Double-lumen Endobronchial Tube Intubation Research Articles

Double lumen endobronchial tube intubation: lessons learned from anatomy

BackgroundDouble lumen endobronchial tubes (DLTs) are frequently used to employ single lung ventilation strategies during thoracic surgical procedures. Placement of these tubes can be challenging even for experienced clinicians. We hypothesized that airway anatomy, particularly of the glottis and proximal trachea, significantly impacts the ease or difficulty in placement of these tubes.MethodsImages from 24 randomly selected Positron Emission Tomography – Computed Tomography (PET-CT) scans were evaluated for several anatomic aspects of the upper airway, including size and angulation of the glottis and proximal tracheal using calibrated CT measurements and an online digital protractor. The anatomic issues identified were confirmed in cadaveric anatomic models.ResultsProximal tracheal diameter measurements in PET-CT scans demonstrated a mean ± standard deviation of 20.4 ± 2.5 mm in 12 males and 15.5 ± 0.98 mm in 12 females (p < 0.001), and both were large enough to accommodate 39 French and 37 French DLTs in males and females, respectively. Subsequent measurements of the posterior angulation of the proximal trachea revealed a mean angle of 40.8 ± 5.7 degrees with no sex differences. By combining the 24 individual posterior tracheal angles with the 16 angled distal tip measurements DLTs (mean angle 24.9 ± 2.1 degrees), we created a series of 384 patient intubation angle scenarios. This data clearly showed that DLT rotation to a full 180 degrees decreased the mean intubation angle between the DLT and the proximal trachea from a mean of 66.6 ± 5.9 to only 15.8 ± 5.9 degrees.ConclusionsRotation of DLTs a full 180 instead of the recommended 90 degrees facilitates DLT intubations.

A Randomized Study of Rigid Video Stylet versus Macintosh Laryngoscope for Double-Lumen Endobronchial Tube Intubation Assistance in Thoracoscopic Pulmonary Surgery.

Double-lumen endobronchial tube (DLT) intubation is more challenging than single-lumen tube intubation is, and the rigid video stylet (RVS) is one of the tools that has emerged to deal with this demanding intubation procedure. We evaluated whether the UE® RVS can shorten the DLT intubation time and improve the first-attempt intubation success rate compared with that of Macintosh laryngoscope (ML). A total of 130 participants scheduled to undergo thoracoscopic pulmonary surgeries were enrolled. They were randomized to receive either ML- or RVS-assisted DLT intubation. The primary outcomes were the intubation time and first-attempt intubation success rate. The secondary outcomes were the overall intubation success rate, mean arterial pressure, postoperative sore throat (POST), and postoperative hoarseness at 1 h and 24 h. Compared with the ML group, the intubation time was significantly shorter in the RVS group (p &lt; 0.001; 30.82 ± 10.61 vs. 39.62 ± 6.54 s), however, the first-attempt success rate was significantly lower (p = 0.048; 83.08% vs. 95.16%). The POST at 1 h was less severe in the RVS group (p = 0.021). No significant differences were found for the other indicators. Among the patients with normal airways, the UE® RVS can achieve faster DLT intubation and decrease the severity of a POST at 1 h, although it was associated with a lower first-attempt intubation success rate.

Airway Management of the Right Anterior Segmentectomy through Uniportal video-assisted thoracoscopic surgery (VATS) after left pneumonectomy by an adapted double-lumen endobronchial tube (DLT): a case report

BackgroundLung resection after previous contralateral pneumonectomy is rare. We present a case of right anterior segmentectomy despite previous left pneumonectomy, demanding special airway management strategy.Case presentationA 48-year-old woman who had left pneumonectomy 2 years ago was scheduled to have the right anterior segmentectomy through uniportal video-assisted thoracoscopy (VATS). A 32-French (Fr) left-sided double-lumen endobronchial tube (DLT) was chosen and adapted. The DLT was intubated into the bronchus intermedius. And the upper lobe can be isolated from the ventilation in the middle and lower lobes when the bronchial cuff’s inflated. The perioperative period was uneventful and the pathological diagnosis was adenocarcinoma.ConclusionLung cancer radical resection was discouraged after previous contralateral pneumonectomy partly due to the challenging ventilation and isolation. With this new DLT adapting and intubation technique showed in this case, the challenging ventilation and isolation that deter the implementation of the operation mentioned above could be solved.

A Randomized Controlled Trial Comparing the Utility of Lighted Stylet and GlideScope for Double-Lumen Endobronchial Intubation

To compare GlideScope and lighted stylet for double-lumen endobronchial tube (DLT) intubation in terms of intubation time, success rate of first attempt at intubation, difficulty in DLT advancement toward the glottis, and postoperative sore throat and hoarseness. A prospective, randomized study. Medical center governed by a university hostpial. Sixty-two adult patients undergoing thoracic surgery using DLT intubation. After the induction of anesthesia, DLT intubation was performed using GlideScope (n = 32) or lighted stylet (n = 32). Number of intubation attempts, difficulty of DLT advancement toward the glottis, time taken for DLT intubation, and the incidence and severity of postoperative sore throat and hoarseness at 1 and 24 hours after surgery were evaluated. Time taken for DLT intubation was shorter in the lighted stylet group compared with the GlideScope group (30 [28-32] s v 45 [38-53] s, median [interquartile range], respectively; p < 0.001). DLT advancement toward the glottis was easier in the lighted stylet group than in the GlideScope group (p = 0.016). The success rate of DLT intubation in the first attempt (96.9% v 90.6% for lighted stylet and GlideScope, respectively), and the incidence and severity of postoperative sore throat and hoarseness were not different between the two groups. The use of lighted stylet allowed easier advancement of the DLT toward the glottis in the oropharyngeal space and reduced time for achieving DLT intubation compared with GlideScope.

A Comparison of 3 Videolaryngoscopes for Double-Lumen Tube Intubation in Humans by Users With Mixed Experience: A Randomized Controlled Study

To test the hypothesis that laryngoscopy using the Airtraq (Prodol Limited, Viscaya, Spain) or King Vision laryngoscope (KVL) (Ambu A/S, Ballerup, Denmark) would result in a shorter time for successful double-lumen endobronchial tube (DLT) intubation by users with mixed experience than the time required using the Macintosh or GlideScope (Verathon Inc., Bothell, WA) laryngoscopes. A randomized, prospective, blind study. A single university hospital. The study comprised 133 patients undergoing elective thoracic surgery. Patients were randomly allocated into the following 4 groups of DLTs: Macintosh (n = 32), GlideScope (n = 34), Airtraq (n = 35), or KVL (n = 32). The following data were recorded: time required for achieving successful DLT intubation; glottis visualization; optimization maneuvers; first-pass success rate; intubation difficulty; failure to intubate, defined as an attempt taking >150 seconds to perform or if peripheral oxygen saturation <92% was noted; and postoperative sore throat and hoarseness were recorded. Compared with GlideScope, the Airtraq resulted in shorter times for achieving successful DLT intubation (median times: 21 s [95% confidence interval 23.9-70.8 s] v 57.5 s [95% confidence interval 46.2-89.1 s], respectively; p = 0.021); a lower score for difficult intubations (p = 0.023); and fewer optimization maneuvers. The 4 laryngoscopes were associated with comparable glottis visualization; first-pass success rate (100%, 100%, 94.4%, and 100%, respectively; p = 0.522); incidence of oropharyngeal trauma; postoperative sore throat; and hoarseness of voice. There were 2 (5.7%) endobronchial intubation failures using the Airtraq due to the inability to advance the DLT through the glottis opening. The experience of the anesthesiologists in using the 4 devices had a statistically significant negative correlation with the time to confirmation of endobronchial intubation (Spearman r -0.392; p < 0.001). When used by operators with mixed experience, the channeled Airtraq required less time for DLT intubation and was easier to use than the GlideScope, although failures did occur with the Airtraq, whereas they did not occur with the other systems.

Trachway Intubating Stylet Facilitates the Double-Lumen Endobronchial Tube Placement in Patients with Limited Mouth Opening

Intubation for one lung ventilation in patients with difficult airways can be a challenge. Severely limited mouth opening restricts the use of direct laryngoscopy or video-assisted laryngoscopy. We present two patients with limited mouth opening undergoing video-assisted thoracoscopic decortication, who were successfully intubated with left-sided double-lumen endobronchial tube (DLT) using the Trachway® intubating stylet. This technique provides a safe and reliable method for DLT intubation in patients with limited mouth opening.

Licorice versus ketamine gargle for postoperative sore throat due to insertion of a double-lumen endobronchial tube

Background Postoperative sore throat (POST) is common after tracheal intubation, especially with double-lumen endobronchial tube (DLT). Licorice has many uses such as dental hygiene and in sore throat. Ketamine gargle is a newly proposed adjunct for reducing the incidence of POST in anesthesia. The aim of this study was to determine the efficacy of licorice and ketamine gargles in patients undergoing the insertion of DLT in preventing POST within 24 h. Methods This prospective, randomized, double-blind study included 90 patients undergoing thoracic surgery requiring DLT for one-lung ventilation. Patients were randomized to three groups (n=30) and were asked to gargle for 1 min to 15 min before operations. Group A received ketamine gargle (0.5 mg/kg ketamine in 30 ml of dextrose water 20%), group B received licorice gargle (500 mg licorice powder in 30 ml of dextrose water 20%), and group C (the control group) received 30 ml of dextrose water 20% gargle. Assessment of patients for the incidence and the severity of POST and any side effect was carried out in the recovery room. Sore throat (yes/no) and severity of its pain measured using visual analogue scale were recorded at baseline in the recovery room and then at 2, 4, and 24 h after operation with a specified questionnaire. Results The incidence of sore throat was significantly higher in group C at all time points in comparison with the other two groups. There was a marked decrease in the incidence of sore throat in groups A and B, with no significant difference between them. The severity of POST pain was significantly higher in group C when compared with the other two groups, with no significant difference between them and with no complications. Conclusion Ketamine and licorice gargles decrease the incidence and severity of sore throat occurring postoperatively due to DLT intubation, with no significant differences between them.

Impact of artificial capnothorax on coagulation in patients during video-assisted thoracoscopic esophagectomy for squamous cell carcinoma

Compared with the lung isolation using double-lumen endobronchial tube intubation, the artificial capnothorax using single-lumen endotracheal tube intubation has shown to be a safe, more convenient, and cost-effective procedure for thoracoscopic esophagectomy. However, the impact of capnothorax on coagulation is not well defined. Herein, we evaluate the impact of a capnothorax on coagulation and fibrinolysis in patients who undergoing thoracoscopic esophagectomy. Between March 2014 and August 2014, 24 patients underwent thoracoscopic esophagectomies for esophageal cancer with the procedure of artificial capnothorax (group P); we also performed 24 thoracoscopic esophagectomy cases without using capnothorax (group N). The demographics and arterial blood gas, as well as the parameters of coagulation and fibrinolysis, of the two groups were analyzed. The pH value of group P after CO2 insufflation was significantly lower than in group N (P<0.05), and the partial pressure of carbon dioxide (PaCO2) was significantly increased compared with group N (P<0.05). The R and K values after CO2 insufflation were significantly longer than before anesthesia (P<0.05), and both α angle and MA value after CO2 insufflation were significantly lower than those before anesthesia (P<0.05). No significant differences in R value, K value, α angle, or MA value were observed between pre-anesthesia and termination of capnothorax. No significant difference in LY30 data was found between different groups (P>0.05). Artificial capnothorax in patients receiving endoscopic resection of esophageal carcinoma had a significant impact on coagulation. These patients showed significant impairments in coagulation not observed in patients without artificial capnothorax.

Effect of prophylactic benzydamine hydrochloride on postoperative sore throat and hoarseness after tracheal intubation using a double-lumen endobronchial tube: a randomized controlled trial.

We evaluated the prophylactic effect of benzydamine hydrochloride (BH) spray on postoperative sore throat and hoarseness secondary to intubation with a double-lumen endobronchial tube (DLT). Ninety-two adult patients undergoing thoracic surgery using DLT intubation were studied. The DLT cuff and oropharyngeal cavity were sprayed with normal saline (Group S; n = 46) or BH (Group BH; n = 46) prior to intubation. Postoperative sore throat and hoarseness were evaluated at one, six, and 24 hr after surgery. Sore throat was evaluated using a 0-100 mm visual analogue scale (VAS). Hoarseness was defined as a change in voice quality. Compared with Group S, postoperative sore throat occurred less frequently in Group BH at one hour (mean difference, 28.3%; 95% confidence interval [CI], 8.7 to 45.1; P = 0.01), at six hours (mean difference, 32.6%; 95% CI, 12.6 to 49.2; P < 0.01), and at 24 hr (mean difference, 28.3%; 95% CI, 9.3 to 44.7; P = 0.01) after surgery. Group BH had lower VAS scores for postoperative sore throat at one hour (mean difference, 12.8; 95% CI, 4.9 to 20.7), at six hours (mean difference, 11.9; 95% CI, 4.8 to 19.1; P < 0.01), and at 24 hr (mean difference, 5.3; 95% CI, 0.9 to 9.7; P = 0.01) after surgery. Hoarseness also occurred less frequently in Group BH at one hour (mean difference, 23.9%; 95% CI, 6.8 to 39.6; P = 0.01), at six hours (mean difference, 23.9%; 95% CI, 7.4 to 39.3; P = 0.01), and at 24 hr (mean difference, 21.7%; 95% CI, 5.5 to 37.0; P = 0.02) after surgery (P < 0.01). Prophylactic application of BH to the DLT cuff and oropharyngeal cavity reduces the incidence and severity of postoperative sore throat and the incidence of hoarseness associated with DLT intubation. The trial was registered at the Clinical Research Information Service (KCT0001068).

Double-lumen tube tracheal intubation using a rigid video-stylet: a randomized controlled comparison with the Macintosh laryngoscope

Despite an increasing need, there is limited experience of double-lumen endobronchial tube (DLT) placement using video laryngoscope. We evaluated DLT intubation using an OptiScope, a rigid video-stylet with a malleable tip derived from the Clarus Video System, in comparison with a Macintosh laryngoscope. After airway evaluation and anaesthetic induction, Cormack and Lehane (C and L) grade was initially assessed in all patients using a Macintosh laryngoscope before tracheal intubation. The trachea was then intubated using either a Macintosh laryngoscope (n=200) or an OptiScope® (n=200). Success rate, intubation time, number of attempts at intubation, vocal cord view during intubation, need for external manipulation, and the incidences of oral mucosal or dental injury were compared between the two devices. Data were analysed for 397 patients. Intubation time with the OptiScope® was faster [median (inter-quartile range): 15 (12-19) s] than with the Macintosh [18(12-28) s] {mean difference [95% confidence interval (CI)}: 5.5 (3.8-13.2) s, P=0.010]. The success rate of the first intubation was higher with the OptiScope® than with the Macintosh [80.4% vs 89.9%, odds ratio (95% CI): 2.2 (1.22-3.87), P=0.036]. Initial view of the vocal cords was also better, although the final success rate was not different between devices. The need for external laryngeal manipulation, oral mucosal, or dental injury was lower with the OptiScope® compared with the Macintosh laryngoscope (all P<0.01). The OptiScope® provides faster tracheal intubation and a higher success rate for the first intubation with less trauma and a better vocal cord view than the Macintosh laryngoscope.

Effect of rhythmic pressure waves on balancing airway basic mucus secretion in dogs

To investigate the effect of different pressure on mucin (MUC) secretion in dog airway mucus layer and explore the participation mechanisms. Totally 24 healthy dogs were randomly divided into 4 groups (n=6) after double-lumen endobronchial tube intubation. In group A the dogs were ventilated bilaterally with normal breathing frequency and pressure; In group B: one side of the dog lung did not ventilate, while the other side was excessively ventilated. In group C: the tension-sensitive cation channel (TRPV) 4 blocker Ruthenium Red (RR) was injected in advance, and ventilated as in group A. In group D: TRPV4 blocker RR was injected firstly, and then ventilated as in group B. After 12 h ventilation, we collected bronchoalveolar lavage fluid (BALF), tested MUC (2, 5AC, 5B) protein content by ELISA, and detected the transcription of MUC (2, 5AC, 5B) mRNA of bronchial lung tissue by RTPCR. Compared with the normal ventilation (A2) group, the protein level of MUC of excessive ventilation (B2) group was significantly higher, mainly MUC5AC (P<0.05); compared with the normal ventilation (A1) group, the protein level of MUC of no ventilation (B1) group was significantly decreased (P<0.05). After pretreatment with RR, the MUC protein level of group C1, C2 were significantly lower than that of group A1, A2 (P<0.05); the MUC protein level of group B2were significantly lower than that of group D2 (P<0.05). The MUC (2, 5AC and 5B) mRNA level was higher in excessive ventilation group (B2) than in normal ventilation group (A2). After pretreatment with RR, in comparison with group A1, A2, the MUC (2, 5AC and 5B) mRNA level of group C1, C2 declined; in comparison with group B2, the MUC (2, 5AC and 5B) mRNA level of group D2 declined. Rhythmic pressure waves may regulate and balance basic airway mucin secretion through activating the TRPV4 channel in dogs.

The use of the Clarus Video System for double-lumen endobronchial tube intubation in a patient with a difficult airway

The use of the Clarus Video System for double-lumen endobronchial tube intubation in a patient with a difficult airway

Use of a video fiberoptic bronchoscope to assist double-lumen endobronchial tube intubation in a patient with a difficult airway

In clinical scenarios, the insertion of double-lumen endobronchial tubes (DLTs) is usually employed as a technique of separation of lungs for treatment purposes inclusive of one-lung ventilation for the ease of thoracic surgery. However, in patients with difficult airways, the DLT intubation can be challenging, even with the aid of a fiberoptic bronchoscope (FOB). Insertion of the FOB itself into the trachea may be relatively simple, but the advancement of the DLT with the FOB enclosed in the lumen may be hindered by the abnormal or diseased laryngeal aperture. Herein, we present an alternative approach by using a 5.5-mm video FOB to monitor the DLT rather than using it to act as an introducer to overcome the difficulties often met in DLT intubation in oral cancer patients.

Unilateral postobstructive pulmonary edema following double-lumen endobronchial tube intubation

Herein, we report a male patient underwent a video-assisted thoracoscopic resection of left lower lobe intralobar bronchopulmonary sequestration that developed unilateral postobstructive pulmonary edema following double-lumen endobronchial tube intubation. Pulmonary edema subsided after receiving positive pressure ventilation at positive end-expiratory pressure of 5 cm H 2 O and the patient was extubated 24 h later. To prevent this complication, correct placement of the tube should be assessed by auscultation during intermittent ventilation of each lung and fiberoptic bronchoscope should always be performed through both tracheal and bronchial lumens after intubation.

Double-Lumen Endobronchial Tube Intubation in Patients with Difficult Airways Using Trachlight® and a Modified Technique

We present a modified method for the insertion of double-lumen endobronchial tubes with Trachlight in patients with difficult airways. We also discuss whether our method is applicable to smaller double-lumen endobronchial tubes.

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.

Independent lung ventilation using a double-lumen endobronchial tube by nasotracheal intubation

Independent lung ventilation (ILV) is effective for the patient who is suffering from unilateral lung disease. When we ventilate the patients with ILV, they should be intubated with a double-lumen endobronchial tube. While ILV is continued for some time a number of difficulties related to the management of the double-lumen endobronchial tube (DLT) arise. Movements of the patient and routine turning of the patient threaten the DLT position and can lead to loss of lung isolation or lobe occlusion. Nasal intubation is better suited for long-term intubation than oral intubation because it is safer tor equipment attachment. We have ventilated six patients (Table) with ILV using the DT by nasotracheal intubation for 25 to 120 h. We intubated Portex #5.5 DT for all cases. There was no case in which DLT was required to correct its position during ILV. Although we examined the condition inside the nose, there was no severe damage by the DLT. We concluded that nasotracheal DLT intubation was done safely and could be used for ILV up to 7 days.

The Incidence of Sore Throat and Hoarseness after Double-Lumen Endobronchial Tube Intubation

The Incidence of Sore Throat and Hoarseness after Double-Lumen Endobronchial Tube Intubation