Anesthésie et recherche clinique
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Fiberoptic Evaluation of Oro-Tracheal Distal End Migration during Video-Laparoscopic Bariatric Surgery

Hani I. Taman

Background: After intubation, tracheal tube position requires special precaution especially during patients positioning, as migration of orotracheal tube may result in endobronchial intubation. This problem increases in video assisted laparoscopic bariatric surgery. Although following guidelines for optimal confirmation of ETT position appears simple to practice, at certain circumstances it becomes confusing. Meanwhile fiber-optic bronchoscopy represents a proper method for confirmation of endobronchial tip position. The primary goal of this study was to detect and measure the changes in the position of distal end of endotracheal tube after abdominal gas insufflation during laparoscopic bariatric surgery. The secondary goal is to find a warning sign that may help in prediction of tubal end migration.

Methods: 70 patients were included in this study. Basic monitoring with pulse oximetry, noninvasive blood pressure, capnography and ECG were attached to the patients. The adequate position of endotracheal tube was confirmed first by direct visualization of the cuff of the tube to pass below vocal cords with the guide mark at the level of the vocal cords, capnography, and auscultation. After that, a fiberoptic bronchoscopy was performed, with a flexible pediatric bronchoscope. The distance from the tip of the endotracheal tube to the tracheal carina was measured after insertion of endotracheal tube and after creation of pneumoperitoneum and after repositioning also the incidence of endobronchial intubation was recorded.

Results: The distance from the tip of the endotracheal tube to the tracheal carina was shorter after creation of pneumo-peritonium and after repositioning when compared to basal value. Endotracheal intubation incidence was also higher after creation of pneumo-peritonium and after repositioning. Both peak and plateau pressures after creation of pneumo-peritonium were significantly higher when compared to the basal values.

Conclusions: In obese patients undergoing gastroplasty, insufflation of the pneumoperitoneum in videolaparoscopic procedures reduces the distance between ETT tip and the carina with higher incidence of endobronchial intubation. Rising of peak and plateau pressures above 30% and of basal value may be an indicative of endobronchial intubation.