LSVC)which is asymptomaticis thought to be the most
common anomaly of the venous circulation and can be a significant hazard with regard to CVP line placement
(see paper by Schummer, Schummer and Gerald (2002) listed in Section 9.6.4).
45 Since the guide-wire is initially introduced via a straight needle, its path to the vein will only remain straight
(after removing the needle) while the Sonosite probe is pressing down over the vein.
46 It is therefore, a good idea to introduce plenty of guide-wire into the vein before starting to thread the dilator.
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of central vein catheter placement: possible mechanisms of injury and suggestions

for prevention. Journal of Cardiothoracic and Vascular Anesthesia; 11, 539.
Muhn M, Sunder-Plassmann G and Druml W (1996). Malposition of a dialysis
catheter in the accessory hemiazygos vein. Anesthesia and Analgesia; 83, 883885.
Oropello JM, Leibowitz AB, Manasia A, Guidice RD and Benjamin E (1996).
Dilator-associated complications of central vein catheter placement: possible mechanisms of injury and suggestions for prevention. Journal of Cardiothoracic and
Vascular Anesthesia; 10, 634637.
Jiha JG, Weinberg GL and Laurito CE (1996). Intraoperative cardiac tamponade
after central venous cannulation. Anesthesia and Analgesia; 82, 661665.
Scott WL and Collier P (2001). The vessel dilator for central venous catheter
placement: forerunner for success or vascular misadventure? Journal of Intensive
Care Medicine; 16, 263269.
9.7
9.7.1
Pulmonary artery catheter
History
Michael Lategola and Hermann Rahn

Balloon-flotation pulmonary artery catheters were first used by the American physiologists Lategola and Rahn for pressure recording, blood sampling and vessel occlusion in
experiments with dogs (Lategola and Rahn 1953). Since their balloon covered the distal tip
they were only able to measure pressures proximal to the occluded vessel. Thermodilution
cardiac output was first described in animals the following year (Fegler 1954).
Ronald Bradley
The first person to describe the use of a pulmonary-artery catheter in man was Ronald
Bradley, a physician at St. Thomas Hospital, London (Bradley 1964). He used an extremely narrow catheter (063 mm diam) having no balloon, to determine pulmonary artery
pressures and waveforms, and later went on to determine thermodilution cardiac output in
man using a thermistor-tipped catheter (Branthwaite and Bradley 1968), and suggested
the use of PA-diastolic pressure as an index of mean left-atrial pressure (Jenkins, Bradley
and Branthwaite 1970). Bradley also wrote an excellent book on the physiology of heart
failure (Bradley 1977).
Harold Swan and William Ganz
Bradleys catheters had no balloon and were extremely difficult to position, and so the
technique remained clinically impractical until Swan et al. (1970) developed the modern
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balloon-flotation catheter. Since Swan wished to determine left atrial pressure he arranged
that pressures could be measured distal to the balloon. Oddly enough Swan fails to credit
Bradley and Branthwaite (1968) with the thermodilution technique in maninstead he
credits this to Ganz (Swan 1991).
Swan (19222005) graduated from St. Thomas Hospital Medical School, London, in
1945, and went on to become the Director of the Division of Cardiology at Cedars-Sinai
Medical Center in Los Angeles, California. He has set on record the key early ideas and
development of the flow-directed balloon-tipped catheter (Swan 1991; 2005) as follows.
In 1950 as a lecturer in physiology at St. Thomas Hospital of the University of London,
I had come to know a young medical student, Ronald Bradley, who was completing a
bachelors degree in physiology. I had noted a paper published in the Lancet (Bradley
1964), in which Bradley had claimed that it was possible to catheterize the pulmonary
artery for measurement of pressures using an extremely fine Portex tubing . . . and I
therefore attempted to place it. . . . In our hands this approach had little success . . .
In the fall of 1967, I had the occasion to take my (then young) children to the beach
in Santa Monica. On the previous evening, I had spent a frustrating hour with an
extraordinary pleasant but elderly lady in an unsuccessful attempt to place one of
Bradleys catheters. It was a hot Saturday and the sailboats on the water were becalmed.
However, approximately half a mile offshore, I noted a boat with a large spinnaker
well set and moving through the water at a reasonable velocity. The idea then came to
to put a sail or a parachute on the end of a highly flexible catheter and thereby increase
the frequency of passage of the device into the pulmonary artery. I felt convinced
that this approach would allow for the rapid and safe placement of a flotation catheter
without the use of fluroscopy and would solve the problem of arrhythmias.
. . . I had been appointed a consultant to the Edwards Laboratories, then a small
manufacturing company whose products included the Starr-Edwards heart valve and
the Fogarty embolectomy catheter. . . . I brought my concept to the attention of Mr
David Chonette and Mr Will Perrie. They had the facilities for extrusion of catheters
of different sizes . . . To test the concept, however, they had the ability to manufacture
balloons (as for the Fogarty catheter) and suggested that, as a first effort, a doublelumen extruded catheter should be manufactured with one lumen available to inflate a
flotation balloon. This proved to be acceptable and they agreed to fabricate five such
catheters.
. . . As luck would have it, when the Edwards Laboratories delivered their first catheters,
Willie [Ganz] was finishing an experiment with his animal in good condition. I brought
the prize catheters to the laboratory and connected the pressure lumen to an appropriate
strain gauge manometer. The catheter was then introduced via the exposed jugular
vein into the right atrium and, observing with fluroscopy, the balloon was inflated.
It immediately disappeared, and the technician reported no change in the recorded
pressure. I immediately assumed an inadequacy of balloon tensile strength and mentally
blamed faulty construction by the Edwards Laboratory. However, repeat visualization
revealed that the catheter had migrated in one heartbeat through the right heart and was
recording the wedge pressure in a distal pulmonary artery. Deflation of the balloon
allowed its prompt return to the superior vena cava. . . . Willie Ganz accepted the
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responsibility of clearing up the many technical details, but the concept was proved
and the new device was born.
. . . A triple-lumen catheter allowed measurement of simultaneous pressures in the
wedge position (the pulmonary occluded pressure) and in the right atrium. With a
slight modification, a thermistor was inserted close to the guiding balloon and the
thermodilution technique of Willie Ganz (Ganz et al. 1971) for determination of
cardiac output was applied.
Swan (1991)
Swan (19222005) died on 7th February, 2005, and his last paper (Swan 2005) appeared
in the October 2005 issue of Anesthesiology. A photograph of Swan can be found on the
Anesthesiology web site.47
Achan V (1999). Another European view: the origin of pulmonary artery catheterization. Critical Care Medicine; 27, 28502851.
Amin DK, Shah PK and Swan HJC (1986). The Swan-Ganz catheter: choosing and
using the equipment. Journal of Critical Illness; 1, 3437.
Amin DK, Shah PK and Swan HJC (1986). The Swan-Ganz catheter: insertion
technique. Journal of Critical Illness; 1, 3845.
Amin DK, Shah PK and Swan HJC (1986). The Swan-Ganz catheter: tips on
interpreting results. Journal of Critical Illness; 1, 4048.
Amin DK, Shah PK and Swan HJC (1986). The Swan-Ganz catheter: indications
for insertion. Journal of Critical Illness; 1, 5461.
Bradley RD (1964). Diagnostic right-heart catheterisation with miniature catheters
in severely ill patients. Lancet; 2, 941942.
Bradley RD (1977). Studies in acute heart failure. (Edward Arnold Ltd., London).
ISBN 0713142952, 76 pp.
Branthwaite MA and Bradley RD (1968). Measurement of cardiac output by thermal
dilution in man. J. Applied Physiology; 24, 434438.
Fegler G (1954). Measurement of cardiac output in anesthetized animals by a
thermodilution method. Quarterly Journal of Experimental Physiology; 39, 153
164. [from: MacKenzie 2003]
47 http://journals.lww.com/anesthesiology/;
follow the enhancements index link 2005.
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Ganz W, Donoso R, Marcus HS, Forrester JS and Swan HJC (1971). A new technique
for measurement of cardiac output by thermodilution in man. American Journal of
Cardiology; 27, 392396.
Jenkins BS, Bradley RD and Branthwaite MA (1970). Evaluation of pulmonary
arterial end diastolic pressure as an indirect estimate of left atrial mean pressure.
Circulation; 42, 75.
Lategola M and Rahn H (1953). A self-guiding catheter for cardiac and pulmonary
arterial catheterization and occlusion. Proc. Soc. Exp. Biol. Med.; 84 667668.
Poplausky MR, Rozenblit G, Rundback H et al. (2001). Swan-Ganz catheter-induced
pulmonary artery pseudoaneurysm formation: three case reports and a review of the
literature. Chest; 120, 21052111.
Shaw TJI (1979). The Swan-Ganz pulmonary artery catheter: incidence of complications, with particular references to ventricular dysrhythmias, and their prevention.
Anaesthesia; 34, 651656. [recommends use of lignocaine 1mg/kg IV]
Swan HJC (2005). The pulmonary artery catheter in anesthesia practice. Anesthesiology, 103, 890893. [Swans final paperincludes some interesting historical
detail regarding the development of the PA catheter]
Swan HJC (1991). Development of the pulmonary artery catheter. Disease-aMonth ; 37 (August), 485508 (Elsevier). [whole of this classic issue (p. 478543)
is devoted to the Swan-Ganz catheter, including a reprint of the excellent fourpart series by Amin, Shah and Swan (1986) listed below. Available on-line via
http://www.sciencedirect.com/ & also via the ATHENS internet database]
Swan HJC, Ganz W, Forrester J, Marcus H, Diamond G and Chonette D (1970).
Catheterization of the heart in man with use of a flow-directed balloon-tipped catheter.
New England Journal of Medicine; 283, 447451.
9.7.2
Decline in use
In recent years the use of pulmonary artery catheters has declined somewhat, partially owing to lack of good evidence that it improves outcome (ESCAPE committee 2005; Shah et al.
2005; Hall 2005), and partly owing to new non-invasive cardiac output monitoring devices
(e.g., PiCCO, LiDCO, oesophageal doppler).
ASA (2003). Practice guide-lines for pulmonary artery catheterisation: an updated
report by the American Society of Anesthesiologists Task Force on pulmonary artery
catheterisation. Anesthesiology; 99, 9881014.
ESCAPE committee (2005). Evaluation study of congestive heart failure and pulmonary artery catheter effectiveness: the ESCAPE trial. JAMA ; 294, 16251633.
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Hall JB (2005). Searching for evidence to support pulmonary artery catheter use in
critically ill patients. JAMA ; 294, 16931694.
9.8
Computers & information technology
The first anaesthetic machine to incorporate a microprocessor was in 1976 (Katz 2006),
and since then computers have progressively influenced anaesthesia delivery and patient
safety. One of the next major influences on anaesthesia practice is likely to be related
to data processing, particularly in the areas of smart alarms and decision support. While
development and take-up in the operating theatre is almost imperceptible just now, the
future surely lies in computers offering anaesthetists seriously useful facilities. The initial
motivation with regard to data handling lay in automating the anaesthesia record. However,
while this technology has been effectively solved for over 15 years (see Kenny 1990), the
take-up by anaesthetists in the UK remains almost zero.
9.8.1
History of the anaesthesia record
The documentation of events, procedures undertaken, physiological parameters (vital signs)

which are associated with the process of anaesthesia (for example, in conjunction with
surgery or an intensive care setting) is known as the Anaesthesia Record. This record
serves two main functions, namely (a) medical (the moment-to-moment drug history and
vital-signs serves as a useful practical aid), and (b) medico-legal (the anaesthesia record is
a legal document in its own right, setting out the facts as they unfold during an anaesthetic).
Background
Effective surgical anaesthesia using inhaled diethyl-ether (ether) was first established
in 1842 by Crawford Long (18151878) in a handful of unpublicised cases. Some four
years later in 1846 ether anaesthesia was rediscovered and popularised by William Morton
(18191868), who gave a public demonstration on 16th October 1846 at the Massachusetts
General Hospital (Boston, USA).
Subsequently, John Snow (18131858), Joseph Clover (18251882), and Mounier
(1855) demonstrated the importance of monitoring the pulse and respiration during anaesthesia (Ellis 1995; Rushman, Davies and Atkinson 1996), but it was not until 1894, at the
Massachusetts General Hospital, Boston, that surgeons Ernst A Codman (18691940) and
Harvey Cushing (18691939) established the practice of keeping a careful written record
(on graph paper) of the patients pulse and respiration rate during operationsknown as
the ether chart (Beecher 1940; Hirsch and Smith 1986). Apparently this was prompted
by a death under anaesthesia in 1893 (Rushman, Davies and Atkinson 1996, p. 128). In
1901 they started including measurements of the arterial blood pressure using the newly
described apparatus of Scipione Riva-Rocci (18631937) of Turin (Cushing 1902; Cushing
1903; Rushman, Davies and Atkinson 1996, p. 157).
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Ralph Waters (1936; 1942) championed and emphasised the importance of written
anaesthetic records, and later Noseworthy (1945) produced special cards on which to record
anaesthetic details (see Rushman, Davies and Atkinson 1996, p. 111, for an illustration).
Automation
An automated anaesthesia record is significantly superior to the usual hand-written record,
since it samples data much more frequently and more accurately, and hence it has significant
medico-legal advantages regarding the documentation of patient care, particularly during
complicated and/or unstable cases.
The first mechanical device capable of printing an anaesthetic record was the Nargraf
machine of 1930 developed by EI McKessons (Westhorpe 1989), which generated a
semi-automated record of inspired oxygen, tidal volume and inspiratory gas pressure.
After this little of real technological significance was developed in the area of anaesthesia monitoring until the 1970s, when advances in chip technology gave rise to clinically
useful portable electronic devices for measuring such things as arterial and central venous
blood pressure, breath-by-breath concentrations of oxygen, carbon dioxide and inhalational
anaesthetics, pulse oximetry, and of course, small computers.
From an interfacing point of view, a very significant and far reaching feature was
incorporated into virtually all early medical monitoring devices, namely a specialised serial
communications interface known as the RS-232 port.48 Equally significant, therefore, was
the decision by IBM to incorporate the RS-232 port into the IBM Personal Computer which
appeared in 1981. Fortunately all IBM-compatible PCs since then have also incorporated
the RS-232 serial port.
Owing to the widespread use of the RS-232 interface in medical equipment it soon
became a relatively easy matter to use a PC to access the numerous measured and derived parameters output by patient monitoring devices, and consequently anaesthetists
increasingly explored methods for automating data collection and processing, with a view
to developing useful trend displays of measured data, real-time calculation of derived
parameters, and hard-copy data printouts.
The RS-232 interface is likely to be replaced at some stage by the Medical Interface Bus
(MIB; IEEE-1073). This is a high-tech high-speed medical plug-and-play version of the familiar domestic USB interface, and will greatly facilitate medical device inter-connectivity,
largely by allowing the relevant interface software to be more easily standardised.
Guidelines
The Royal College of Anaesthetists has published a summary of what data ought to be
collected (in addition to the electronic data from the anaesthesia monitors) as part of the
48 The
Electronic Industries Association Recommended Standard 232. In 1986 the prefix RS was superceded
by the prefix EIA. In 1988 the Telecommunications Industry Association (TIA) was formed by the merger of the
US Telephone Suppliers Association and EIA/ITG, and subsequent documents are therefore prefixed by EIA/TIA.
The 1991 revision was EIA/TIA-232-E. (Nickalls and Ramasubramanian 1995).
RWD Nickalls
Anaesthesia Record (Adams 1996), building on the work of Lack et al. (1994). The extent
to which these guidelines are actually being met has also been looked at (Smith 1997). The
required record set which appears to be emerging, consists of a number of fields within the
following general categories: pre-, per- and postoperative information, untoward events
and hazard flags.
9.8.2
The anaesthesia workstation
It is clear that computerisation, both in the operating theatre and in ITU, has the potential
to free anaesthetists and nurses from much of the work of documentation (e.g., drug doses,
procedures, measured parameters etc.), releasing significant amounts of time which is
better spent on direct patient care. Anaesthesia Information Management Systems (AIMS)
which incorporate sophisticated record-keeping systems clearly offer the advantage of
allowing the anaesthetists to concentrate fully on the patient, leading to enhanced vigilance
and improved patient care and safety.
Much work has gone into studying the anaesthetistss workload (Weinger et al. 1997;
Byrne, Sellen and Jones 1998; Leedal and Smith 2005). For example, Kennedy et al.
(1976) showed that anaesthetists commonly spend 1015 % of their time producing the
handwritten record. Similarly, Smith (1997) pointed out that about 10 % of the anaesthetists
time was related to record keeping, and that if this were to increase then this would likely
be to the patients detriment. A similar study by Wong et al. (2003) showed that an ICU
information system reduced the time spent by nurses on documentation by 31 %, with
the significant benefit being that almost half of the time saved was transferred to patient
assessment and direct patient care.
Secondary data processing by anaesthetists in the UK is well behind other countries,
with electronic data collection being actively supported by foreign health organisations.
For example, in 2001 the summer newsletter of the Anesthesia Patient Safety Foundation
(APSF) was devoted to Information systems in anaesthesia (Thys, 2001). In 2002 the
APSF formally endorsed the use of automated anesthesia information management systems
(AIMS) as the following quote indicates.
In this context it is heartening that the . . . APSF has recently endorsed the use of
automated anesthesia information management systems (AIMS): The Anesthesia
Patient Safety Foundation endorses and advocates the use of automated record keeping
in the perioperative period and the subsequent retrieval and analysis of that data to
improve patient safety.
Gage (2002)
Anaesthetists urgently need to harness the power of computing technology in a way

which can help both in the operating theatre and in the clinic, most likely via some form
of anaesthesia workstation. While such systems will probably be commercial, this is not
necessarily the only route. Providing anaesthetists take some interest in the details, it is
quite possible for useful systems to be developed along the Open Source model, as for
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example, the immensely successful Linux operating system, and the excellent software
tools TEX, LATEX, Perl and others.
The emphasis for such a workstation needs to be on helping the anaesthetist give a safe
anaesthetic during difficult circumstances. It would access data from a range of sources
via the Medical Interface Bus (e.g., anaesthesia monitors, HIS) and then process the data
in various ways; for example, generating the anaesthesia record, offering smart alarms,
decision support and predictive physiological and pharmacokinetic modelling, as well as
enabling data export, data storage and emergency communications.
For a long time now, even with a modest PC, it has been a simple matter to access high
quality data from anaesthesia monitors (Nickalls and Ramasubramanian 1995; Nickalls
1998, Nickalls, Dales and Nice 2010) and create excellent anaesthesia records offering
medico-legal security. These are relatively straightforward to write and get up and running,
as, for example, the graphic record shown in Figure 8.1 (page 135) generated by the
authors open-source anaesthesia workstation software.49 With little additional work a
theatre-based PC can also display warnings, equipment status information and valueadded parameters; for example, real-time age-corrected MAC (Nickalls and Mapleson
2003), smart diabetes monitoring & management, as well as extensive general and drug
information support (see Figure 9.5, page 159).
Although there has been widespread uptake of AIMS technology by anaesthetists, it
is clear that the optimum interface design to facilitate easy and intuitive use is difficult
to achieve. Interface design must minimise keyboard/mouse entries by the anaesthetists
while maximising information display. All too often the user interface is awkward to use
with the effect that time is wasted and data collection is incomplete (Driscoll et al., 2007).
However, since anaesthesia practice is much the same the world over, it is to be expcted
that with sufficient computer-engineering research an optimum and intuitive interface will
emerge given time. A typical example of current progress in making practical automated
anaesthesia records and the involvement of XML is that described by Meyer-Bender et al.
(2010). The wider adoption of AIMS technology also has the potential to bring about a
significant reduction of intraoperative awareness (Nickalls and Mahajan 2010).
Of course commercial AIMS technology is available and can be extremely useful (for
example, the NarKoData system 50 see Benson et al. 2000, and the Saturn Information
System, Dragersee Driscoll et al. 2007), but some can be far from ideal, and relatively
unhelpful in facilitating anaesthesia-related activities, or even generating good quality
records. These latter failings largely account for the poor take-up of commercial systems
by anaesthetists in the UK. That said, improvements are of course being made all the time.
Computerisation also offers a significant research benefit. For example, in a study by
Muller et al. (2002) anaesthetists were able to search the database of their automated anaesthesia record-keeper and establish useful risk factors predictive of subsequent inotropic
support requirement following cardio-pulmonary bypass. Driscoll et al. (2007) used AIMS
49 Xenon5; Nickalls RWD, Dales S and Nice AK (19962011) see Figure 9.5, (page 159) and Figure 8.1
(page 135).
50 IMESO, GmbH, Huttenberg, Germany.
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data to establish underdosage as the cause of awareness in three patients.

Databases
Extracting data from big databases requires a good data dictionary (Sanderson and Monk
2003) as, for example, the currently well advanced SNOMED Clinical Terms program
(SNOMED - CT),51 which is a dynamic health care terminology infrastructure being developed as part of the NHS National Program for Information Technology (NPfIT). A
demonstration program can be accessed from the SNOMED - CT home page.
Another NPfIT dictionary database of interest to anaesthetists is the Dictionary of
Medicines and Devices (dm+d).52 This consists of a number of coordinated XML-encoded
pharmaceutical databases, which also incorporate the associated SNOMED encoding. Of
particular interest to anaesthetists is the Virtual Therapeutic Moiety (VTM) database of
approximately 2000 official drug names which are to be used henceforth in all European
computer interactions relating to drugs. This list is updated frequently and can be downloaded from the website (password required). This useful list was incorporated into the
authors experimental anaesthesia workstation used in the CHN thoracic theatres.
The future
The future holds the exciting prospect of developing sophisticated (and possibly Open
Source) anaesthesia workstations giving anaesthetists access to good data displays and
trends, sophisticated alarms (smart-alarms), real-time predictive modelling for drugs
and physiological parameters, information management and decision-support systems
(Sanderson, Watson and Russell 2005; Tarassenko, Hann and Young 2006, Berkenstadt et al. 2006). A possible view of the future was presented recently by John, Peter, Chacko et al. (2009). Finally, we note that since 2010 the NHS has been embracing the Open Source domainthis can only be a good sign for anaesthetists (see
http://www.ehealthopensource.org/).
9.8.3
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51 http://www.ihtsdo.org/snomed-ct/
52 http://www.dmd.nhs.uk/
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Colophon
. . . TEX is potentially the most significant invention in typesetting this century. It introduces a standard language in computer typography and in terms of importance could
rank near the introduction of the Gutenberg press.
Gordon Bell (1979) 1
booklet was typeset using the 2010 TEXLive 2 implementation of the opensource 3 LATEX system 4 5 on a PC (Mandriva2006-Linux operating system), and
printed at 300 dpi from PDF files generated using PDFLATEX. The line drawing in
Figure 5.1 and the iso-MAC charts were generated using mathsPICPerl.6 Image manipulation
was achieved using standard Open Source utilities, including GIMP, DVIPS, fitps.pl,
GhostScript, ps2pdf and epstopdf. The text-editor used was KILE 1.6. The index was
compiled automatically using the TEX package makeindex.
The hazard glyph shown in the margin (used on page 47) was created by the Stanford computer scientist Donald Knuth 7 and featured prominently in Knuths TEX books 8 .
This delightful and unusual dangerous-bend notation has a curious provenance; it was
originally the brain-child of a remarkable and prolific group of mathematicians, known
collectively as Bourbaki,9 10 who used a variant form of it to highlight the trickier mathematical sections in their series of books.
HIS
1 In the Forword to: Knuth, DE (1979). T X and METAFONT, new directions in typesetting. (American
E
Mathematical Society and Digital Press, Stanford).
2 http://www.tug.org/texlive/
3 The Open Source initiative defines nine requirements which software must comply with in order for it to be
regarded as Open Sourcesee http://www.opensource.org/docs/definition.html.
4 LAT X is the de facto standard for the production of scientific documents (http://www.tug.org/).
E
5 For an overview of T X & LAT X see http://www.nickalls.org/dick/links/rwdnLinks.html#tex
E
E
6 http://www.ctan.org/tex-archive/graphics/mathspic/perl/
7 DE Knuth. In: Shasha D and Lazere C (1995). Out of their minds: the lives and discoveries of 15 great
computer scientists (Copernicus [Springer-Verlag New York]).
8 Knuth DE (1990). The T Xbook, (American Mathematical Society & Addison-Wesley).
E
9 Halmos PR (1957), Nicolas Bourbaki. Scientific American, (May issue).
10 Aczel AD (2007). The artist and the mathematician: the story of Nicolas Bourbaki, the genius mathematician
who never existed, (High Stakes Publishing, London, UK.)
196
Index
Abrams, H, 173
ACTc software, 152
acute lung injury, 118
adrenaline, 127, 128
Aeby, CT, 61
Aintree intubation catheter, 57
airway
difficult problems, 54
jet ventilation, 54
Allen test, 168
history, 168
modified Allen test, 168
anaesthesia
bronchoscopy, 87
carcinoid, 133
computer workstation, 189
drug database, 191
history of anaesthesia record, 187
lung biopsy, 20
lung volume reduction, 22
myasthenia gravis, 21
one-lung, 100, 111
extubation, 116
management of, 113
postoperative complications, 116,
117
preparation, 112
returning to two-lungs, 115
turning patient supine, 115
ventilation, 112
patient with tracheostomy, 52
pleurectomy-bilateral, 22
SNOWMED clinical terms, 191
thymectomy, 21
tracheal resection, 21
use of computers, 187
anaesthesia record
automation, 188
carcinoid case, 135
history, 187
anatomy
aberrant bronchus, 66
Aeby, CT, 61
anatomical terms, 59
arterial circulation of the hand, 167
Boyden, EA, 62
bronchopulmonary segment, 61
carina, 65
central veins, 176, 177
displaced bronchus, 66
epidural, 31
Ewart, W, 61
Glass, A, 62
history (lung anatomy), 61
Hunter, W, 61
Kramer, R, 62
lingula, 60
lung, 59
lung embryology, 63
palmar arches of the hand, 167
right-upper lobe orifice, 66
supernumerary bronchus, 66
Swammerdam, J, 61
tracheal bronchus, 124
wax models of lung, 61
Aoyagi, T, 144
197
INDEX
APUD, 133
Arndt bronchus-blocker, 93
arterial line, 166
history, 166
systolic pressure variations, 170
atelectasis, 117
awareness & MAC, 157
axial rotation of bronchoscope, 85
axillary vein, 180
central line and, 180
Baum, S, 173
bending of bronchoscope, 86
Bernoulli, D, 166
Bourbaki, N, 196
Boyden, EA, 62
Bradley, R, 183
Brock, RC, 59
BronchoCath double-lumen tube, 96
bronchopulmonary segment, 61
bronchoscopy, 78, 80
anaesthesia for, 87
axial rotation of bronchoscope, 85
bending of bronchoscope, 86
camera-mode, 86
carina, 80
complications, 90
history, 79
Ikeda, S, 79
image orientation, 85
intubation, 90
left subcarina, 81
local anaesthesia for, 41
right subcarina, 83
simulators, 80
Tyndall, J, 79
venturi jet ventilation, 89
bronchus
aberrant bronchus, 66
bronchus blocker, 92, 93
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Arndt, 93
Broviac, JW, 174
Bryce-Smith double-lumen tube, 94
bupivicaine, 34
camera-mode (bronchoscopy), 86
carcinoid, 133
anaesthesia for, 133
anaesthesia record, 135
APUD, 133
blood glucose, 134
chlorpheniramine, 134
HIAA, 133
ketanserin, 133
octreotide, 133
ondansetron, 134
ranitidine, 134
carina, 65, 80
Carlens double-lumen tube, 94
Carlens, E, 94, 95
Carroll, S, 63
catechol, 127
catecholamines, 127
central line, 171
Abrams, H, 173
anatomy of central veins, 176
axillary vein, 180
Baum, S, 173
Broviac, JW, 174
complications, 182
Cournand, A, 172
Dotter, C, 174
external jugular vein, 180
femoral vein, 181
Forssmann, W, 171
general references, 178
history, 171
J-wire, 174
optimum position, 176
position of tip, 177
Richards, D, 172
Seldinger, S-I, 172
ultrasound guided, 179
INDEX
central veins
anatomy, 176, 177
axillary vein, 180
femoral vein, 181
chest drains, 24
Clover, J, 187
Codman, EA, 187
colophon, 196
complications, 36
acute lung injury, 118
arterial line, 170
atelectasis, 117
epidural abscess, 36
epidural haematoma, 37
one-lung anaesthesia, 116, 117
pulmonary oedema, 117, 118
tracheal damage, 116
tracheal rupture, 116
computers, 187
drug dictionary/database, 191
IBM PC, 188
MAC software, 152
MIB, 188
RS-232 port, 188
SNOWMED clinical terms, 191
Virtual Therapeutic Moiety (VTM),
191
Corenham, J, 145
Cournand, A, 172
Cushing, H, 187
CVP line
anatomy of central veins, 176
anatomy problems, 182
axillary vein, 180
complications, 182
femoral vein, 181
general references, 178
guide-wire problems, 182
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J-wire, 174
position of tip, 177
ultrasound guided, 179
Darwin, C, 63
data sharing, 160
desflurane, 155
difficult airway, 54
dobutamine, 127, 128
dopamine, 128
Dotter, C, 174
double-lumen tube, 94
BronchoCath, 96
bronchoscopyleft DLT, 106
bronchoscopyright DLT, 109
Bryce-Smith, 94
Carlens, E, 94, 95
checking equipment, 103
database, 97
history, 94
intubation, 103
optimum method, 101
placing, 101
preparation, 102
railroading, 104
Robertshaw, FL, 95
stethoscope check, 105
summary, 102
Table of sizes, 96
TEPID database, 97
tidal volume and pressure check, 110
tracheostomy, 122
turning patient laterally, 110
White, GMJ, 95
drugs, 126
adrenaline, 127, 128
bupivicaine, 34
cardiovascular, 126
catechol, 127
catecholamines, 127
INDEX
desflurane, 155
dictionary/database, 191
dilutions, 128
dobutamine, 127, 128
dopamine, 128
enoxaparin, 37
ephedrine, 126
fentanyl, 34
GTN, 128
haemostatic agents, 138
heparin, 37
infusions, 128
isoflurane, 153
isoprenaline, 127, 128
ketanserin, 133
LMWH, 37
metaraminol, 126, 127
methoxamine, 126
neostigmine, 21
noradrenaline, 127, 128, 130, 131
octreotide, 133
ondansetron, 134
phenylephrine, 126, 127
propofol, 87
TCI, 87, 88
pyridostigmine, 21
ranitidine, 134
recombinant factor VIIa, 138
remifentanil, 87, 88, 138
bolus, 138
infusion, 139
MAC equivalent, 139
TCI, 87, 88, 139
sevoflurane, 154
single strength dilution, 128
SNP, 128
somatostatin analogues, 133
suxamethonium infusion, 88
tablesingle strength dilutions, 128
tablevasoactive drugs, 126
TCI, 139
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terlipressin, 127
tinzaparin, 37
TIVA, 87, 139
vasopressin, 128
DVT prophylaxis and epidurals, 37
Eger, EI, 150
embryology of lung, 63
empyema, 25
enoxaparin, 37
ephedrine, 126, 127
epidural, 30
abscess, 36
anatomy, 31
awake or GA?, 33
bupivicaine, 34
catheter disconnection, 36
database, 32
depth (midline), 32
disconnection, 36
drugs, 34
DVT prophylaxis, 37
fentanyl, 34
fibreoptic-guided placement, 34
haematoma, 37
Huber point, 143
Huber, RL, 143
Lee epidural needle, 32, 143, 144
Lee, JA, 32, 143, 144
midline, 33
paramedian, 33
paravertebral block, 37
radiographic placement, 34
reducing catheter fallout, 34
TEPID database, 32
Tuohy needle, 143
Tuohy, EB, 143
evolution of the lung
Carroll, S, 63
Darwin, C, 63
Ewart, W, 61
INDEX
femoral vein, 181

fentanyl, 34
fibreoptics
Tyndall, J, 79
flail chest, 23
Forssmann, W, 171
Ganz, W, 183
glass fibres, 79
Glass, A, 62
GTN, 128
Gutenberg press, 196
haemostatic drugs, 138
Hales, S, 166
Harvey, W, 94
Head, H, 94
heparin, 37
HIAA, 133
history
Abrams, H, 173
Aeby, CT, 61
Allen test, 168
Allen, EV, 168
anatomy of the lung, 61
Aoyagi, T, 144
arterial line, 166
Baum, S, 173
Bernoulli, D, 166
Bourbaki, N, 196
Boyden, EA, 62
Bradley, R, 183
bronchoscopy, 79
Broviac, JW, 174
Carlens, E, 94, 95
central line, 171
Clover, J, 187
Codman, EA, 187
computing, 187
Corenham, J, 145
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Cournand, A, 172
Cushing, H, 187
Dotter, C, 174
double-lumen tube, 94
Eger, EI, 150
Ewart, W, 61
Forssmann, W, 171
Ganz, W, 183
Glass, A, 62
Gutenberg press, 196
Hales, S, 166
Harvey, W, 94
Head, H, 94
Hooke, R, 94
Huber, RL, 143
Hunter, W, 61
Ikeda, S, 79
Knuth DE, 196
Kramer, R, 62
Lategola, M, 183
LATEX, 196
Leader, S, 42
Lee, JA, 32, 143, 144
Lloyd, J, 145
Long, C, 141, 187
lung anatomy, 61
MAC, 146, 150, 151
Mann, H, 142
Mapleson, WW, 151
McKessons, EI, 188
Morton, W, 141, 146, 187
Mounier, CCR, 187
Nargraf machine, 188
New, W, 145
Noseworthy, M, 188
oximetry, 144
Pasteur, L, 141
Poiseuille, J-L, 166
Portex, 42
pulmonary artery catheter, 183
pulse oximetry, 144
INDEX
Rahn, H, 183
Richards, D, 172
Riva-Rocci, S, 187
Seldinger, S-I, 172
serendipity, 142
Severinghaus, JW, 150
Shaw, R, 144
Snow, J, 141, 146, 187
calculation of inhaled %, 149
temperature effect, 157
Swammerdam, J, 61
Swan, H, 183
TEX, 196
Tuohy, EB, 143
Tyndall, J, 79
Walpole, H, 142
Waters, R, 188
wax models, 61
White, GMJ, 95
Hooke, R, 94
Huber, RL, 143
Hunsaker jet ventilation tube, 93
Hunsaker tube, 90, 122
Hunter, W, 61
IBM PC, 188
Ikeda, S, 79
image orientation (bronchoscopy), 85
iso-MAC chart
ACTc software, 152
desflurane, 155
for download, 152
isoflurane, 153
MACpalm software, 152
sevoflurane, 154
isoflurane, 153
isoprenaline, 127, 128
J-wire, 174
Jackson-Rees T-piece circuit, 112
jet ventilation
airway control, 54
tracheostomy, 54
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ketanserin, 133
knots
rolling-hitch, 105
Knuth, DE, 196
Kramer, R, 62
laryngectomy
and tracheostomy, 52
Lategola, M, 183
LATEX, 196
Leader, S, 42
Lee, JA, 32, 143, 144
left subcarina, 81
lingula, 60
Linux, 196
Lloyd, J, 145
Long, C, 141, 187
lung
volume reduction, 22
anatomical terms, 59
anatomy, 59
biopsy, 20
embryology, 63
lung anatomy, 59
history, 61
lung function
evaluation, 18
obesity, 20
tests, 18
lung volume reduction, 22
MAC, 146
ACTc software, 152
age correction, 151
awareness, 157
desflurane, 155
Eger, EI, 150
history, 146
iso-MAC chart
desflurane, 155
for download, 152
isoflurane, 153
sevoflurane, 154
INDEX
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isoflurane, 153
Lerou nomogram, 152
Mapleson, WW, 151
research, 160
sevoflurane, 154
Snow, J, 146
table of MAC data, 152
temperature correction, 157
Mallinckrodt BronchoCath DLT, 96
Mann, H, 142
Mapleson, WW, 151
mathsPIC, 196
McKessons, EI, 188
metaraminol, 126, 127
methoxamine, 126
MIB, 188
Montgomery tracheostomy tube, 54
Moore tracheostomy tube, 43
Morton, W, 141, 146, 187
Mounier, CCR, 187
myasthenia gravis, 21
bronchoscopyright DLT, 109

complications, 116, 117
extubation, 116
Hunsaker jet ventilation tube, 90,
122
intraoperative complications, 116
Jackson-Rees T-piece circuit, 112
left double-lumen tube, 100
management of, 113
placing double-lumen tubes, 101
postoperative complications, 117
preparation, 112
returning to two-lungs, 115
right double-lumen tube, 100
stethoscope check, 105
tidal volume and pressure check, 110
tracheostomy, 122
ventilation, 112
oximetry
Aoyagi, T, 144
history, 144
Nellcor, 145
pulse oximetry, 144
Nargraf machine, 188

Nellcor, 145
neostigmine, 21
Netter images (anatomy), 77
New, W, 145
nitrous oxide, 23
cavity expansion, 23
noradrenaline, 127, 128, 130, 131
Noseworthy, M, 188
paravertebral block, 37
Pasteur, L, 141
percutaneous tracheostomy, 43, 49
phenylephrine, 126, 127
pleurectomy-bilateral, 22
pneumothorax, 23
chest drains, 24
nitrous oxide, 23
surgical emphysema, 25
Poiseuille, J-L, 166
Portex
history, 42
tracheostomy tube, 42
preoperative evaluation, 18
cardiac status, 20
lung status, 18
propofol, 87
obesity, 20
lung function, 20
octreotide, 133
ondansetron, 134
one-lung, 100
anaesthesia, 100, 111
bronchoscopyleft DLT, 106
INDEX
TCI, 87, 88
pulmonary artery catheter, 183
Bradley, R, 183
decline in use, 186
Ganz, W, 183
history, 183
Lategola, M, 183
Rahn, M, 183
Swan, H, 183
pulmonary oedema, 118
pulse oximetry, 144
history, 144
pyridostigmine, 21
Rusch double-lumen tube, 43
Rusch tracheostomy tube, 43
radial artery, 167
harvesting of, 168
Rahn, M, 183
ranitidine, 134
remifentanil, 87, 88, 138
bolus, 138
infusion, 139
MAC equivalent, 139
TCI, 87, 88, 139
research & data sharing, 160
research & MAC, 160
Richards, D, 172
right subcarina, 83
right upper-lobe orifice, 66
Riva-Rocci, S, 187
Robertshaw double-lumen tube, 95
Robertshaw, FL, 95
rolling-hitch, 105
RS-232 port, 188
Seldinger, S-I, 172
Serendip, three princes of, 142
serendipity, 142
sevoflurane, 154
Shaw, R, 144
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sickle cell disease, 25

simulators
bronchoscopy, 80
single strength dilution (drugs), 128
Snow, J, 141, 146, 187
calculation of inhaled %, 149
temperature effect, 157
SNP, 128
software
MAC software, 152
somatostatin analogues, 133
sternal split, 22
supporting technologies, 141
surgical emphysema, 25
surgical tracheostomy, 45, 49
suxamethonium infusion, 88
Swammerdam, J, 61
Swan, H, 183
syllabus
advanced-level training, 12
higher-level training, 12
intermediate-level training, 12
TCI, 87, 88
propofol, 88
remifentanil, 88, 139
technology
supporting, 141
TEPID database
epidural database (midline), 32
tube database, 97
terlipressin, 127
TEX, 196
three princes of Serendip, 142
thymectomy, 21
tinzaparin, 37
TIVA, 87, 139
tracheal damage, 116
tracheal rupture, 116
INDEX
tracheostomy, 40
Aintree intubation catheter, 57
air leak, 57
anaesthetising patient with, 52
changing a tracheostomy, 49
Hunsaker jet ventilation tube, 90,
122
inner tube problems, 57
laryngectomy, 52
local anaesthesia for bronchoscopy,
41
miscellaneous problems, 55
Montgomery tube, 54
Moore tube, 43
obstruction, 56
one-lung ventilation, 122
percutaneous, 43, 49
Portex tube, 42
Rusch tube, 43
surgical, 45, 49
recommendations, 45
Tabletube sizes, 50
timing, 43
Tracoe tube, 42
Tracoe tracheostomy tube, 42
tube, 92
database, 97
double-lumen, 92, 94
TEPID database, 97
Univent, 92
Tuohy, EB, 143
Tyndall, J, 79
ulna artery, 167
harvesting of, 168
Univent tube, 92
vasopressin, 128
venturi
RWD Nickalls
jet ventilation (bronchoscopy), 89

Virtual Therapeutic Moiety (VTM), 191
Walpole, H, 142
Waters, R, 188
wax models of lung anatomy, 61
White, GMJ, 95

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Notes on Thoracic Anaesthesia

.. .... ..... .... ...

Notes on Thoracic Anaesthesia

Comprehensive TEX Archive Network (CTAN)

Copyright RWD Nickalls 20032011

PORTEX Smiths Medical, Hythe, Kent, UK

The single biggest problem we face is that of visualisation.

Mathematical Gazette, (1996); 80, 267

A unique local service with over

Anatomy what is the useful functional anatomy for thoracic anaesthetists?

of Radiology, Nottingham University Hospitals, City Hospital Campus, Nottingham, UK.

Tracheostomy & related airway problems

3.11.4 Tracheostomy recently removed . . . . . . . . . . . . . . . . . .

Tubes and bronchus blockers

thoracic anaesthesia syllabus for the CCT in Anaesthesia is detailed in the

CHAPTER 1. GENERAL TOPICS

CHAPTER 1. GENERAL TOPICS

CHAPTER 1. GENERAL TOPICS

CHAPTER 1. GENERAL TOPICS

Thoracic Surgery Clinics

Clinics in Chest Medicine

CHAPTER 1. GENERAL TOPICS

Acute respiratory distress syndrome (2000); 21 (September).

CHAPTER 1. GENERAL TOPICS

Medscapes clinical reference website: http://emedicine.medscape.com/

Lung function evaluation

CHAPTER 1. GENERAL TOPICS

Brunelli A (Ed.) (2008). Preoperative evaluation of lung resection candidates.

CHAPTER 1. GENERAL TOPICS

Cardiac function evaluation

Eagle KA et al. (2002). ACC/AHA guideline update for perioperative cardiovascular

Open lung biopsy

CHAPTER 1. GENERAL TOPICS

Differential lung ventilation

Thymectomy and myasthenia gravis

is the preferred agent owing to its longer action.

CHAPTER 1. GENERAL TOPICS

Bilateral pleurectomy via sternal split

Lung-volume reduction surgery

CHAPTER 1. GENERAL TOPICS

Ahmed Z and Mohyuddin Z (1995). Management of flail chest injury: internal

OConnor AR and Morgan WE (2005). Radiological review of pneumothorax.

Cavity expansion with N2 O

CHAPTER 1. GENERAL TOPICS

Hunter J (2008). Chest drain removal. Nursing Standard ; 22(45), 3538.

CHAPTER 1. GENERAL TOPICS

Thompson R, Parker E, Sivaprakasam J and Hong V (2007). Observational study

Beck PL, Heitman SJ and Mody CH (2002). Simple construction of a subcutaneous

DTB (2006). Managing empyema in adults. Drug and Therapeutics Bulletin;

Sickle cell disease

One-lung anaesthesia in patients with a sickle-cell condition is a formidable problem

those I have indicated with a triangle 4.

CHAPTER 1. GENERAL TOPICS

CHAPTER 1. GENERAL TOPICS

4 Neumayr L, Koshy M and Haberkern C et al. (1998). Surgery in patients with

The transfusion controversy

Managing sickle-cell crisis

CHAPTER 1. GENERAL TOPICS

Mozzarelli A, Hofrichter J, and Eaton WA (1987). Delay-time of hemoglobin-S

CHAPTER 1. GENERAL TOPICS

Swazey JP and Reeds K (1978). Todays medicine, tomorrows science: essays

HbS & O2 dissociation curve

Becklake MR et al. (1955). Oxygen dissociation curves in sickle-cell anemia, and

CHAPTER 2. EPIDURAL BLOCK