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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Case Series
Full Version
Effective Troubleshooting of EZ-BlockerTM Endobronchial Blocker Insertion in Minimally Invasive CABG Surgery: A Case Series
Correspondence Address :
Arupratan Maiti,
665, Madurdaha, Jeet Tapoban Complex, Block D, Flat J6, Kolkata-700107, West Bengal, India.
E-mail: arupratanmaiti2018@gmail.com
EZ-BlockerTM is a specially designed semi-rigid Y-shaped Bronchial Blocker (BB) containing two inflatable cuffs. The difficulties and challenges encountered while inserting the Rusch EZ-BlockerTM (Teleflex Life Sciences Ltd., Athlone, Ireland) for isolating the left lung in Minimally Invasive Coronary Artery Bypass Graft (MICS CABG) surgery are numerous and varied. The present case series describes 28 different patients (out of 102 patients with attempted EZ-BlockerTM) who faced various difficulties and technical problems while introducing the EZ-BlockerTM and how troubleshooting was performed in those cases with different manoeuvres. The difficulties in inserting the EZ-BlockerTM were due to a variety of reasons such as inadequate space between the carina and bronchus, a prominent right main bronchus at an acute angle compared to the obtuse angle of the left main bronchus, a compressed left main bronchus, deviation of the airway and a deep posterior bronchus. The manoeuvres used to overcome these challenges included controlled pulling of the endotracheal tube upwards, rotation of the head to the right-side with or without direct tracheal manual compression to the right-side, manual widening of the distal Y end of the EZ-BlockerTM and extension of the head in selected cases. Out of 102 attempted cases of EZ-BlockerTM , difficulty (insertion time >90 seconds) was noted in 28 cases, which were managed with the different clinical manoeuvres mentioned above. However, in four other cases, the EZ-BlockerTM could not be introduced and the attempts failed. Although the EZ-BlockerTM is a safe and easy alternative to the Double Lumen Tube (DLT), it has not been widely used in India to date. The proposed manoeuvres will surely help clinicians use it more efficiently in cases where they encounter difficulty during insertion.
Coronary artery bypass graft, Clinical Manoeuvres, Difficult insertion, Lung isolation
In MICS CABG surgery, it’s mandatory to isolate the left lung for a left anterior thoracotomy. This can be achieved by using either a left DLT or a BB. Both DLT and BB have different pros and cons (1),(2). Sometimes, correct placement of a DLT may be technically difficult and bear additional risk of trauma to the trachea and the bronchi (3),(4). EZ-BlockerTM are relatively new in India and only a few centres use them. Apart from this, other blockers available are single-cuff endobronchial blockers (for example, COOPDECH™, Diaken Medical Company Ltd., Japan and the Arndt™ blocker, Cook Medical Inc., Bloomington, IN, USA, etc.). All BBs are placed under direct vision using a Fibreoptic Bronchoscope (FOB). The EZ-Blocker is a semi-rigid endobronchial blocker made of polyurethane. It is 7-French in outer diameter and 75 cm long. It has four lumens and is Y-shaped (Table/Fig 1). This blocker has two different coloured (blue and yellow) 4 cm long symmetrical distal extensions (Table/Fig 2),(Table/Fig 3). Both have an inflatable cuff and a small central lumen and a pressure line connected to the external blue and yellow-coloured balloons. Two proximal colour-coded balloons of the blocker serve to inflate or deflate the cuffs. Two additional lumens at the distal end are used for suction or oxygen insufflation into the non dependent lung. The EZ-BlockerTM is supplied with a multiport adaptor. This adaptor connects to the ventilator end of a single lumen tube (minimum diameter 7 mm) and also allows the introduction of a FOB or a suction catheter. The right deployment of the Y-shaped distal part usually needs a minimum of 4 cm distance from the distal end of the single lumen tube and the carina. The Y-shape helps the device to anchor onto the carina. Therefore, the EZ-BlockerTM poses less chance of secondary malposition compared to other blockers (5),(6). Usually, the EZ-BlockerTM is considered a user-friendly blocker for easy one-lung ventilation (7),(8),(9). Although the average time taken for a BB insertion was reported to be as high as 4-6 minutes (8), Vegh T et al., in a study concluded that the mean time for the placement of the EZ-BlockerTM was 76±15 seconds (10). Based on this study by Vegh T et al., in this reported case series, difficult insertion has been taken as >90 seconds as the mean time of placement was 76±15 seconds in their study (10). The EZ-BlockerTM is a relatively new blocker available in India. The manoeuvres described below come from our wide clinical practice as it has been used in a large number of cases. It has not been described in the literature before, but these are really effective ways to manage difficult cases.
In a one and a half-year time duration, 102 EZ-BlockerTM placements were attempted for MICS CABG surgery. An 8-8.5 size endotracheal tube for male patients and a 7-7.5 size endotracheal tube for females were used. After the insertion of a single-lumen tube, a check with fibreoptic bronchoscopy was done to approximately get an idea about the distance between the tube end and the carina. This distance should ideally be more than 4 cm for easy opening of EZ distal cuffs. The length of fixation of the single tube was changed if necessary by bronchoscopy. As preparation for EZ-BlockerTM insertion, two pilot balloon cuffs were inflated and checked for air leaks before insertion. A silicone gel spray was applied to the distal ends for smooth insertion. After the induction of general anaesthesia and endotracheal intubation with a single-lumen tube, the EZ-BlockerTM was introduced through the multiport adaptor until it reached and straddled at the carina. For adequate cuff seal, the authors used 8-10 mL of air under FOB (3.8 mm, Pentax EB-1170K, Breda, The Netherlands) guidance. The time from insertion of the EZ-BlockerTM through the multiport adaptor to the final check of its proper position by fibreoptic bronchoscopy was recorded. In most cases, the EZ-BlockerTM reached the correct position smoothly in less than 90 seconds. The term ‘difficult’ was used when the operator failed to place the EZ-BlockerTM correctly in less than 90 seconds. This is based on the study conducted by Veg T et al., who showed that the mean time to insert the EZ-BlockerTM was 76±15 seconds. Different clinical manoeuvres were applied when it was found to be difficult (unable to place in less than 90 seconds). All the blockades were performed by the same anaesthetist with more than 10 years of experience in cardiac anaesthesia.
Out of the 102 attempted cases of EZ-BlockerTM , 28 cases were found to be difficult (insertion time more than 90 seconds) and challenging and different manoeuvres were applied to facilitate quick and successful positioning of the EZ-BlockerTM to isolate the left lung.
Out of 28 difficult insertions, in 10 patients, there was inadequate length and space between the distal end of the endotracheal tube and the carina (although being checked by fibreoptic bronchoscopy beforehand). So, the cuff of the single-lumen tube was deflated and it was cautiously pulled further up (Table/Fig 4) to create more length while ensuring that the tube is not coming out too far and out of the vocal cords. This extra length made the manipulation of the EZ-Blocker™ easy and facilitated successful placement, as atleast 4 cm of length should be available from the distal end of the endotracheal tube to the carina (11).
In seven cases, the right main bronchus originated at a more acute angle, while the left main bronchus originated at a more obtuse angle. This led to the passage of the EZ-Blocker™ with both cuffs to the right-side repeatedly. In these cases, the head was turned completely to the right-side, which made the left bronchus more prominent and centered, facilitating successful EZ insertion with the cuff on the left-side.
In six patients, the above situation became more extreme with a more compressed left main stem bronchus, causing the two balloons of the EZ-Blocker™ to enter the right main bronchus. Along with turning the head to the right-side, manual compression of the trachea towards the right-side was performed to make the left main bronchus more pr
In three patients, the trachea was relatively small and the two distal cuffs of the EZ-Blocker™ were adhered to each other due to mucus and thick secretions. The EZ-Blocker™ was removed from the multiport adaptor, cleaned and the Y distal end was manually spread before reinsertion. This maneuver resolved the above problem and enabled successful EZ placement.
In a couple of patients, the airway carina was quite posterior, causing the EZ-Blocker™ to slide towards the anterior part and hit above the carina instead of entering the lumens. Removing the pillow and extending the neck improved the situation by slightly anteriorly
positioning the airway, allowing the EZ distal balloons to enter each main bronchus.
In four cases, despite all manoeuvres and spending more than 10 minutes with repeated attempts, EZ-Blocker™ insertion failed. In three of those patients, single-lumen COOPDECH™ blockers were used, while in another patient, blocker placement was abandoned due to significant hypoxemia followed by bradycardia and asystole. Immediate open sternotomy and cardiopulmonary bypass were performed, eventually saving the patient.
The incidence of postoperative hoarseness and sore throat among a total of 102 patients was approximately 5 (4.9%) patients and 14 (13.72%) patients, respectively. A summary of all the patients and the manoeuvres has been presented in (Table/Fig 6),(Table/Fig 7).
The present case series has described the different types of technical difficulties and challenges during the insertion of the EZ-BlockerTM , as well as the different manoeuvres to overcome them. To date, not too many problems and factors for difficult EZ-BlockerTM insertion have been reported in the literature. Rispoli M et al., proposed the inflated positioning technique when both cuffs go into the right main bronchus (11). Goto M et al., reported almost the same technique with the inflation of both balloons (12). Entrapment of the EZ-blocker in the Murphy eye has also been reported (13).
The present case series reports 28 cases (out of a total of 102 attempted EZ-BlockerTM insertions) where the EZ-BlockerTM insertion was “difficult.” In the present case series, 05 different manoeuvres (used alone or in combination) to troubleshoot the obstacles for successful placement have been described. Ultimately, by applying these manoeuvres, there was success in most of the difficult cases. The practiced manoeuvres in the present case series came from the vast experience of using EZ-BlockerTM in large numbers by the authors. By using them, it can be confirmed that the EZ-BlockerTM are a safe, easy and reliable blocker and the quality of lung isolation is comparable to DLT, as reported by Mourisse J et al., and Végh T et al., in studies (9),(10). Compared to the systematic review conducted by Palacznski P et al., the incidence of hoarseness and sore throat is less in this study (14). The recent study by Palacznski P et al., reported the incidence of hoarseness and sore throat as 13% and 23.3%, respectively. The experience and knowledge of the operator about the anatomy and the device are key factors to potentially deal with difficult EZ-BlockerTM successfully. This is a new study on EZ-BlockerTM and no similar study has been published in the literature to date. The present case series will raise awareness among anaesthesiologists and clinicians to know the range of difficulties and their probable solutions associated with EZ-BlockerTM . It can be concluded that the EZ-BlockerTM is a safe, easy and reliable device for lung isolation in the hands of clinicians with good clinical expertise.
The present case series highlighted the wide range of difficulties related to real-time insertion of the EZ-BlockerTM and how we managed them with different simple but efficient manoeuvres. The EZ-BlockerTM is a safe, user-friendly and reliable endobronchial blocker with a great success rate in the hands of experienced operators. The authors are not promoting any device brand and this device is mentioned only for research purposes.
DOI: 10.7860/JCDR/2024/74814.20305
Date of Submission: Aug 07, 2024
Date of Peer Review: Sep 03, 2024
Date of Acceptance: Oct 14, 2024
Date of Publishing: Nov 01, 2024
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Aug 08, 2024
• Manual Googling: Sep 10, 2024
• iThenticate Software: Oct 10, 2024 (07%)
ETYMOLOGY: Author Origin
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