1. EZ-Blocker ® Jan. 2010

2. EZ-Blocker ®  A bronchoscope is mandatory  Bronchoscopic control for all in-, and deflations

3. EZ-Blocker ®  ETT Endotracheal tube  EZB EZ-Blocker ®  DLT Double Lumen Tube  MPA Multiport Adaptor

4. Preparations

5.  Sterile cloth  ETT  Lubricant  Syringe  Marker  EZ-Blocker ® set  EZB  Multiport Adaptor  Closing caps  CPAP connection piece

6. Preparations  Inspect for damage  Remove protection shaft of the EZB carefully by pulling the label at the top of the shaft Fix 2 blue closing caps on CPAP ports  Inflate cuffs to check for leakage  Deflate completely  vacuum  Lubricate

7. Preparations (*)

8. Preparations  Compare the lengths of EZB with ETT plus MPA, place mark on the proximal shaft or remember distance in cm’s  The EZB should wedge on the carina within 8 cm from this mark (*). 4 cm towards the carina and 4 cm to wedge upon the carina

9. Intubation

10.  ETT cuff directly behind the vocal cords  ETT tip to carina at least 4 cm  Connect MPA to ETT and start ventilating through MPA Approx. 100% O 2

11. Intubation Distal end ETT 4 cm Carina EZB extensions need 4 cm to spread before wedging the carina

12. EZB placement (*)

13. EZB placement  First action after intubation  Check by bronchoscope for abnormalities in anatomy  Confirm: depth of ETT (4 cm to carina)  Insert EZB through MPA  Check under vision closing main stem bronchus and/or RUL -> if necessary manipulate cuff in right position

14. EZB placement  Fiberscopic inspection of cuffs  Inflate the cuff in the target bronchus until Minimum Occlusive Volume (MOV) has been reached  Deflate the cuff  vacuum

18. EZB Procedure lung collapse  Ventilate with deflated cuffs. Approx. 100% O 2  Position the patient  Disconnect ventilation from MPA as soon as the surgeon enters the thoracic cavity  Lung will collapse

19. EZB Procedure lung collapse  If needed, the surgeon manipulates the lung to the size of his desire  After successful collapse, the cuff is inflated under vision, start One Lung Ventilation  Through resorption lung collapse will improve  If collapsed lung starts ventilating again, deflate cuff and disconnect ventilation -> re-collapse!  When lung has the right size -> re-inflate cuff and restart ventilation -> Always check with scope!

20. EZB removal  End of operation  deflate cuff. Vacuum!  Ventilate carefully to remove all atelectases  Block the other lung for bi-lateral procedure, or remove the EZB  The same ETT is used postoperatively

21. Essentials

22.  ETT cuff must be introduced directly behind the vocal cords

23. Essentials  First action after intubation  Bronchoscopy  Confirm: Depth of ETT (4 cm from carina) and location of right upper lobe  If a cuff is not inflated, it should be deflated completely (vacuum)  Both cuffs should never be inflated at the same time  †

24. Essentials  After the EZB extends from the ETT, the EZB will wedge on the carina within ± 8 cm  After wedging the EZB on the carina, the ETT may be advanced a few cm for even more stability  No wedge?  Both extensions situated in the same bronchus  Check with scope, retry and/or withdraw ETT for a few cm to provide space for spreading

25. Essentials ALWAYS withdraw your scope first After that remove the EZ-Blocker NEVER withdraw the EZ-Blocker first

26. Essentials  Deflate cuffs completely (vacuum)  Carefully ventilate until all atelectases are gone  PEEP is needed before wound closure  Check lung expansion  Remove Bronchoscope first, then the EZB  Never jet-ventilate a patient with a EZB in place -> The lung could be damaged