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A 50-year-old man presents with a 6-month history of progressive paraparesis. He had sustained a fall at work about 12 months ago and has complained of back pain since that time. He also complains of difficulty with urination and constipation over the past several weeks. Magnetic resonance imaging (MRI) reveals disc herniation at T10-T11 and spinal cord compression. He has been scheduled for T11 vertebrectomy, spinal cord decompression, and spinal instrumentation via a left thoracotomy. He is otherwise healthy. His medications include acetaminophen, and dexamethasone which has recently been added.
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On examination, he is 173 cm (5 ft 8 in) tall and weighs 77 kg (170 lb). His vital signs are: blood pressure (BP) 140/80 mm Hg, heart rate (HR) 69 beats per minute (bpm) and regular, respiratory rate (RR) 16 breaths per minute, temperature 36.9°C, and oxygen saturation is 99% on room air. Examination of the lower extremities reveals 3/5 motor power in the left leg and 5/5 in the right leg. Sensation is altered below T11. The chest is clear to auscultation and the heart sounds are normal.
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Airway examination reveals a Mallampati II classification, thyromental distance of 5 cm, mouth opening of 5 cm, mandibular mobility of 2 cm, normal cervical spine extension, and full dentition.
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36.2.1 Is This Patient Fit for Anesthesia?
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The patient has spinal cord compression with slowly progressive neurologic symptoms and requires surgery. He has no significant comorbidities and needs no preoperative medical optimization.
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36.2.2 What Anesthetic Technique Is Required?
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General anesthesia is required. Lung separation has been requested by the surgeon to optimize the surgical exposure.
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36.2.3 How Can One Lung Ventilation or Lung Separation Be Achieved?
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Double lumen tubes (DLT) have been considered to be the gold standard for lung separation.1-4 However, recently introduced bronchial blockers (BBs) have been shown to provide equivalent surgical exposure when compared to the DLT.5-8 The DLT is preferred when lung isolation is required to protect the nondiseased lung from contamination with blood or pus, in the presence of a bronchopleural or bronchopleural cutaneous fistula, and to perform unilateral pulmonary lavage.1 A contralateral DLT is preferred when a sleeve resection, or lung transplant is performed.5,9 However, there are many clinical situations in which a DLT may not be the best primary choice.2 The indications for the use of a bronchial blocker include the difficult airway, distorted bronchial anatomy, the presence of a tracheostomy, when a nasal intubation is required, and to avoid the need for a tube exchange. Currently available BBs include the Univent Torque Control Blocker, the Arndt Wire-Guided Endobronchial Blocker, the Cohen Flexitip Endobronchial Blocker, the Fuji Uniblocker, the HS Endoblocker, and the Coopdech Endobronchial Blocker.3,5,10-13
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One lung ventilation using a DLT is planned in the ...