Correct positioning of double-lumen tubes

Abstract

Today it is your turn in the thoracic operating room, and your patient is scheduled for a right video-assisted thoracoscopic surgery (VATS). You know about the benefits of protective lung ventilation, a strategy that involves small tidal volumes and modest plateau pressures during onelung ventilation (OLV). You have no problem inserting a left-sided double-lumen tube (DLT), and you check its position with fibreoptic bronchoscopy (FOB). After turning your patient to the left lateral decubitus position, you institute OLV with the following parameters: tidal volume: 6 mL kg; respiratory rate: 15 breaths min; initial inspired oxygen fraction: 0.80; and positive endexpiratory pressure (PEEP) 5 cmH2O. You are happy now because you managed OLV using the best technique you know. A few minutes after the start of surgery, the spirometer shows a defect in the expiratory loop, indicating a leak. A few seconds later, the oxygen saturation levels decrease to the low 90s. Moreover, the surgeon mentions to you that the right lung is inflating; consequently, it is impossible to proceed with the VATS. The conditions are deteriorating from bad to worse. A beautiful day is turning so easily into a bad one! How could you have avoided this situation? Since the introduction of modern disposable polyvinyl chloride DLTs at the beginning of the 1980s and the routine use of FOB, anesthesiologists have increased their expertise in positioning DLTs. Their thorough knowledge of tracheobronchial anatomy and refinements in DLT positioning techniques has produced excellent results. Correct FOB positioning of DLTs is probably the main factor responsible for reducing the incidence of desaturation during OLV and increasing the safety of OLV. Correct positioning of the DLT prior to surgery decreases the number of repositionings required during surgery.