Right Versus Left Double-Lumens for Left-Sided Thoracic Surgery

Abstract

In Response: We appreciate the interest and comments of Dr. Schulman regarding our study (1). Benumof (2) recommends that the nonoperated mainstem bronchus should be routinely intubated because intubation of the operative mainstem bronchus may interfere with the performance of surgery. The “ball valve obstruction” suggested by Dr. Schulman, and described by others (3–4), leads us to believe that this may be another advantage of a right-sided double-lumen endotracheal tube (R-DLT) for left-sided thoracic surgery. We did not observe this problem in the 20 patients who received left-sided double-lumen endotracheal tubes (L-DLT) for left-sided thoracic surgery (1). Furthermore, we have not experienced this problem in our thoracic surgical practice overall–approximately 400 thoracotomy and thoracoscopic cases per year. Factors that should be considered before selecting a R-DLT for the “ball valve problem” include size of the tumor and proximity to the tracheal bifurcation or mediastinum. We advocate the use of a L-DLT for a left-sided thoracic surgery, unless there are contraindications to its use, for example, an exophytic lesion that causes compression of the left mainstem bronchus, intraluminal tumor that arises from the left main bronchus, tracheobronchial disruption, left-sided pneumonectomy, left lung transplantation, or a descending thoracic aortic aneurysm that compresses the left main bronchus. We believe that the “ball valve problem” is probably rare, but always should be considered when double-lumen endotracheal tubes and one-lung ventilation are planned. Javier H. Campos MD* Kemp H. Kernstine MD†