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Original Research: Pulmonary Procedures |

Percutaneous Dilatational Tracheostomy With a Double-Lumen Endotracheal TubeDouble Lumen Endotracheal Tube for Tracheostomy: A Comparison of Feasibility, Gas Exchange, and Airway Pressures FREE TO VIEW

Maria Vargas, MD; Paolo Pelosi, MD; Gaetano Tessitore, MD; Fulvio Aloj, MD; Iole Brunetti, MD; Enrico Arditi, MD; Dorino Salami, MD; Robert M. Kacmarek, PhD, RRT; Giuseppe Servillo, MD
Author and Funding Information

From the Department of Neurosciences (Drs Vargas, Tessitore, and Servillo), Reproductive and Odonthostomatological Sciences, University of Naples “Federico II,” Naples, Italy; Department of Surgical Sciences and Integrated Diagnostics (Drs Vargas and Pelosi), IRCCS AOU San Martino IST, University of Genoa, Genoa, Italy; Anesthesia and Intensive Care Unit (Drs Aloj and Servillo), IRCCS Neuromed, Pozzilli (IS), Italy; Intensive Care Unit (Drs Brunetti, Arditi, and Salami), IRCCS AOC San Martino IST, Genoa, Italy; and Department of Anesthesiology and Critical Care and Department of Respiratory Care (Dr Kacmarek), Massachusetts General Hospital, Boston, MA.

CORRESPONDENCE TO: Giuseppe Servillo, MD, Department of Neurosciences, Reproductive and Odonthostomatological Sciences, University of Naples “Federico II,” Corso Umberto I, 40, 80138 Naples, Italy; e-mail: servillo@unina.it


FUNDING/SUPPORT: The authors have reported to CHEST that no funding was received for this study.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(5):1267-1274. doi:10.1378/chest.14-1465
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OBJECTIVE:  Gas exchange and airway pressures are markedly altered during percutaneous dilatational tracheostomy (PDT). A double-lumen endotracheal tube (DLET) has been developed for better airway management during PDT. The current study prospectively evaluated the in vivo feasibility, gas exchange, and airway pressures during PDT with DLET compared with a conventional endotracheal tube (ETT).

METHODS:  According to eligibility criteria, patients were divided into a case group (those receiving PDT with DLET) and a control group (those receiving PDT with a conventional ETT). The Ciaglia single-dilator technique was used for PDT in both groups. The primary end point of this study was the feasibility of tracheostomy with DLET. The secondary end points were a comparison of gas exchange, airway pressures, minute volume, and tidal volume before, during, and after PDT performed with DLET and conventional ETT.

RESULTS:  Ten patients meeting the inclusion criteria were assigned to each group. PDTs were performed without difficulties in nine patients in the DLET group and 10 patients in the conventional ETT group. During PDT, gas exchange, airway pressures, and minute ventilation remained more stable in the DLET group and were significantly different from those in the conventional ETT group.

CONCLUSIONS:  PDT with DLET can be performed safely without difficulties limiting the technique. Furthermore, during PDT, the use of the DLET resulted in more stable gas exchange, airway pressures, and ventilation than PDT with a conventional ETT.

TRIAL REGISTRY:  ClinicalTrials.gov; No.: NCT01691222; URL: www.clinicaltrials.gov

Figures in this Article

Percutaneous dilatational tracheostomy (PDT) is a common procedure in the ICU due to prolonged mechanical ventilation, airway protection and suctioning, and difficult weaning.1 Various methods of performing PDT have been proposed. Stoma dilation may be performed with such devices as the single dilator variant of the Ciaglia method,2 whereas a single-lumen endotracheal tube (ETT) or laryngeal mask airway (LMA) is used for airway management.3 All PDT methods are usually performed with a flexible fiber-optic bronchoscope (FFB) to decrease complications.2 However, ventilation during PDT may be difficult because of the partial airway obstruction caused by the FFB.3 The safest approach to ventilation during PDT is unknown. All current approaches result in air trapping as a result of the reduced lumen available for ventilation because of dilators and the FFB.4

We developed a double-lumen endotracheal tube (DLET) for airway management during PDT. The DLET is divided into an upper channel for placement of an FFB and a lower channel exclusively dedicated to the patient’s ventilation. The data we have obtained from an in vitro airway model showed that the DLET had a lower Rohrer constant during continuous flow and a lower resistance to gas flow during mechanical ventilation than a similar-sized ETT with an FFB in place. According to these in vitro data, use of the DLET during PDT allowed bronchoscopy without imposing an excessive increase in airway resistance.5

The current study prospectively evaluated the in vivo feasibility and safety of PDT with the DLET compared with a conventional ETT. Gas exchange, airway pressures, minute volume (MV), and tidal volume (Vt) were evaluated before, during, and after the procedure. To date, no in vivo trial using the DLET has been reported to our knowledge. In this study, we demonstrate proof of concept in critically ill patients.

Percutaneous Tracheostomy With DLET

The DLET [Bilumen ventilation tube; DEAS SRL; international patent application No. PCT/IT2012/000154] is divided into an upper channel that allows passage of an FFB and a lower channel that is exclusively dedicated to patient ventilation (Fig 1). The upper lumen is 18.8 cm in length with an internal diameter of 9 mm. The lower lumen is elliptical from the level of the vocal cords to the distal tip with an asymmetric distal cuff. The lower lumen is 29 cm in length with an internal diameter of 7 or 7.5 mm (21F or 22F).5

Figure Jump LinkFigure 1 –  Technical characteristics of the double-lumen endotracheal tube (DLET). The upper lumen at section A-A has an internal diameter of 9 mm (27F), whereas the lower lumen has an internal diameter of 7 or 7.5 mm (21F or 22F) according to the size of the lower channel. The two lumens at section A-A have an external diameter of 16.5 or 17 mm (49.5F or 51F) according to the size of the lower lumen. At the level of the vocal cords, the DLET has an external diameter of 8 mm (24F). At section B-B, the lower channel has an internal diameter of 7 or 7.5 mm (21F or 22F) according the size of lower channel. The DLET is 298 or 303 mm long according to the size of the lower channel.Grahic Jump Location

Orotracheal intubation with the DLET is achieved by direct laryngoscopy, and the tube is positioned with the first black line at the level of vocal cords (Fig 2). Reintubation with the DLET is safely performed with an airway exchange catheter, which allows oxygen insufflation or jet ventilation if needed during the exchange.

Figure Jump LinkFigure 2 –  A, The correct positioning of DLET after orotracheal intubation. The lower channel of DLET should be placed on the posterior tracheal wall with the asymmetric distal cuff at the level of the carina. During percutaneous dilatational tracheostomy, the DLET should be kept in the middle of the mouth. B, Needle insertion. C, Dilatational step. D, Cannula placement with DLET. See Figure 1 legend for expansion of abbreviation.Grahic Jump Location

The correct positioning of the DLET inside the trachea is controlled with an FFB positioned in the upper lumen. The lower lumen is centrally positioned on the posterior tracheal wall with its distal cuff positioned just above the carina (Fig 2). Once correct positioning of the DLET is confirmed, the distal cuff is inflated.

The FFB is kept in the upper lumen of the DLET during the tracheostomy to control the different procedural steps. The puncture of the anterior tracheal wall, Seldinger insertion, dilatation, and cannula positioning are all performed with the DLET correctly placed in the trachea (Fig 2). The DLET is removed at the end of the tracheostomy when the cannula is inserted and correctly positioned with the FFB.

Study Design and Patient Selection

This prospective case-control study was approved by the ethics committee of IRCCS San Martino IST, Genoa (protocol number 53/12 and 90/12) and registered with ClinicalTrials.gov (NCT01691222). The patients’ relatives gave informed consent for all procedures associated with this study. Patients admitted to the ICU of IRCCS San Martino IST and requiring elective tracheostomy were consecutively screened during a period of 2 years for possible inclusion. Patients were divided into either a case group (those receiving PDT with the DLET) or a control group (those receiving PDT with the conventional ETT).

The eligibility criteria for the DLET group were as follows: age > 40 years, Simplified Acute Physiology Score (SAPS) II < 80, Glasgow Coma Scale (GCS) score ≤ 8, duration of translaryngeal intubation before tracheostomy > 5 days, Pao2/Fio2 ratio between 100 and 300, and Paco2 > 35 mm Hg. Patients were included in the DLET group if they met all these criteria.

Control subjects were selected from a cohort of patients consecutively admitted to the ICU. All patients in the control group met the same eligibility criteria as those in the DLET group. The physician who made the selection of control patients did not know the specifics of the study and was not informed about the feasibility of DLET tracheostomies. For each patient included in the DLET group, one matching control was selected according to the following criteria: age within 8 years, SAPS II within 5 points, GCS score within 3 points, duration of translaryngeal intubation before tracheostomy within 5 days, Pao2/Fio2 ratio within 20 points, and Paco2 within 5 points of the patients managed with DLET. The matched control patients were included if they had a Pao2/Fio2, Paco2, and duration of translaryngeal intubation before tracheostomy within the previous range plus met three of the following five criteria: age, sex, GCS score, SAPS II, and reason for admission to the ICU. Patients meeting any of the following criteria were excluded from the study: emergency intubation for CPR, respiratory arrest, or severe hemodynamic instability.

End Points

The primary end point of this study was the feasibility of tracheostomy with the DLET. The secondary end points were a comparison of gas exchange, airway pressures, MV, and Vt before and during PDT performed with the DLET and the conventional ETT.

Technical Aspects

The Ciaglia single-dilator technique (Portex ULTRAperc; Smiths Medical) was used for PDT in both groups. Two intensive care physicians with at least 10 years of experience in this procedure (one performing the tracheostomy and one managing the FFB) performed the tracheostomies at the ICU bedside. Fiber-optic guidance and control with an FFB (5 mm external diameter) was used in both groups throughout the procedure. Patients were monitored with ECG, invasive BP, and pulse oximetry.

Before PDT, patients in each group were anesthetized with midazolam 0.3 to 0.35 mg/kg, fentanyl 0.1 mg, and cisatracurium 0.2 mg/kg. Before the beginning of the procedure, volume control ventilation was set at a rate of 15 breaths/min with an Fio2 of 1.0, Vt of 500 mL, and positive end-expiratory pressure of 5 cm H2O, and the high airway pressure alarm was set at 80 cm H2O. After 3 min of preoxygenation with these ventilation settings, the ETT in place in each group was exchanged using an airway tube exchanger (Rapi-Fit, Cook Medical). In the DLET group, the ETT was replaced with the DLET.

To evaluate the feasibility of PDT with the DLET, we designed the following feasibility scale: I = percutaneous tracheostomy was performed from the needle insertion to cannula positioning without difficulties; II = percutaneous tracheostomy was performed from the needle insertion to cannula positioning with one or more difficulties not limiting the technique; and III = percutaneous tracheostomy with the DLET was impossible, and the procedure was shifted to conventional ETT. Difficulties not limiting the technique were defined as (1) minor difficulties in needle insertion, (2) puncture of lower lumen of the DLET, (3) minor difficulties in dilatation, (4) kinking of the guidewire, (5) minor difficulties in cannula placement, and (6) minor difficulties in retraction of the DLET at the end of the procedure. Difficulties limiting the technique were defined as (1) difficult or impossible needle insertion, (2) difficult or impossible dilatation, (3) difficult or impossible cannula placement, and (4) difficult or impossible retraction of the DLET at the end of the procedure.

To evaluate gas exchange, we recorded arterial blood gases obtained before and after PDT. Before PDT refers to the baseline evaluation with the conventional ETT not yet withdrawn to the level of the vocal cords or to the DLET correctly positioned, and after tracheostomy refers to correct placement of the cannula as determined by FFB.

Ten minutes before tracheostomy, peak, plateau, and mean airway pressures, intrinsic positive end-expiratory pressure (PEEPi), MV, and Vt were recorded from three consecutive breaths. A similar series of three measurements were recorded during the procedure at tracheal puncture and at dilatation and after the procedure at cannula positioning.

Statistical Analysis

Data are reported as mean ± SD or proportions as appropriate. Normal distribution was evaluated with the Shapiro-Wilk normality test. Comparisons between groups and within groups were performed with one-way analysis of variance for continuous variables. Statistical significance was set at P < .05. SPSS version 20.0 software (IBM) was used for the statistical analyses. A statistical post hoc power analysis on observed effect with the probability level (α) set at .05 was performed to assess the power of this study.

We consecutively screened for possible inclusion into this study 176 patients suitable for elective PDT from February 2012 to February 2014. Ten of 94 patients requiring PDT met the criteria for eligibility in the DLET group. These patients were compared with 10 matched patients from the remaining 82 for the control group. Baseline characteristics and gas exchange data for DLET and control patients did not differ (Table 1).

Table Graphic Jump Location
TABLE 1 ]  Characteristics and Gas Exchange of Patients Enrolled in Each Group at Baseline

Data are presented as mean ± SD unless otherwise indicated. DLET = double-lumen endotracheal tube; ETT = endotracheal tube; GCS = Glasgow Coma Scale; pHa = arterial pH; SAPS = Simplified Acute Physiology Score.

PDTs were performed without difficulty in nine patients in the DLET group (level I). In one patient, PDT was performed from the needle insertion to cannula positioning with one or more difficulties not limiting the technique (level II). In this patient, the guidewire kinked. Kinking of the guidewire was resolved by a slightly upward retraction of the DLET. All procedures with the DLET were successfully completed without any requiring insertion of a conventional ETT. PDTs were performed without difficulties limiting the technique in all patients in the conventional ETT group (level I).

As shown in Figure 3 and e-Table 1, gas exchange before PDT did not differ between groups. After tracheostomy, arterial pH and Pao2 were significantly higher and Paco2 significantly lower in the DLET group than in the conventional ETT group.

Figure Jump LinkFigure 3 –  A-C, Gas exchange in the DLET and conventional ETT groups before and after the percutaneous dilatational tracheostomy procedure. The x-axis shows the timing (before and after) of the measurements. The y-axes show the arterial pH (A), PaO2 (B), and PaCO2 (C). *Statistically significant difference. ETT = endotracheal tube. See Figure 1 legend for expansion of other abbreviation.Grahic Jump Location

As shown in Figure 4 and e-Table 2, peak and mean airway pressures, MV, and Vt did not differ before PDT between groups, whereas plateau airway pressure significantly differed. During PDT, peak, plateau, and mean airway pressures and PEEPi were significantly lower in the DLET group compared with the conventional ETT group (Fig 4). MV and Vt were significantly higher after PDT in the DLET group than in the conventional ETT group. The duration of PDT was 15 ± 16 min in the DLET group and 11 ± 5 min in the conventional ETT group (P = .415). The power analysis performed on observed effect size of Pao2 and plateau airway pressure with an α level of .05 showed a power of 0.86 and 0.99.

Figure Jump LinkFigure 4 –  A-F, Airway pressures, minute volume, and tidal volume in the DLET and conventional ETT groups. The x-axis is the timing of the measurements. The y-axes report the Ppeak (A), Pplat (B), Pmean (C), PEEPi (D), minute volume (E), and tidal volume (F). *Statistically significant difference. PEEPi = intrinsic positive end-expiratory pressure; Pmean = mean airway pressure; Ppeak = peak airway pressure; Pplat = plateau airway pressure. See Figure 1 and 3 legends for expansion of other abbreviations.Grahic Jump Location

The main findings of this study are the following: (1) PDT with the DLET can be performed safely without difficulties limiting the technique and (2) during PDT, the use of the DLET resulted in more stable gas exchange, airway pressures, and ventilation than PDT with the conventional ETT. PDT is the procedure of choice in critically ill patients but is associated with major complications.6 According to a recent meta-analysis, intraprocedural complications occurred in 168 of 363 procedures, with an OR of 1.30.7 Bleeding was the most common intraprocedural complication (50 of 168).7 The incidence of death related to PDT is 0.17% mainly due to airway complication and vascular injuries.8 The greatest risk of fatality occurs during PDT, suggesting that the safety of this operative technique could still be improved.9 The use of an FFB during PDT is known to reduce bleeding8 by guiding each step of the procedure and identifying possible vascular compression of the trachea. On the other hand, the use of an FFB worsens the patient’s ventilation due to ETT obstruction and increases the risk of accidental extubation during withdrawal of the ETT to the vocal cords.3 The use of an LMA during PDT may overcome the problems of accidental extubation, but ventilation is still compromised.10,11 The use of the DLET in PDT avoids the risk of accidental extubation and inadequate ventilation with the presence of a distal cuff. Performing PDT with an FFB reduces possible vascular injuries, but when a vascular injury occurs, the presence of the DLET distal cuff protects the lung from aspirating blood, keeping ventilation stable. Furthermore, the DLET provides better protection of the posterior tracheal wall from puncture and other damage because of its lower channel.

The use of the DLET and FFB during PDT may add more safety to this procedure in terms of airway management and vascular complications. However, to perform the PDT with the DLET, patients need to be reintubated. In two recent surveys, it was reported that the ETT was replaced by 17% and 8% of respondents before PDT.5 Even when using an LMA, patients needed to be extubated. In our experience with the DLET, to safely reintubate patients, the patients should be preoxygenated with 100% oxygen and receive a neuromuscular blocking agent, and an airway tube exchanger should be used to allow ventilation in case of difficult tube positioning.12 In addition, a careful assessment for a difficult airway should occur, and a clear plan for reintubation is needed to ensure a successful intubation on the first attempt.12

Gas exchange with the DLET was not impaired by the tracheostomy procedure. In this case-control study, gas exchange in the DLET group remained stable without any variation in Pao2 and Paco2 levels, whereas in the conventional ETT group, the same parameters markedly varied with a trend toward respiratory acidosis and hypoventilation. These findings are consistent with the current literature where PDT performed with the conventional ETT plus FFB was associated with a decrease of Pao2 and arterial pH and an increase of Paco2 independent of the ventilation mode or settings used.1315 Similar findings have been reported when the PDT was performed with the LMA; Pao2 decreased and Paco2 increased in the LMA group similarly to the ETT plus FFB group despite the ventilating surface area being greater in the LMA group.3 During PDT, the insertion of the FFB reduces the ventilatory surface area of the ETT or LMA, causing a partial obstruction to inspiratory and expiratory flow, hypoxemia, and hypercapnia.16 As a result of this important impairment in gas exchange, physicians may be reluctant to perform PDT in patients with severe respiratory failure or needing high positive end-expiratory pressure.17 Surgical tracheostomy offers a more stable gas exchange than PDT, but it is associated with more bleeding, infection, mortality, and cost.16,18

DLET establishes more stable ventilation during tracheostomy by keeping ventilation separate from bronchoscopy guidance and protects the lung parenchyma with its distal cuff. The better ventilation obtained with the DLET may enable the use of PDT even in patients previously considered not suitable for this procedure.

In addition, respiratory airway pressure remained stable in the DLET group but increased during PDT in the conventional ETT group. Obstruction of the ETT by the bronchoscope was responsible for the increased resistance to airflow, requiring high airway pressure to deliver each Vt. However, peak airway pressure during bronchoscopy does not accurately reflect alveolar pressures.19,20

PEEPi during PDT with the DLET was lower than with a conventional ETT. Placing the FFB in the ETT limits expiratory flow, resulting in air trapping within the lung and consequently increased PEEPi.1921 In critically ill patients, PEEPi may have detrimental effects on the respiratory and cardiovascular systems.22,23 The use of the DLET avoided the development of PEEPi in these critically ill patients.

MV and Vt decreased more in the conventional ETT group than in the DLET group during PDT. Other studies have also documented a reduction in MV from 35% to 73% due to different ETT and FFB combinations during PDT.24,25 In the present study, the use of a 5-mm external diameter FFB decreased the MV by 40% in the conventional ETT group and only 19% in the DLET group, whereas the Vt was reduced 34% (ETT) and 7% (DLET). The reduction of MV and Vt in the DLET may be caused by (1) a minimal compression on the lower channel during dilatation and cannula positioning and (2) the elliptical shape of the lower DLET channel.

At this time, the commercial cost of the DLET has not been determined. We expect the cost of a DLET to be similar to a standard ETT or other double-lumen ETT. Using the DLET for PDT will add costs to the PDT procedure because reintubation with a new ETT is needed. However, the procedural safety added by the use of the DLET should easily offset any increased cost. As we have shown, the use of the DLET ensures better gas exchange and safer airway pressures and has the potential for reducing vascular injury and the aspiration consequences of vascular injury.

Limitations

This study has several limitations that need to be addressed. First, it is a prospective case-control not a randomized study. Second, the potential negative or limiting effects of the DLET should be further assessed with a larger cohort of patients to reach a power > 80%. Finally, a clear strategic plan and a careful evaluation of the airway are required before reintubation of critically ill patients with a DLET, even if the reintubation with a DLET is performed with an appropriate tube exchanger.

This study is a proof of concept that PDT with the DLET is feasible without major difficulties limiting the technique. DLET may also ensure better airway management, respiratory function, and patient comfort during PDT with greater safety than a conventional ETT. However, a randomized controlled clinical trial is needed to demonstrate that patient outcome is better following a PDT with the DLET than with a conventional ETT.

Author contributions: M. V. and G. S. had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. P. P. and R. M. K. contributed to the study design, data analysis and interpretation, and writing of the manuscript; G. T., F. A., I. B., E. A., and D. S. contributed to the data acquisition, data analysis and interpretation, and critical revision of the manuscript for important intellectual content; and M. V., P. P., G. T., F. A., I. B., E. A., D. S., R. M. K., and G. S. contributed to the final approval of the manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Drs Tessitore and Servillo hold a national patent (No. RM2011A000258) and an international patent (No. PCT/IT2012/000154–Orotracheal tube for Tracheostomy Procedure). Both patents have been licensed to DEAS SRL (Italy). Dr Kacmarek is a consultant for Covidien and has received an honorarium for a single lecture at the American Association for Respiratory Care annual meeting from MAQUET Holding BV & Co KG. Drs Vargas, Pelosi, Aloj, Brunetti, Arditi, and Salami have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: The authors thank DEAS SRL (Italy) for providing the double-lumen endotracheal tube.

Additional information: The e-Tables can be found in the Supplemental Materials section of the online article.

DLET

double-lumen endotracheal tube

ETT

endotracheal tube

FFB

flexible fiber-optic bronchoscope

GCS

Glasgow Coma Scale

LMA

laryngeal mask airway

MV

minute volume

PDT

percutaneous dilatational tracheostomy

PEEPi

intrinsic positive end-expiratory pressure

SAPS

Simplified Acute Physiology Score

Vt

tidal volume

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Figures

Figure Jump LinkFigure 1 –  Technical characteristics of the double-lumen endotracheal tube (DLET). The upper lumen at section A-A has an internal diameter of 9 mm (27F), whereas the lower lumen has an internal diameter of 7 or 7.5 mm (21F or 22F) according to the size of the lower channel. The two lumens at section A-A have an external diameter of 16.5 or 17 mm (49.5F or 51F) according to the size of the lower lumen. At the level of the vocal cords, the DLET has an external diameter of 8 mm (24F). At section B-B, the lower channel has an internal diameter of 7 or 7.5 mm (21F or 22F) according the size of lower channel. The DLET is 298 or 303 mm long according to the size of the lower channel.Grahic Jump Location
Figure Jump LinkFigure 2 –  A, The correct positioning of DLET after orotracheal intubation. The lower channel of DLET should be placed on the posterior tracheal wall with the asymmetric distal cuff at the level of the carina. During percutaneous dilatational tracheostomy, the DLET should be kept in the middle of the mouth. B, Needle insertion. C, Dilatational step. D, Cannula placement with DLET. See Figure 1 legend for expansion of abbreviation.Grahic Jump Location
Figure Jump LinkFigure 3 –  A-C, Gas exchange in the DLET and conventional ETT groups before and after the percutaneous dilatational tracheostomy procedure. The x-axis shows the timing (before and after) of the measurements. The y-axes show the arterial pH (A), PaO2 (B), and PaCO2 (C). *Statistically significant difference. ETT = endotracheal tube. See Figure 1 legend for expansion of other abbreviation.Grahic Jump Location
Figure Jump LinkFigure 4 –  A-F, Airway pressures, minute volume, and tidal volume in the DLET and conventional ETT groups. The x-axis is the timing of the measurements. The y-axes report the Ppeak (A), Pplat (B), Pmean (C), PEEPi (D), minute volume (E), and tidal volume (F). *Statistically significant difference. PEEPi = intrinsic positive end-expiratory pressure; Pmean = mean airway pressure; Ppeak = peak airway pressure; Pplat = plateau airway pressure. See Figure 1 and 3 legends for expansion of other abbreviations.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Characteristics and Gas Exchange of Patients Enrolled in Each Group at Baseline

Data are presented as mean ± SD unless otherwise indicated. DLET = double-lumen endotracheal tube; ETT = endotracheal tube; GCS = Glasgow Coma Scale; pHa = arterial pH; SAPS = Simplified Acute Physiology Score.

References

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