RU2145883C1 - Method for intraoperationally sanifying tracheobronchial tree - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves applying intubation with endotracheobronchial tube. The left and right regions of the tracheobronchial tree are separated by means of inflatable cuffs. The regions are sanified by periodically sucking-off pathologic contents by means of catheter or fibrobronchoscope unit introduced through intubation tube. The upper dead space built by rima glottides in cranial position, by tracheal cuff in caudal way, with trachea walls and walls of the tube placed inside of it is additionally sanified. The inferior dead space built by tracheal cuff in cranial position, by bronchial cuff in caudal way and by suprabifurcation trachea segment walls, initial segments of the right and left main bronchi and walls of the tube laterally placed inside is also sanified. Fibrobronchoscope is used for sanifying the tracheobronchial tree, that is introduced into the trachea through the rima glottides in parallel to the intubation tube and/or through corresponding intersected bronchus stump from the side of pleural cavity. EFFECT: reduced risk of bronchopulmonary complications and lethal outcomes in intra- and postoperative period. 4 dwg

Description

 The invention relates to medicine, namely to thoracic surgery.

 Thoracic surgery, as a rule, is performed under general anesthesia with mechanical ventilation (mechanical ventilation). This involves endotracheal or endobronchial intubation with a special tube, which, depending on the specific clinical and surgical situation, can have 1 or 2 working channels, corresponding to or more inflatable cuffs (tracheal and bronchial obturators). Regardless of the model, design, and manufacturer, all orotracheal single-channel endotracheal tubes, by our definition, have an upper “dead” space, and orotracheobronchial 1- and 2-channel endotracheal tubes, in addition to the upper one, have a lower “dead” space.

 The upper “dead” space is formed by the cranial glottis, the tracheal inflatable cuff caudally, the tracheal walls and the walls of the tube enclosed in it laterally (Fig. 1).

 The lower “dead” space is formed by the cranial tracheal cuff, the caudal bronchial cuff, the walls of the bifurcation of the trachea, the initial sections of the right and left main bronchi and the walls of the tube enclosed in them laterally (Fig. 2).

 In connection with the presence of these “dead” spaces, the problem arises of the complete removal of the pathological contents of the nasopharynx and stomach, pus, sputum, blood, which inevitably accumulate in more or less in them during the execution of a thoracic operation.

 The most difficult problem is the provision of an adequate and effective mechanical ventilation, prevention of aspiration of the contents of the nasopharynx and stomach, infected sputum, pus, pleural exudate, blood into healthy sections of the ipsi and contralateral lung, prevention of the development of obstruction of the tracheobronchial tree (TBD) and asphyxiation during surgery , as well as atelectasis, aspiration pneumonia and Mendelssohn syndrome in the early postoperative period, are patients with a thoracic profile. Statistics indicate the highest incidence of these complications in patients who underwent emergency, urgent and planned surgical interventions for health reasons if they have a large amount of purulent sputum (caseous pneumonia, abscess and lung gangrene, pyopneumothorax and the like), ongoing massive pulmonary bleeding , as well as pleural empyema with bronchopleural fistula (fistula) of significant diameter and a large amount of purulent exudate in the empyema cavity [U. Mashin "Anesthesia for intrathoracic operations". Moscow, "Medicine", 1967, pp. 144-160; LK Bogush, A. A. Travin, Yu. L. Semenenkov "Operations on the main bronchi through the pericardial cavity", Moscow, "Medicine", 1972, pp. 132-138; A.L. Kostyuchenko, G.A. Livanov. V.T. Pleshakov, M.Ya. Matusevich, O.I. Zhukov "Ensuring the safety of operations for diseases of the lungs and pleura" in the book "Surgery of the lungs and pleura", Leningrad, "Medicine", 1988, pp. 335-339 ].

 The method of intraoperative rehabilitation of the tracheobronchial tree during thoracic surgery with artificial ventilation of the lungs is widely known, including sealing and isolation of the pulmonary tube and lung tissue by intubation of the trachea with a single-channel tube with an inflated cuff. Additional isolation of the LDP from the nasopharynx, esophagus and stomach is carried out by tamponade with a gauze swab of the pharynx and larynx in order to prevent the saliva, food masses and gastric juice from flowing into the trachea through the glottis near the endotracheal tube (Figs. 1 and 3). Sanitation and removal of the contents of the oral cavity, pharynx, and larynx are performed at the end of the operation before extubation with a tuffer or by aspiration with a catheter. The contents of the tracheobronchial tree is also removed by aspiration through an endotracheal tube using a catheter [G.P. Kubryakov "The use of antihistamines in surgery" in the book "Questions of anesthesiology and operative pathophysiology", Moscow, 1959, pp. 91-103; N. M. Sadykov, GP Kubryakov "The technique of intubation during operations in the chest cavity", ibid., Pp. 148-167].

However, this method has inherent serious disadvantages, especially negatively affecting cases of thoracic surgery, namely:
tamponade, including tight, pharynx and larynx with a gauze swab, does not solve the problem of reliable isolation of the upper "dead" space, since the contents of the nasopharynx, impregnating the gauze swab, naturally penetrate it near the endotracheal tube through the glottis, and then inevitably flows into the pulmonary tube and lung tissue after opening the cuff before removing the endotracheal tube (Fig. 3). A preventive installation into this space through the glottis of the permanent catheter for regular suction of its contents during the operation, as recommended by a number of previously cited authors, does not solve the problem, but rather aggravates it, as it facilitates the flow of the contents of the nasopharynx and stomach through the glottis between endotracheal tube and no less rigid catheter;
tamponade of the pharynx and larynx with a gauze swab quite firmly fixes the endotracheal tube, which makes it difficult to manipulate it (turns and displacement along the longitudinal axis), which are often extremely necessary in the process of performing thoracic operations;
intubation with a single-channel endotracheal tube, partially solving the problem of isolation of TBD from the nasopharynx and stomach, is not able to completely solve the problem of protecting (isolating) the healthy sections of the ipsi and contralateral lung in the presence of a large number of pathological contents coming from pathological pleuropulmonary cavities.

 The stated shortcomings of endotracheal intubation led to the development and use of a wide variety of single and two-channel tracheobronchial tubes, designed to simultaneously solve the problem of protecting and isolating the TBD from the nasopharynx, esophagus and stomach, as well as the reliable separation of the right and left sections of the TBD and the implementation of one-lung or intermittent mechanical ventilation, which became an independent section of thoracic anesthesiology. In this case, the Carlens tube was most widely used (Fig. 2).

 There is a method of intraoperative rehabilitation of TBD during thoracic operations with artificial ventilation of the lungs by conducting, as necessary, through the appropriate working channel of a two-channel orotracheobronchial Carlens intubation tube (Fig. 2), a special catheter or fibrobronchoscope and removing the pathological contents of the TBD by aspiration [G.P. Kubryakov "Issues of anesthesiology and operational pathophysiology", Moscow, 1959, pp. 168-177].

However, this method of rehabilitation of the LDP does not allow:
remove the pathological contents that inevitably appear in the upper and lower "dead" spaces even if a high vacuum is created in the aspiration system connected to the catheter or fibrobronchoscope;
to evacuate a pathological secret from lung tissue that quickly and naturally gets there by virtue of pushing distally through the bronchi by the air-gas wave of the ventilator.

 As the closest analogue, the method of intraoperative rehabilitation of LDP during thoracic surgery with mechanical ventilation was adopted (A. S. N 1289503, class MKI A 61 M 16/00; 1987). The authors of this invention used their own design of an orotracheobronchial tube of the Gebaurer type, but with a mobile internal membrane and 4 inflatable cuffs that allow one-lung artificial ventilation, block, isolate and sanitize the right and left sections of the LDP.

 Sanitation of LDP is carried out through an endotracheal tube using a catheter connected to an aspiration system (suction). At the same time, a distinctive feature and advantage of the tube is the creation of the necessary tightness - separation of the inner space of the tube from the tube due to tight gripping of the catheter by the bronchial cuff inside the tube.

 The remaining techniques are not different from the well-known.

 Compared with well-known and close analogues (Carlens, Kubryakov, Kiprensky, Macintosh-Literal, Brits-Smith-Salt, Gordon-Green, White, and many others), the tube design proposed by the authors more reliably prevents leakage of the pathological contents of the operated lung into the contralateral and it is more effective to remove the pathological contents of the LDP using a catheter.

 However, a certain positive effect of the tube by N.S. Prikhodko and co-authors is achieved due to a significant complication of its design, and therefore, is accompanied by difficulties in its industrial production and serial production, which impedes its clinical operation in a wide range of practical institutions.

 In addition, the correct installation of the tube in the LDP is difficult to perform, and the tube itself allows only one-lung ventilation. Due to the presence of 4 inflatable cuffs, working with the tube during the operation and mechanical ventilation requires constant attention and control, and the unexpected displacement of the tube in the tube, the rupture of one of the cuffs or the membrane that divides the tube into two working channels, can create a critical and even life-threatening situation, since in these cases it acquires the characteristics of a single-channel orotracheobronchial tube with two holes. Thus, this tube only partially solves the problem of sanitation of the dead spaces of the LDP.

 Therefore, all the problems that arise when using endotracheal orotracheal and orotracheobronchial tubes are preserved, all known methods for rehabilitation of the LDP are required, but which, unfortunately, do not allow the contents of the upper and lower "dead" spaces to be evacuated.

 Thus, the further development, implementation and clinical testing in practice of all new models and types of endotracheal tubes from more advanced, including thermoplastic materials, could not completely solve the problem of reliable, easily achievable separation of the right and left sections of the LDP and its rehabilitation, and therefore , intra- and postoperative complications, including life-threatening and death-causing patients. This is due to the fact that regardless of the type, design, model, and manufacturing tube of the company, there always arise upper or lower “dead” spaces, the evacuation of the pathological contents of which is impossible by all known methods, including fibrobronchoscopy, since their fundamental principle (concept) of tube construction is not has changed. Therefore, there are no effective ways to rehabilitate these spaces, which does not allow to protect both the thoracic operation and mechanical ventilation, and to prevent the development of dangerous intra- and early postoperative complications in an extremely severe group of patients with respiratory pathology who receive surgery with the separation of a large amount of purulent sputum , exudate and especially blood in TBD from pleuropulmonary cavities.

 The objective of the invention is the creation of a simpler, affordable, reliable, safe and effective method for intraoperative rehabilitation of LDP during thoracic surgery with mechanical ventilation through all known and found practical application of endotracheal tubes, which reduces the frequency and severity of the development of intra- and postoperative bronchopulmonary complications and the lethal complications caused by them outcomes.

 The essence of the invention lies in the fact that in the method of intraoperative rehabilitation of the tracheobronchial tree during thoracic surgery with artificial lung ventilation, including endotracheal intubation with the achievement of sealing the tracheobronchial tree, isolating it from the larynx and pharynx, separating its right and left departments using inflatable cuffs and subsequent reorganization of these departments by regular suction of pathological contents using a catheter or fibrobronchoscope conducted through an intub the tube, additionally carry out the sanitation of the upper "dead" space formed by the glottis cranially, the tracheal cuff caudally, the walls of the trachea and the walls of the tube enclosed in it laterally and the lower "dead" space formed by the tracheal cuff cranially, the bronchial cuff caudally, the walls of the bifurcation section of the trachea , the initial sections of the right and left main bronchi and the walls of the tube enclosed in them using a fibrobronchoscope, which is carried out into the trachea through the voices a slit parallel to the endotracheal tube and / or through the stump of the corresponding crossed bronchus from the pleural cavity, moving it into the bifurcation of the trachea with the consecutive opening of the cuffs until the pathological contents are completely removed.

Using the invention allows to obtain the following technical result:
to simplify the choice of the optimal design of the endotracheal tube and its diameter in each case of congenital and acquired pathology of the respiratory system, mediastinum and diaphragm;
to increase the number of cases of the use of single-channel endotracheal tubes N 9, 10 and 11, characterized by a simpler technique of insertion and fixation in the tube, passing through them a catheter and a fiber bronchoscope;
to increase the efficiency of the rehabilitation of the tracheobronchial tree during and at the end of a thoracic operation in patients with respiratory tract pathology that secrete a significant amount of infected sputum, pus, pleural exudate or blood through the use of catheters and fibrobronchoscopes with a large working channel diameter;
to completely exclude intra- and postoperative leakage into the healthy sections of the right and left lung of the pathological contents of the tracheobronchial tree enclosed in “dead” spaces bounded by the cranial glottis, caudally tracheal cuff of the endotracheal tube, and also between the tracheal and bronchial cuffs, which was previously unattainable;
to effectively prevent massive obstruction of the bronchi during thoracic surgery, leading to asphyxiation, and in the postoperative period to atelectasis and pneumonia of the ipsi and / or / contralateral lung;
to improve the results of surgical treatment of patients with respiratory diseases, belonging to the most complex and difficult group, characterized by the presence of vital indications for performing operations, including in an emergency and urgent manner, by reducing the number and severity of pleuropulmonary intra- and postoperative complications.

 In the process of performing urgent and urgent surgical interventions, their anesthetic and endoscopic support, especially in urgent situations in patients with pulmonary and pulmonary pleural bleeding caused by gangrene, caseous pneumonia, fibrocavernous tuberculosis or lung cancer, the detection of significant blood volume was established, pus or sputum in the TBD of the operated and / or / contralateral lung at the end of the operation, at the time of removal of the endotracheal tube, including endoscopy scopic control using fibreoptic bronchoscope and subject of careful and regular readjustment during LDP execute the surgery. The discovered facts convinced that the pathological contents in the TBD, primarily liquid blood and its clots, appeared in the operated and / or / contralateral lung after the tracheal and / or / bronchial cuffs were opened. Therefore, during the operation, the pathological contents accumulated in the “dead” spaces and were not evacuated using standard and generally accepted methods for its removal. Patients were also identified who suddenly developed acute or sharply aggravated initial pulmonary heart failure immediately after the operation, or in the first 3-5 days after it, and during treatment and diagnostic tracheobronchoscopy in the postoperative period, blood or purulent sputum was found in the contralateral lung, and which before and during the operation in the contralateral lung were not detected. In addition, a number of patients were diagnosed with postoperative pneumonia, including a single lung, which required long-term mechanical ventilation through a tracheostomy. It was concluded that the cause of pneumonia was the aspiration of the contents of the “dead” spaces by the patient during the execution or at the end of the surgical intervention at the time of preparation and implementation of the extubation of the patient.

 Thus, a causal relationship was established between the pathological contents of the upper and lower "dead" spaces of the TBD and the development of intra- and postoperative bronchopulmonary complications due to the lack of adequate sanitation of these "dead" spaces by known and generally accepted anesthetic and bronchoscopic methods.

 The foregoing served as a justification for the development of a new method for the rehabilitation of the tracheobronchial tree and the prevention of life-threatening bronchopulmonary postoperative complications when performing thoracic operations under general anesthesia with mechanical ventilation through various designs of endotracheal tubes.

 The method is as follows.

 When performing an emergency, urgent, or planned thoracic operation under general anesthesia using mechanical ventilation, the indicated endotracheal or endobronchial intubation is performed with a single or double channel tube, while achieving complete sealing of the LDP and separation of its right and left sections using inflatable cuffs.

 In the process of performing a surgical intervention, regular rehabilitation of the LDP is carried out by aspirating its contents (sputum, pus, exudate or blood) using a special catheter or fibrobronchoscope. The multiplicity of manipulations depends on the amount of LDP contents, the position of the patient on the operating table, the nature and extent of the surgical intervention performed, and other factors. At the same time, they constantly monitor the tightness of the cuffs, the correct installation and fixation of the endotracheal tube in the tube, the completeness of separation of its right and left sections.

 Most often, the filling of "dead" spaces with pathological contents occurs with the lateral and abdominal position of the patient and the head end of the operating table lowered; the technical complexity of the initial intubation and the optimal installation of the endotracheal tube in the tube; prolonged surgical manipulations on the trachea, main bronchi, mediastinum, significant lateral tractions of the operated lung; performing an operation against the background of ongoing massive pulmonary hemorrhage, intraoperative breakthrough of an echinococcal cyst, abscess, empyema cavity in TBD; performing operations such as pleurectomy, extrapleural pneumolysis, pleural empyema fenestration, thoracoplasty, pneumotomy, a number of economical lung resections using mechanical staplers without separate processing of root elements, operations on the esophagus and other organs of the mediastinum. With the above surgical interventions using well-known techniques, the possibility of monitoring and debridement of the upper "dead" space formed by the cranial glottis, caudal tracheal cuff, the tracheal walls and the walls of the tube enclosed in it laterally, and the lower "dead" space formed by the tracheal cuff was completely excluded cranial, bronchial cuff caudally, the walls of the bifurcation of the trachea, the initial sections of the right and left main bronchi and the walls encapsulated therein pipe laterally from the pleural cavity or dissected through mediastinal intersected bronchial stump, as a technique and equipment for performing these operations does not include the intersection of major bronchi.

 The protection of TBD and its most effective rehabilitation at all stages of surgical intervention against the backdrop of the specific clinical situations listed above is especially complicated with one-lung mechanical ventilation throughout the operation, with the forced use of a single-channel endotracheal tube with one cuff located in the right or left main bronchus. This is due to the fact that the volume of the upper "dead" space increases significantly not only due to the trachea and ipsilateral main bronchus, but also due to the bronchial tree of the contralateral lung. The latter is observed with the frequent use of a standard single-channel endotracheal tube with one cuff as an endobronchial tube during a pulmonectomy operation for a destroyed lung, caseous pneumonia, gangrene, central cancer with atelectasis of the entire lung and a number of other operations, which, unfortunately, continues to be used in practice.

Given all of the above, as well as the specific type and design of the endotracheal tube selected for the implementation of mechanical ventilation, the protection of the TBD, the reorganization of the “dead” spaces, both current and final, providing prophylaxis for the development of intra- and postoperative complications, is carried out as follows:
1) when performing surgical interventions that are not accompanied by technical manipulations on large (segmental, lobar or main) bronchi, which could allow a catheter or a fibrobronchoscope to be inserted through the bronchus stump to sanitize the upper and lower "dead" spaces, it is performed by performing fibrobronchoscopy through the glottis next to and in parallel with the endotracheal tube, without changing the position of the tube itself in the tube. After passing through the vocal cords with a fibrobronchoscope and examining the upper "dead" spaces, it is thoroughly sanitized by suctioning the contents through the working channel of the fibrobronchoscope under visual control. After this, the tracheal cuff is opened (in the presence of 2 or more cuffs) and the contents of the lower "dead" space, and if necessary, the LDP of the right and left lungs, are carefully evacuated as well. Remediation of the upper and lower "dead" spaces is completed by sequential inflation of cuffs and measures to prepare the patient for extubation;
2) when performing operations involving the intersection of a large bronchus (segmental, lobar or main), when performing operations of resections of the lungs and pulmonectomy, as well as tracheobronchoplasty operations before the stage of suturing the bronchus stump, applying a tracheobronchial or interbronchial anastomosis, a fibrobronchoscope is inserted directly through the crossed bronchus or trachea after examining the relevant sections of the tracheobronchial tree, the lower dead space is reorganized without dissolving ealnuyu cuff. Then slowly and incompletely dissolve the tracheal cuff with the simultaneous suction of the contents of the upper "dead" space. If it contains thick, viscous contents, including blood clots, the tracheal cuff is completely dissolved, they enter the upper “dead” space with a fibrobronchoscope and, under the control of vision, it is completely and completely rehabilitated, followed by extraction of the bronchoscope from the TBD. Once again, the tracheal and bronchial cuffs are inflated, the operation is completed according to generally accepted rules;
3) in difficult clinical situations, especially when performing operations against a background of ongoing or increasing in intensity pulmonary hemorrhage, the 1st and 2nd options for rehabilitation of the TBD at the individual stages of the surgical intervention and after it are combined are combined. The sequence of application of the 1st and 2nd options is determined by the specific prevailing clinical situation during surgery.

 The method has passed clinical trials when performing emergency and planned thoracic operations in patients with caseous pneumonia, fibrocavernous tuberculosis, pleural empyema with bronchopleural fistula, lung cancer. Most often, with these pathologies, the method is used when performing emergency operations against the background of ongoing or increasing in its intensity pulmonary hemorrhage according to vital indications in an urgent situation with a limited amount and time of preoperative examination and preparation of the patient for surgery.

 Example. Patient D-va A.A., 33 years old, medical history number 266, was treated at TKB No. 7 of the KZ of Moscow from 01/28/97 to 02/19/97.

 Delivered by ambulance from home with a diagnosis of Pulmonary Tuberculosis. Hemoptysis. She has been sick with tuberculosis for more than a year and has practically not been treated. Pulmonary hemorrhage (LC) recurred within 2 months, which was the reason for the patient's arrival in Moscow. The last episode of LA developed 20 hours before hospitalization and was accompanied by intense hemoptysis.

 In the hospital admission department, the patient coughed up about 100 ml of sputum mucus with a plentiful admixture of blood in two hours. In the thoracic department, complex hemostatic therapy was prescribed, including artificial hypotension by Pentamin. Against this background, pulmonary hemorrhage was wavy, false-recurring in nature with periods of cessation of hemoptysis and its resumption when the systolic blood pressure rose to 115-135 mm Hg. In primary fibrobronchoscopy, the side and localization of the source of pulmonary hemorrhage could not be established. On radiographs, against the background of poorly defined polymorphic focal shadows in C1-C5 and C6 of the left lung, distinct signs of hypoventilation C6-C10 with a shift of the mediastinum to the indicated side were determined. In the morning of 02/03/97, despite constantly maintained hypotension with blood pressure of 95/60, the intensity of hemoptysis increased again. An anesthetic stiff tracheobronchoscopy on the operating table revealed an intense flow of red blood from the left main bronchus. After aspiration of liquid blood and clots, it was found that the source of bleeding is localized in the lower lobe. A detailed examination of the TBD is not possible due to the continuous flow of fresh blood. After installing a foam rubber obturator in the lower lobe bronchus with obstruction of the C6 bronchus, blood flow to the TBD completely stopped.

 A growing variant of pulmonary hemorrhage with the threat of transition to asphyxia was diagnosed. Given the presence of life-threatening pulmonary hemorrhage, clinical, radiological, and endoscopic signs of total hemobstruction and hemoaspiration of the lower lobe of the left lung, the ineffectiveness of hemostatic therapy, the threat of developing asphyxiation and hemoaspiration pneumonia, it was decided to urgently remove the lower lobe from the antero-lateral intercostal costus according to vital signs .

 Intubation with a double-lumen orotracheobronchial right tube passed without technical features. After thoracotomy, during lung revision, it was found that the lower lobe was significantly reduced in volume, purple-cyanotic color, dense consistency, contains a tuberous formation in the root up to 4 cm in diameter, clutch-like covering the lower lobar bronchus distal to the discharge of bronchus C6. In C1-C2 and C6, small, dense caseous lesions. Lower lobectomy started. After isolation and intersection of the inferior pulmonary vein using the UKSN-25 apparatus, an increase in blood flow through the left channel of the endotracheal tube was noted. Endoscopically confirmed ongoing pulmonary hemorrhage through a foam bronchial obturator and next to it an increasing threat of asphyxiation on the operating table was determined. In an emergency, a UO-60 stapler was placed on the root of the lower lobe, the last cut off and removed. An intraoperative study of a macrodrug revealed a solid structure of a mixed-growth tumor emanating from the bronchus of the basal segments, as well as C6-C10 blood apoplexy. Thorough aspiration of blood from TBD. Fibrobronchoscopy without extubation of the patient. A bronchoscope was placed next to the endotracheal tube through the glottis. Removed a small amount of mucous contents from the upper "dead" space. The tracheal cuff is dissolved, after which liquid blood and clots are immediately detected in the lower "dead" space. Held aspiration. A bronchoscope was placed in the superbifurcation section of the trachea. Clots from the left main bronchus, as well as a small amount of liquid blood from the right sections of the tracheobronchial tree, were removed. Fibrobronchoscope removed. The tracheal cuff is again inflated. The bronchial cuff did not open. The operation is completed. The patient was extubated and re-performed a rigid bronchoscopy with final rehabilitation and examination of the LDP.

 The postoperative period was uneventful. Discharged with a recommendation to continue therapy in a tuberculosis institution, medical examination by an oncologist.

 Histological conclusion: highly differentiated epidermoid cancer (carcinod) of the lower lobe bronchus, bronchiectasis, focal tuberculosis in the infiltration phase, VK "-".

Claims (1)

 The method of intraoperative sanitation of the tracheobronchial tree during thoracic surgery with mechanical ventilation, including intubation of the endotracheobronchial tube with the achievement of sealing the tracheobronchial tree, separation of its right and left departments using inflatable cuffs and subsequent sanitation of these departments by regularly aspirating the pathological contents with the help of a catheter conducted through an endotracheal tube, characterized in that it further there is a reorganization of the upper "dead" space formed by the cranial vocal glottis, caudally tracheal cuff, the tracheal walls and the walls of the tube enclosed in it laterally, and the lower "dead" space formed by the cranial tracheal cuff, caudally bronchial cuff, the walls of the bifurcation of the trachea, the initial sections of the right and the left main bronchi and the walls of the tube enclosed in them laterally, using a fibrobronchoscope, which is carried out into the trachea through the glottis parallel to the intubation constant tube and / or through the respective stump bronchus dissected from the pleural cavity by advancing it to the carina with a serial blooming cuff to completely remove pathological content.

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