Diaphragmatic Dysfunction FollowingCardiac Surgery: Is There a Role forPulmonary Ultrasound?

Abstract

from incisors to secondary carina on the left side to determine the depth of insertion of the left DLT. Similarly, 1 cm is added to the measured distance from incisors to the takeoff of right upper lobe bronchus to determine depth of insertion of a right DLT (tip of the right DLT is approximately 1 cm beyond the slot for right upper lobe ventilation). At our institute, we commonly use this technique to know the depth of insertion, especially when a PFOB is not available, and we find it useful in achieving optimum position of the DLT, particularly in small-sized individuals, in which we have seen significant variations in the tracheobronchial dimensions. Blind insertion to a depth estimated by height-based formulae often overestimates the depth of insertion in small-sized Asian patients, thereby increasing the risk of tracheobronchial injury associated with inserting the DLT too far. A limitation of this technique is that the distance measured from incisor to secondary carina may vary with the position of the head and neck during bronchoscopy, and therefore it is important to make the measurements with the head in a neutral position. Confirmation of position of the DLT with a PFOB remains the gold standard and should be followed whenever possible. Thus, in addition to CT scan-guided measurement, preintubation measurement of distance between incisor and secondary carina using adult bronchoscope is an effective, less resourceintensive method to know the depth of insertion of the DLT. Use of these methods improves the rate of successful placement of the DLT when a PFOB is unavailable.

Point of Care Ultrasound to Identify Diaphragmatic Dysfunction after Thoracic Surgery

“…Conversely, we reported the incidence of diaphragm dysfunction after thoracic surgery with a reliable, noninvasive, and widely available ultrasonographical examination. Given the increasing popularity of diaphragmatic ultrasound in several postoperative contexts, 41 our research might represent a starting reference for further studies. Since we found a significant association between diaphragmatic dysfunction and postoperative pulmonary complications (table 4), the ultrasound assessment of diaphragm motion could be a useful tool to identify patients at greater risk of postoperative pulmonary complications that should be managed more cautiously, for example, with continuous positive airway pressure, 36 noninvasive ventilation, or incentive ventilation and physiotherapy.…”

Mechanical ventilation weaning issues can be counted on the fingers of just one hand: part 1

“…Bedside ultrasound assessment of the diaphragm in critically ill patients can also be used to detect diaphragm dysfunction (diaphragm activity is classified as: usual, reduced, or loss of function) [49]. Although it may help the clinician make therapeutic decisions, a possible role in ventilation and weaning from mechanical ventilation has yet to be fully determined [49][50][51][52].…”

“…Two diaphragm sonographic predictors of successful weaning have been proposed [45,[49][50][51][52][53][54][55][56]:…”

Routine practice in mechanical ventilation in cardiac surgery in Italy

“…This is especially essential in cardiac surgery since many factors can contribute to lung injury, including general anesthesia itself, cardiopulmonary bypass (CPB), blood transfusions, cardiac failure, and diaphragmatic dysfunction-all of which increase the risk of postoperative pulmonary complication (PPC), as defined by Abbott et al (4) in up to 25% of patients after surgery (5)(6)(7). Nevertheless, evidence regarding the best way for lung protective ventilation is still lacking.…”