Bronchial Cuff Research Articles

Comparison of a Silicon Double-Lumen Endobronchial Tube (Silbroncho®) with a Polyvinyl Chloride Tube (Broncho-Cath®) in Right-Side Thoracic Surgery

Background: Double-lumen endobronchial tube (DLT) malposition and displacement can occur easily by blind intubation or moving a patient into the lateral position. We compared a silicon DLT (Silbroncho) with a polyvinyl chloride tube (Broncho-Cath) to determine whether Silbroncho can reduce the incidence of DLT malposition and displacement during anesthesia for one lung ventilation in right-side thoracic surgery. Methods: Thirty nine patients requiring right lung deflation were randomly assigned to one of two groups. Eighteen patients received a Broncho-Cath DLT and 21 patients received a Silbroncho in the left mainstem bronchus. After blind intubation, we checked the incidence of right DLT intubation and tracheobronchial injury by fiberoptic bronchoscopy (FOB). After correcting DLTs for exact position and moving patients into the lateral position, we assessed the incidence of DLT displacement and changes of peak inspiratory pressure according to this position change during one lung ventilation. Results: The incidence of right DLT intubation and tracheobronchial injury were not significantly different (P > 0.05) in the two groups (16.7% vs 0%, 38.9% vs 14.3%, Broncho-Cath vs Silbroncho, respectively). After position change, the incidence of DLT displacement in the Silbroncho group (4.8%) was lower (P group (44.8%). No significant difference was found between the two groups in terms of peak inspiratory pressure (P > 0.05). Conclusions: Our results suggest that Silbroncho can reduce the incidence of DLT displacement because of the small-sized bronchial cuff, which is located more distally than the Broncho-Cath cuff. We conclude that Silbroncho is superior to Broncho-Cath for one lung ventilation during thoracic surgery.

The Single-connector Technique for Initial Placement of Double-lumen Tubes

Due to the presence of major lung or extra-pulmonary pathology, which may be unilateral or bilateral, the initial placement of a double-lumen tube is not always straightforward. Although fibreoptic bronchoscopy is often used to confirm "correct" placement, a "blind" technique is frequently used for the initial insertion. The currently widely taught blind technique involves tracheal cuff inflation and ventilation of both lungs as a first manoeuvre, with a subsequent assessment of single-lung ventilation by clamping off in turn, the two limbs of the double-lumen tube double-connector: An alternative approach involves the bronchial cuff being inflated first, and then using a single-connector to transfer ventilation from one lung to the other. In this paper this technique is described and compared to the more traditional method. On a purely "number of steps" basis, the single-connector approach has several advantages. Furthermore, use of a technique that involves bronchial cuff inflation and single-lung ventilation as a first manoeuvre may reduce the risk of a temporarily malplaced double-lumen tube creating a potentially harmful ball-valve effect in a partially obstructed lobe or lung.

Should a fibreoptic bronchoscope be used to confirm double lumen tube placement?

The authors commonly use PVC BronchoCath double lumen tubes (DLTs) (Mallinckrodt Medical Inc., St. Louis, MO, USA). The DLT is introduced through the vocal cords after appropriate sizing, the stylet removed, the DLT rotated anti-clockwise and advanced down the airway. The airway is secured by inflating the tracheal cuff. The patient is ventilated with a volume of 8 ml/kg, the chest auscultated and peak airway pressure recorded. To isolate a lung the bronchial cuff is inflated with <3 ml of air until there is no audible leak. The connector on the redundant side is clamped, the limb is opened to air and ventilation occurs via the appropriate lumen.

Comparison of surgical procedures for vascular and airway anastomoses that utilize a “modified” non-suture external cuff technique for experimental lung transplantation in rats

Background Lung transplantation in rats is technically difficult and results may vary. The non-suture cuff technique (non-suture [NS]), which involves using a cuff for anastomoses of vessels and airways, is commonly utilized to perform transplant procedures. However, the standard bronchial cuff may occlude the lumen, resulting in diminished graft survival. In contrast, the non-suture cuff technique for vascular anastomoses with bronchial suturing (bronchial suture [BS]), although more technically difficult, is known to have prolonged bronchial patency. We developed a “modified” NS technique that uses a larger and longer cuff for anastomoses and compared the efficacy of this procedure to the BS technique for lung transplantation. Methods The BS procedure was performed in 146 transplant procedures. The modified NS procedure, which uses a larger cuff than the standard NS procedure, was performed in 113 procedures. Results Although total ischemic times were comparable, the total operation time in the NS group was significantly shorter than in the BS group ( p < 0.0001). Bronchial leakage occurred in 9.6% of BS group patients and 0% of NS group patients. Survival rates were comparable between groups. Although the BS technique is widely acknowledged to provide prolonged patency of bronchial anastomosis, graft survival in the NS group was observed up 17 months post-transplant. Conclusions These data show that the NS technique, which is less technically difficult, results in shorter operative times compared with the BS procedure, and results in durable anastomoses of lung grafts.

A double-lumen tube technique for selective lobar isolation

EDITOR: A 72-yr-old female (height 162 cm, weight 55 kg) was admitted to our Intensive Care Unit (ICU) because of acute respiratory failure (PaO2/inspired O2 fraction (FiO2) 10.3 kPa). On admission, her trachea was intubated with a 7.5 mm inner diameter endotracheal tube (Portex, Kent, UK) and lungs mechanically ventilated in a pressure-regulated volume-controlled mode (Siemens 300C®, Berlin, Germany). Tidal volume was set at 380-400 mL, respiratory rate 20 breaths min−1, externally applied positive end-expiratory pressure (PEEP) 0 cmH2O. The achieved PaO2/FiO2 was 12 kPa. The patient was sedated with propofol (4 mg kg−1 h−1). The admission chest radiograph revealed diffuse, bilateral pulmonary infiltrates. She had no prior history of chronic inhalation of dusts causing inflammation and pulmonary fibrosis. Microbiological, serological and imaging investigations for patients with suspected interstitial lung disease [1] failed to establish a definitive, causal diagnosis. Thus, surgical lung biopsy [1-4] under selective lobar collapse [5] was decided. For selective left upper lobar collapse, the following technique was employed. (a) Determination of left mainstem bronchus length. A 3.4 mm fibreoptic bronchoscope was inserted through the original endotracheal tube; the upper incisor-to-carina distance (23.5 cm) was determined by subtracting the endotracheal tube connector-to-upper incisor length (part of endotracheal tube protruding from the patient's mouth) from the fibreoptic bronchoscope insertion length at the level of carina (endotracheal tube connector-to-carina); in a similar way, the upper incisor-to-left upper bronchus orifice distance (26.0 cm) was determined by subtracting the endotracheal tube connector-to-upper incisor length from the fibreoptic bronchoscope insertion length at the level of the left upper bronchus orifice; lastly, the difference of the aforementioned distances yielded the left mainstem bronchus length (2.5 cm). (b) LUL isolation. Additional propofol (1 mg kg−1), fentanyl (3 μg kg−1) and cisatracurium (0.2 mg kg−1) were given. Then the original endotracheal tube was replaced by a 37-FG, left-sided, double-lumen tube (BronchoCath®; Mallinckrodt Medical Inc., St. Louis, MO, USA); the double-lumen tube was inserted to the 28.0 cm mark at upper incisor level, and the inflation of both tracheal and bronchial cuffs resulted in the desired selective LUL isolation (Fig. 1).Figure 1: Selective isolation of the left upper lobe with the left-sided double-lumen tube inserted to the 28 cm mark.(c) Confirmation of LUL isolation. A fibreoptic bronchoscope inspection via the tracheal lumen of the double-lumen tube revealed the carina and both mainstem bronchial orifices; on inspection through the bronchial lumen only the segmental left lower bronchial orifices were visualized; on chest auscultation, with both double-lumen tube cuffs inflated, breath sounds were diminished solely over the left upper lobe. In the right lateral decubitus position, the desired double-lumen tube positioning was reconfirmed as above. Following left upper lobe collapse [5], an uneventful videothoracoscopic biopsy of the left upper lung was performed within 40 min. Intraprocedural ventilator settings were: FiO2, 1.0; tidal volume, 350-360 mL; respiratory rate, 23 breaths min−1; inspiratory time-to-total respiratory cycle time ratio 0.5; externally applied PEEP 0 cmH2O. Peak, plateau and mean airway pressures were 45-46, 28-30 and 8-9 cmH2O, respectively; intrinsic PEEP was 2 cmH2O. PaO2 was maintained ≥8 kPa throughout the procedure. In patients in respiratory failure with a short (≈2.5 cm) left mainstem bronchus [6], we recommend our selective left upper lung isolation technique for open lung biopsy. The left lower lobe can still be ventilated through the left endobronchial lumen of the double-lumen tube and the right lung is ventilated through the tracheal lumen. This is likely to minimize the risk of intraoperative hypoxaemia. S. D. Mentzelopoulos K. Rellos M. J. Tzoufi A. S. Michalopoulos Department of Intensive Care Medicine; Henry Dunant General Hospital; Athens, Greece E. P. Papageorgiou Department of Anaesthesiology; Henry Dunant General Hospital; Athens, Greece

Left double-lumen tubes: clinical experience with 1,170 patients

MODERN DISPOSABLE plastic double-lumen tubes (DLTs) are generally safe and easy to use.1,2 However, a misplaced or improperly used DLT can jeopardize any procedure and even injure the patient. This article reviews considerations for the selection and placement of left-sided DLTs based on data collected from a large series of patients undergoing thoracic procedures requiring one-lung ventilation (OLV) at this institution. Although the information presented represents the authors’ experience at a single center, others can apply many of the lessons in their own practices. With the permission of the Human Subjects Committee at Stanford University Medical Center, over an 8-year period from 1993 and 2001, 1,170 consecutive patients undergoing anesthesia for noncardiac, general thoracic surgical procedures were studied. All patients were anesthetized by anesthesia residents under the supervision of one of the authors (JBB). At the time of operation, patient sex, height, weight, site, and type of surgical procedure were recorded. When the patient’s chest radiograph (CXR) was available the width of trachea, and in some patients the width of the left bronchus, were measured. The size of the DLT selected, the depth of placement of the DLT in the bronchus, and the volume of air used to inflate the bronchial cuff were recorded. Data are reported as the mean standard deviation unless indicated otherwise. Relationships between parameters were analyzed using regression analysis. Any difficulties encountered, complications, or changes in tube position during the procedure were also noted. Data for measured parameters were not complete for some patients.

Dimensions of double-lumen tracheobronchial tubes.

The diameter of the left main bronchus is the determining dimension when selecting the size of a left tracheobronchial (double-lumen) tube for lung separation. However, this information is not given by any manufacturer, either on the tube or in the package insert. This paper describes the lengths and diameters of the deflated bronchial cuff segment of left tracheobronchial tubes in common use. One hundred and seventy-one left tracheobronchial tubes ranging in size from 28 to 41 nominal French gauge from four manufacturers were measured. There was wide variation between tubes of the same nominal size from the same manufacturer. For tubes of the same size from the same manufacturer, the diameter of the segment with the deflated bronchial cuff varied by more than 1 mm in diameter in some instances. The diameter of the bronchial cuff segment did not consistently decrease as the nominal size decreased even for the same manufacturer. There was major overlap in diameters of the bronchial segments between Fr 41, Fr 39, and Fr 37 tubes from most manufacturers, so that some of the Fr 39 tubes have a bronchial cuff segment diameter as much as 0.5 mm larger than the Fr 41 tube. It is concluded that the current French gauge markings on left tracheobronchial tubes are of very limited value in determining the appropriate size to be selected for a patient. More accurate and consistent dimensions of tracheobronchial tubes are required to improve clinical selection.

Contralateral Tension Pneumothorax During One-Lung Ventilation for Lobectomy: Diagnosis Aided by Fiberoptic Bronchoscopy

Contralateral Tension Pneumothorax During One-Lung Ventilation for Lobectomy: Diagnosis Aided by Fiberoptic Bronchoscopy

Bronchial cuff pressure change caused by left-sided double-lumen endobronchial tube displacement.

The bronchial cuff pressures (BCPs) of left-sided double-lumen endobronchial tubes (DLTs) manufactured by Rüsch and Mallinckrodt were measured in 80 patients when the tubes were withdrawn to compare the effect of tube design on BCP change. During general anesthesia with muscle relaxation, the cephalad surface of the endobronchial cuff was positioned either 2.5 cm distal to the carina (Rüsch Group R-I; n = 20 and Mallinckrodt Group B-I; n = 20) or just below the carina (Rüsch Group R- II; n = 20 and Mallinckrodt Group B- II; n = 20) and the cuff was inflated to 35 cm H2O. The tube was then withdrawn in 0.5-cm steps until the cuff was 2.0 cm proximal to the carina, the position just before the capnogram or pressure-volume loop of tracheal lumen changed. The BCP at each step was measured. The rate of decrease in BCP was defined as the decrease of BCP divided by the length of displacement of DLT. The rates of decrease from the +2.5 cm position to the end point in Group B-I (7.7+/-0.8 cm H2O x cm(-1) and those from the most proximal acceptable position to the end point in Group B-II (19.5+/-4.8 cm H2O x cm(-1) were greater than those in Group R-I (6.9+/-0.9 cm H2O x cm(-1) (P<0.01) and in Group R-II (12.4+/-3.1 cm H2O x cm(-1)) (P<0.01), respectively. The BCP decreased in both of the Mallinckrodt and Rüsch DLTs, and the rates of decrease of the former were greater than those of the latter.

The Sealing Volume and Pressure of the Bronchial Blocker Cuff of Univent(R) Tubes

The Sealing Volume and Pressure of the Bronchial Blocker Cuff of Univent(R) Tubes

Methods for single-lung ventilation in pediatric patients.

Because many children are too small for doublelumen tubes (DLTs), other techniques are often required for single-lung ventilation (SLV) in pediatric patients. This article offers tube selection guidelines for SLV in children.

Computed tomography-based tracheobronchial image reconstruction allows selection of the individually appropriate double-lumen tube size

Objectives: To determine whether individualized selection of double-lumen tubes or alternatives based on three-dimensional reconstruction of the tracheobronchial image from routine preoperative computed tomography (CT) scans leads to clinically appropriate choices. Design: Prospective observational study; comparison to historic controls. Setting: Anesthesia and radiology facilities of a university medical center. Participants: Forty-nine patients undergoing thoracic surgery requiring one-lung ventilation. Interventions: Three-dimensional image reconstruction of individual tracheobronchial anatomy was performed from routine preoperative spiral CT scans as well as from scans of five left-sided and four right-sided double-lumen tubes. Results of image-based tube size selection were compared with literature recommendations. Prospectively, individualized tube selection was performed by superimposition of printed transparencies of tubes over the tracheobronchial system and was validated using bronchoscopic and clinical criteria (n = 24). Measurements and Main Results: Three-dimensional reconstruction visualized individual anatomy with good accuracy and resolution. Correlations between patient morphology and tracheobronchial dimensions were weak (height versus mainstem bronchial diameters: r < 0.50). In 11 of 48 patients (23%). CT-fitted double-lumen tube sizes would have differed from a conventional height-based and gender-based selection. Individual, prospective, CT-based double-lumen tube selection was associated with (1) good fit and positioning confirmed by fiberoptic bronchoscopy, (2) adequate bronchial cuff seal volumes, (3) complete lung separation, and (4) oxygenation and ventilation parameters during one-lung ventilation similar to those with conventional size selection. In one patient, three-dimensional CT study allowed noninvasive evaluation of a tracheal stenosis precluding double-lumen tube placement. Conclusion: Individualized selection of double-lumen tube size using CT-based reconstructions of tracheobronchial anatomy leads to clinically appropriate choices. Risks resulting from variations in tracheobronchial morphology are recognized in advance.

An Unusual Cause of a Double-Lumen Endotracheal Tube Obstruction

To the Editor: A 40-yr-old woman was scheduled for left pulmonary hydatit cyst resection. Preoperative fiberoptic bronchoscopy disclosed no airway malformation and a normal trachea. After the induction of anesthesia, a 37F left endobronchial tube was inserted into the trachea after minimal resistance at the cricopharyngeus, and the tube was rotated 45[degree sign] counterclockwise. The bronchial and tracheal cuff were inflated with 3 and 6 mL of air, respectively. Chest auscultation revealed a decrease of left breath sounds. Manual ventilation was difficult after clamping of the bronchial tube because of high airway resistance. An inability to pass a suction of catheter beyond the tip of the tracheal tube suggested tube obstruction. The double-lumen tube (DLT) was pulled back and the trachea was extubated. On examination of the DLT obstruction of the distal aperture of the tracheal lumen caused by the carinal hook was noted (Figure 1).Figure 1: Closeup of the Double-lumen tube. The carinal hook is bent into the distal tracheal aperture.Potential problems with carinal hook have been observed [1]. A similar incident was reported in a recently published case [2]. A possible mechanism is that the laryngeal lumen was too small for the tip of the DLT and that the hook was bent by the lateral wall of the larnynx and trapped in the distal orifice of the tracheal lumen. Lack of lubrication of the DLT and the use of an inappropriate size of the DLT could have contributed to the incident. We recommend that fiberoptic bronchoscopy of both lumens of the DLT be routinely performed when the DLT is used, and choice of an appropriate DLT size seems important. Bouaggad Abderrahmane, MD Abassi Omar, MD Department of Anesthesiology; Ibn Rochd University Medical; Center of Casablanca, Morocco 20000

Selecting Double-Lumen Tubes for Small Patients

In Response: We would like to thank Brodsky et al. for their interest in and comments on our article [1]. We agree that the introduction of a 32F double-lumen tube (DLT) provides a much welcomed addition to the range of DLT sizes available for smaller patients, and their new guidelines, which included a 32F DLT, would be appropriately used for DLT selection. According to Brodsky et al.'s [2] recent guidelines, some of our patients, who received an oversized 35F DLT, may have been better fitted with a 32F DLT. However, contrary to their expectations, seven of our eight patients who received an oversized 35F DLT in our study had tracheal diameters of 14-15 mm. Only one patient had a tracheal diameter of 13.6 mm, and only that patient would have been selected to receive a 32F DLT by Brodsky et al.'s new guidelines. We believe that the key differences between our results and those of Brodsky et al. [2] lie both in the demographics of the population studied and is the definition of an oversized DLT. We took a conservative view with regard to the definition of a correctly sized DLT, compared with Brodsky et al., who accepted a DLT as appropriately sized based on clinical and functional grounds. For the purpose of the study, we regarded absence of air leak when the bronchial cuff was deflated as being oversized. We felt that this definition was important because a tube that fits too snugly into the airway can cause airway injury. We agree that airway rupture during placement of DLTs should be rare if done properly. However, pressure necrosis can occur with an overinflated cuff and can certainly occur with an oversized DLT that is wedged tightly into the airway. Lesser degrees of airway trauma, including petechiae and erosions, have been reported even after uneventful DLT placement and removal [3]. We agree that our Asian population differs from that of Brodsky et al.'s non-Asian shorter patients. However, a significant relationship between airway size and patient height has been reported in one other study group [4]. The reason and the magnitude to which body height should influence the predictive relationship between the tracheal and bronchial diameter is intriguing. Clearly, the latter would be a more important index. As Brodsky et al. have pointed out, the difference in outer diameters of the bronchial lumen varies very little among the DLT sizes. Hence, in selecting the appropriate DLT size, a means of directly measuring the left main bronchial width (such as computer tomographic scan measurements) more accurately than an indirect method of measuring tracheal width from the chest radiograph would be useful. However, in the absence of the availability of such a method, we agree that the tracheal width measurement (with some modification in short patients) would be a helpful guideline. Mark Y. H. Chow, MMed* B. L. Liam, MMed[dagger] Thomas W. K. Lew, MMed[dagger] R. Y. Chelliah, MMed[dagger] B. C. Ong, MMed* Departments of Anesthesia; *Singapore General Hospital [dagger]Tan Tock Seng Hospital; Singapore 169608

Management Of Left-sided Double Lumen Tube Placement Using A Video-optical Intubation Stylet

We report the successful use of a video-optical intubation stylet for left-sided double-lumen tube placement in a 13 year old girl. An ultrathin video-optical intubation stylet has been inserted into the bronchial lumen of a left-sided 28 Ch double-lumen tube before starting anesthesia. The trachea was intubated under direct vision using conventional laryngoscopy and the video-view from the stylet tip was used to direct and to place the bronchial tube correctly in the left mainstem bronchus. Then the videooptical intubation stylet was inserted into the tracheal lumen to confirm and adjust the proximal margin of the bronchial cuff. During one-lung ventilation, the video-optical intubation stylet was reinserted into the tracheal lumen to monitor continuously the position of the endobronchial cuff. The technique allowed visualized left-sided DLT insertion control in a simple and safe manner with correct DLT placement at the first attempt. Continuous visual subglottic airway monitoring was a valuable aid for maintaining correct double-lumen tube position during one-lung ventilation and may allows early detection and correction of tube dislocation. In addition, it provided an useful teaching and supervising tool. Please check the Web Site of Video-Assisted Airway Management at http://www.vaama.net

A Comparison of the Reliability of Two Techniques of Left Double-Lumen Tube Bronchial Cuff Inflation in Producing Water-Tight Seal of the Left Mainstem Bronchus

A Comparison of the Reliability of Two Techniques of Left Double-Lumen Tube Bronchial Cuff Inflation in Producing Water-Tight Seal of the Left Mainstem Bronchus

Damaged Univent[registered sign] Tubes

Univent[registered sign] endotracheal tube (Fuji Systems, Tokyo, Japan) damage is rare, but we have encountered two such cases: a fragmented tube and a fractured tube. Case Reports Case 1 The patient was a 62-yr-old, 158-cm, 58-kg man scheduled for surgery with a diagnosis of esophageal cancer. After placement of a 8.5-mm single-lumen cuffed Univent[registered sign] tube made of silicon, the built-in cuff was advanced into the right mainstem bronchus with the aid of fiberoptic bronchoscopy. The bronchial blocker cuff was inflated to permit one-lung ventilation that was confirmed by auscultation of the lungs. The patient was in a left semilateral decubitus position, and the operating Table wasrotated to the left according to the surgical procedure. During two-lung ventilation, analysis of arterial blood gases was normal, and pulse oximetry showed 99%-100% oxygen saturation. However, during one-lung ventilation, oxygen saturation decreased to 93%, and PaO2 gradually decreased from 130 to 52 mm Hg despite the inhalation of 100% oxygen. One-lung ventilation time was 90 min in total, and during this period, both lungs were ventilated manually a few times until oxygen saturation recovered to 100%. Surgery was completed in 6 h 20 min; the anesthesia time was 7 h 40 min. The patient entered the intensive care unit with the Univent[registered sign] endotracheal tube still in place. When the trachea was suctioned, using a fiberoptic bronchoscope, we found a foreign body at the proximal region of the left anterior segmental bronchus, and the object was removed. As it seemed to be a silicon fragment, the Univent[registered sign] endotracheal tube was replaced with a single-lumen tube, and we inspected the Univent[registered sign] tube carefully. The inner part where a slip joint (a tracheal tube connector) attached to the tube was broken, and the object that was removed from the patient's bronchus fit perfectly into the defective area (Figure 1). Neither atelectasis nor the foreign object was seen on chest radiograph taken immediately after the patient entered the intensive care unit.Figure 1: A fragmented Univent[registered sign] tube and a silicon tip that was removed from the patient's bronchus. The size of the fragment is approximately 9 x 3 mm. The outer diameter of the slip joint (the tracheal tube connector) shown on the right is apparently larger than the inner diameter of the tube.Case 2 The patient was a 57-yr-old, 160-cm, 56-kg man undergoing surgery for esophageal cancer. A 9.0-mm Univent[registered sign] tracheal tube was used. During surgery, the slip joint disconnected from the Univent[registered sign] tube several times and had to be reconnected. After extubation, we checked the Univent[registered sign] tube for fracture and noticed that the inside of the tube was damaged (Figure 2).Figure 2: The orifice of the Univent[registered sign] tube is fractured at the same place as in the first case.Discussion Before intubation, the tube and the slip joint must be joined together because the Univent[registered sign] tube itself and its connector, the slip joint, are packed separately. It seems to be easier to detach the slip joint from the Univent[registered sign] tube after inserting it into the tube if a fiberoptic bronchoscope with a large diameter is used to verify adequate placement of the tube. The inner diameter of the tube is smaller than the outer diameter of the slip joint by 1 mm (Figure 1). Consequently, if a tube and a slip joint are attached improperly, they can easily disconnect. However, so much force is needed to connect them properly that it may cause a fracture in the inner layer of the tube. The silastic Univent[registered sign] tubes are more elastic and fragile than conventional tubes made of polyvinyl chloride. In the first case, we assume that a silicon fragment chipped away from the tube on connection and traveled into the patient's bronchus [1] when we were performing fiberoptic bronchoscopy or when the airway was suctioned. Fortunately, the silicon tip fragment did not cause a serious complication, such as airway obstruction [2,3] or atelectasis. In the second case, the tube was fractured at the same place as in the first case, and this was not noticed until tracheal extubation. Our experiences illustrate that the tracheal tube connector can damage the Univent[registered sign] tube. The two parts should be connected cautiously.

Bronchial Injury During Lung Isolation in a Pediatric Patient

Bronchial Injury During Lung Isolation in a Pediatric Patient

A Simple Method to Protect the Tracheal Cuff of a Double-Lumen Tube

To the Editor: Both cuffs of a modern plastic double-lumen endobronchial tube (DLT) can be damaged by teeth or by the laryngoscope blade during intubation of the airway. The larger tracheal cuff is usually at greater risk than the bronchial cuff. When a cuff tear occurs, the tube must be replaced with an intact DLT. This is not only expensive, but requires additional time and may place the patient at increased risk while the airway is being secured. We protect the tracheal cuff of Broncho-Cath[registered sign] DLTs (Mallinckrodt Medical, Inc., St. Louis, MO) in the following way (Figure 1). A 7 x 2-in. piece of pink or silk tape is folded in half, and the ragged edge is trimmed so that the final piece is 3 in. long by 2 in. wide. A 2-foot long piece of 1-in. wide clear tape is then folded lengthwise, leaving approximately 3 in. free at one end. This is torn in half lengthwise so that the final strip is approximately 1 foot long and 1/2 in. wide. The folded pink or silk tape is then wrapped around the tracheal cuff and secured with the sticky portion of the clear tape strip. A small amount of the sticky portion of the clear tape secures the strip to the main body of the DLT.Figure 1: Our technique for protecting the tracheal cuff of a plastic double-lumen tube with strips of tape is shown.During laryngoscopy, the tip of the bronchial lumen is advanced through the vocal cords. Once the protected tracheal cuff is past the teeth, the clear tape strip is pulled and the cuff protector slides up the body of the DLT. The tape cuff protector is removed and the DLT is rotated to the left and advanced down the trachea. The tape cuff protector can be used for either or both cuffs of a DLT or for the cuff on a conventional endotracheal tube. We do not use this method routinely; however, it is especially useful during difficult intubations and for patients with prominent teeth. Over the past 6 mo, we have used this method successfully in 10 of these patients who required intubation with a DLT. Gary P. Coppa, MD Jay B. Brodsky, MD Department of Anesthesiology; Stanford University School of Medicine; Stanford, CA 94305

A Simple Method to Protect the Tracheal Cuff of a Double-Lumen Tube

To the Editor: Both cuffs of a modern plastic double-lumen endobronchial tube (DLT) can be damaged by teeth or by the laryngoscope blade during intubation of the airway. The larger tracheal cuff is usually at greater risk than the bronchial cuff. When a cuff tear occurs, the tube must be replaced with an intact DLT. This is not only expensive, but requires additional time and may place the patient at increased risk while the airway is being secured. We protect the tracheal cuff of Broncho-Cath[registered sign] DLTs (Mallinckrodt Medical, Inc., St. Louis, MO) in the following way (Figure 1). A 7 x 2-in. piece of pink or silk tape is folded in half, and the ragged edge is trimmed so that the final piece is 3 in. long by 2 in. wide. A 2-foot long piece of 1-in. wide clear tape is then folded lengthwise, leaving approximately 3 in. free at one end. This is torn in half lengthwise so that the final strip is approximately 1 foot long and 1/2 in. wide. The folded pink or silk tape is then wrapped around the tracheal cuff and secured with the sticky portion of the clear tape strip. A small amount of the sticky portion of the clear tape secures the strip to the main body of the DLT.Figure 1: Our technique for protecting the tracheal cuff of a plastic double-lumen tube with strips of tape is shown.During laryngoscopy, the tip of the bronchial lumen is advanced through the vocal cords. Once the protected tracheal cuff is past the teeth, the clear tape strip is pulled and the cuff protector slides up the body of the DLT. The tape cuff protector is removed and the DLT is rotated to the left and advanced down the trachea. The tape cuff protector can be used for either or both cuffs of a DLT or for the cuff on a conventional endotracheal tube. We do not use this method routinely; however, it is especially useful during difficult intubations and for patients with prominent teeth. Over the past 6 mo, we have used this method successfully in 10 of these patients who required intubation with a DLT. Gary P. Coppa, MD Jay B. Brodsky, MD Department of Anesthesiology; Stanford University School of Medicine; Stanford, CA 94305