Double-lumen Tube Placement Research Articles

Anaesthesia for thorascopic sympathectomy

Anaesthesia for thorascopic sympathectomy

A Retrospective Evaluation of the Use of Video-Capable Double-Lumen Endotracheal Tubes in Thoracic Surgery

The objective of this study was to evaluate whether the use of a video double-lumen tube reduced the need for fiberoptic bronchoscopy for (1) verification of initial tube placement and for (2) reverification of correct placement after repositioning for thoracotomy. A single-center retrospective study. Thoracic surgery in a medical university hospital. After institutional review board approval, 29 patients who underwent thoracic surgical procedures using video double-lumen tubes were included in the final retrospective analysis. For 27 (93.2%) patients, the use of fiberoptic bronchoscopy was not needed either for initial placement or for verification of correct video double-lumen tube placement upon final positioning of the patient. However, for two patients, fiberoptic bronchoscopy was needed: for (1) one patient with severe left mainstem bronchus distortion as a result of a large left upper lobe tumor, and (2) a second patient with secretions that were difficult to clear. This study demonstrates that the video double-lumen tube requires significantly less (6.8%) fiberoptic use for both initial placement and verification of final position, in stark contrast to standard practice in which bronchoscopy is always used to verify final positioning of the double-lumen tube. As opposed to intermittent bronchoscopy, the continuous visualization offered by an embedded camera may confer an added measure of safety.

Board 366 - Research Abstract Teaching Basic Lung Isolation Skills on Human Anatomy Simulator (Submission #263)

Introduction/Background Lung isolation skills (LIS) are essential in anesthesia training and learning how to correctly insert a double lumen tube (DLT) and bronchial blocker (BB) is important. How to teach the novices LIS to an expert level of competency is under explored. We hypothesized that: (a) Novices can be trained to expert competency; (b) Simulation-based teaching is better than Video-didactic teaching; and (c) the LIS decay over time without practice. Methods We recruited 5 thoracic anesthesiologists (Expert), 9 senior residents (Experienced) and 30 medical students (Novice Group). The DLT and BB correct placement and insertion time were assessed on the Human Airway Anatomy Simulator (HAAS). First, Expert Group’s LIS was established. After baseline didactic teaching, Novices were randomized to video-didactic or simulation-based trainings. Video-didactic group watched training videos under supervision. Simulation-based group was trained in HAAS. Novices learning were compared with the Expert Group and within the two training groups on: (a) correct placement on 5-point Global Rating Scale (GRS); (b) pass/fail scoring; and (c) time to insert DLT/BB. Novices were retested 2 months later to assess skill decay. Results After training, there was no difference between the Novice and Expert groups in: (a) correct placement on GRS; (b) pass/fail; and (c) time to insert. There was no difference found between the Novice training groups. LIS decayed in two months without practice. Conclusion The novices can be trained to an expert competency level. The Video-didactic and Simulation-based trainings are equally successful in teaching LIS. However, LIS decay without practice. Disclosures None.

The usefulness of Glidescope in the placement of double lumen tubes

The usefulness of Glidescope in the placement of double lumen tubes

Treatment of Acute Silicoproteinosis by Whole-Lung Lavage

Acute silicoproteinosis is a rare disease that occurs following a heavy inhalational exposure to silica dusts. Clinically, it resembles pulmonary alveolar proteinosis (PAP); silica exposure is thought to be a cause of secondary PAP. We describe a patient with biopsy-confirmed acute silicoproteinosis whose course was complicated by acute hypoxemic respiratory failure requiring mechanical ventilation. Without clinical improvement despite antibiotic and steroid treatment, the patient was scheduled for whole-lung lavage under general anesthesia. Anesthetic challenges included double-lumen tube placement and single-lung ventilation in a hypoxic patient, facilitating lung lavage, and protecting the contralateral lung from catastrophic spillage.

Video-Assisted Thoracoscopic Extended Thymectomy in Myasthenic Children

Myasthenia gravis (MG) is an autoimmune disease marked by weakness of voluntary musculature. Medical and surgical therapy of adult myasthenia is well documented. There is little pediatric surgical evidence, only a few case reports being available. The aim of this paper is to verify whether the surgical and anesthesiological techniques can warrant an early and safe discharge from the operating room. The secondary aim is to assess the presence of perioperative indicators that can eventually be used as predictors of postoperative care. During the years 2006–2009, 10 pediatric patients were treated according to a surgical approach based on video assisted thoracoscopic extended thymectomy (VATET). Standard preoperative evaluation is integrated with functional respiratory tests. Anesthetic induction was made with propofol and fentanyl/remifentanyl and maintenance was obtained with sevoflurane/desflurane/propofol ± remifentanyl. A muscle relaxant was used in only one patient. Right or left double-lumen bronchial tube (Rüsch Bronchopart® Carlens) placement was performed. Six patients were transferred directly to the surgical ward while 4 were discharged to the intensive care unit (ICU); ICU stay was no longer than 24 h. Length of hospital stay was 4.4±0.51 days. No patient was readmitted to the hospital and no surgical complications were reported. Volatile and intravenous anesthetics do not affect ventilator weaning, extubation or the postoperative course. Paralyzing agents are not totally contraindicated, especially if short-lasting agents are used with neuromuscular monitoring devices and new reversal drugs. Perioperative evaluation of the myasthenic patient is mandatory to assess the need for postoperative respiratory support and also predict timely extubation with early transfer to the surgical department. Availability of new drugs and of reversal drugs, the current practice of mini-invasive surgical techniques, and the availability of post anesthesia care units are the keys to the safety and successful prognosis of patients affected by MG who undergo thymectomy.

Efficiency, Efficacy, and Safety of EZ-Blocker Compared with Left-sided Double-lumen Tube for One-lung Ventilation

Double-lumen tubes (DLTs) or bronchial blockers are commonly used for one-lung ventilation. DLTs are sometimes difficult or even impossible to introduce, and the incidence of postoperative hoarseness and airway injuries is higher. Bronchial blockers are more difficult to position and need more frequent intraoperative repositioning. The design of a Y-shaped bronchial blocker, the EZ-Blocker (Teleflex Life Sciences Ltd., Athlone, Ireland) (EZB), combines some advantages of both techniques. The objective of this study was to assess whether EZB performs clinically better than left-sided DLTs (Broncho-cath; Mallinckrodt, Athlone, Ireland) without causing more injury. Primary outcome was the frequency of initial malpositions. Eligible patients were adults scheduled for surgery requiring one-lung ventilation who met criteria for placement of both devices. In this parallel trial, 100 consecutive and blinded patients were assigned randomly using a computer-generated list to two groups. The incidence of malposition and ease and time of placement were recorded. Blinded assessors investigated quality of lung deflation, postoperative complaints, and damage to the airway. Placement of a DLT was unsuccessful twice. The incidence of initial malposition was high and comparable between EZBs (37 of 50) and DLTs (42 of 49) (P = 0.212). Placing single-lumen tubes and EZBs took more time but was rated easier. Quality of lung deflation was comparable. Fewer patients in the EZB group complained of sore throat at day 1. There was a higher incidence of tracheal hematoma and redness and bronchial hematoma in the DLT group. The EZB is an efficient and effective device for one-lung ventilation and causes less injury and sore throat than a DLT.

Comparison of GlideScope video-laryngoscope and Macintosh laryngoscope for double-lumen tube intubation

Objective To compare the GlideScope video-laryngoscope and Macintosh laryngoscope for double-lumen tube (DLT) intubation.Methods Seventy ASA Ⅰ-Ⅲ patients,aged 18-75 yr,scheduled for thoracic surgery and requiring one-lung ventilation,were randomly divided into 2 groups (n =35 each):Macintosh laryngoscope group (group M) and GlideScope video-laryngoscope group (group G).Anesthesia was induced with propofol,fentanyl and rocuronium.The exposure of glottis obtained with Macintosh laryngoscope and GlideScope video-laryngoscope was assessed using Cormack-Lehane grade.DLT intubation was assisted with Macintosh laryngoscope or GlideScope video-laryngoscope.The Cormack-Lehane grade,difficulty of DLT placement,and reverse DLT placement were recorded.The success rate of DLT placement at first attempt and intubation time were also recorded.Blood pressure and heart rate were recorded before intubation and at 0 and 3 min after intubation.The postoperative side effects were recorded.Results Compared with M group,the intubation time was significantly prolonged,the difficulty of DLT placement and blood pressure at 0 and 3 min after intubation were increased in G group (P ＜ 0.05).There was no significant difference in the success rate of DLT placement at first attempt,rate of reverse DLT placement,Comark-Lehene grade and heart rate at each time point between the two groups (P ＞0.05).The Comark-Lehene grade obtained with GlideScope video-laryngoscope was superior to that obtained with Macintosh laryngoscope in G group (P ＜ 0.05).Conclusion GlideScope video-laryngoscope can provide a better exposure of glottis and improvement in the intubating conditions,but the method is more complex and the response to intubation is stronger than Macintosh laryngoscope for DLT intubation. Key words: Laryngoscopes; Intubation,intratracheal

Incidental tracheal cuff rupture during placement of double-lumen tubes, What to do?

Incidental tracheal cuff rupture during placement of double-lumen tubes, What to do?

A randomised trial comparing the CEL‐100 videolaryngoscopeTM with the Macintosh laryngoscope blade for insertion of double‐lumen tubes

We performed a randomised trial comparing the CEL-100 videolaryngoscope(TM) with the Macintosh laryngoscope blade in 170 patients undergoing double-lumen tube placement for thoracic surgery. Compared with the Macintosh laryngoscope blade, use of the CEL-100 resulted in significantly more patients with a Cormack and Lehane Grade-1 laryngeal view (90.4% vs 61.0%, p < 0.001), a higher rate of successful intubation on the first attempt (92.8% vs 79.3%, p = 0.012), a lower median (IQR [range]) intubation difficulty score (0 (0-0 [0-60]) vs 15 (0-30 [0-80]), p < 0.001), a higher incidence of correct positioning of the tube (90.3% vs 79.2%, p = 0.041) and significantly fewer patients requiring external laryngeal pressure (19.3% vs 32.9%, p = 0.046). Median (IQR [range]) time to successful intubation was 45 (38-55 [22-132]) s with the CEL-100 compared with 51 (40-61 [30-160] s using the Macintosh laryngoscope blade. We conclude that the CEL-100 videolaryngoscope is superior to the Macintosh laryngoscope blade for double-lumen tube insertion.

Atrial Fibrillation Complicating Left Pneumothorax After Malpositioning of a Double-Lumen Tube

A 66-year-old woman (weight 133.3 lbs, height 158 cm) was scheduled for atrial septal defect (ASD) repair through a thoracotomy. Preoperative chest radiography was normal, and an electrocardiogram showed an incomplete right bundle-branch block. Transesophageal echocardiography revealed moderate right atrium and ventricle dilation, a pulmonary arterial pressure of 52 mmHg, and an ASD-associated left-to-right shunt. In the operating room, her blood pressure was 125/75 mmHg, her heart rate was 94 beats/min, and the SpO2 was 97% on room air. The patient was intubated with a 35F left-sided double-lumen tube (DLT) under direct laryngoscopy to a depth of 31 cm at the incisors. The DLT placement was checked by auscultation. During manual ventilation, increased airway resistance was noted, and no breath sounds were heard over either lung fields. The tube was pulled back 2 cm, and bilateral breath sounds were again documented. The end-tidal carbon dioxide waveform was present on the monitor. At that time, rapid-rate atrial fibrillation of 130 beats/min occurred with a blood pressure of 63/40 mmHg. Phenylephrine boluses were given to maintain hemodynamic stability. Correct positioning of the DLT was confirmed by fiberoptic bronchoscopy. Meanwhile, SpO2 remained within the normal range. Soon thereafter, a median sternotomy was performed instead of a thoracotomy, and a left pneumothorax was diagnosed and released by pleural opening. This was followed by rapid conversion of the atrial fibrillation into sinus rhythm and restoration of normal blood pressure. During one-lung ventilation, barotrauma from excessive tidal volume and high airway pressure may occur if a left-sided DLT is positioned distally such that the entire tidal volume is directed to only one lobe.1Silvalingam P. Tio R. Tension pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema in a 15-year-old Chinese girl after a double-lumen tube intubation and one-lung ventilation.J Cardiothorac Vasc Anesth. 1999; 13: 312-315Abstract Full Text PDF PubMed Scopus (34) Google Scholar, 2Malik S. Shapiro W.A. Jablons D. et al.Contralateral tension pneumothorax during one-lung ventilation for lobectomy: Diagnosis aided by fiberoptic bronchoscopy.Anesth Analg. 2002; 95: 570-572PubMed Google Scholar In our patient, high peak airway pressure may have been generated during manual ventilation to check the DLT position, which was placed too distal. The average depth of insertion for patients 170 cm tall was 29 cm, and for each 10-cm increase or decrease in height, the average placement depth was increased or decreased 1 cm.3Brodsky J.B. Benumof J.L. Ehrenwerth J. et al.Depth of placement of left double-lumen endobronchial tubes.Anesth Analg. 1991; 73: 570-572Crossref PubMed Scopus (95) Google Scholar A pneumothorax presents as increased airway pressure, decreased tidal volume, decreased SpO, and hypotension. Sudden-onset atrial fibrillation may occur for a variety of reasons during anesthesia. Our patient developed rapid-rate atrial fibrillation with hypotension, probably as a complication of the pneumothorax, which was diagnosed only after sternotomy. Had we initiated one-lung ventilation, cardiovascular collapse would have developed. Previous reports showed that a pneumothorax may be associated with numerous electrocardiographic changes.4Price J.W. Novel electrocardiographic changes associated with iatrogenic pneumothorax.Am J Crit Care. 2006; 15: 415-419PubMed Google Scholar, 5Strizik B. Forman R. New ECG changes associated with a tension pneumothorax.Chest. 1999; 115: 1742-1744Crossref PubMed Scopus (37) Google Scholar The sudden rise in intrathoracic pressure and rotation around the longitudinal axis of the heart has been suggested as a cause of these changes. A proposed mechanism for PR-segment changes is atrial ischemia caused by compression of air on the collapsed lung and subsequently on the heart. In our patient, a shift in heart position secondary to the pneumothorax in addition to the atrial enlargement may have predisposed to this mechanical irritation and subsequent atrial fibrillation. In conclusion, we report a case of atrial fibrillation complicating a left pneumothorax that was caused by barotrauma after malpositioning of a DLT in the presence of an ASD. Atrial fibrillation was reverted by releasing the pneumothorax. The diagnosis of a pneumothorax should be considered during DLT insertion whenever a patient develops cardiovascular instability.

Retromolar Placement of a Double-Lumen Tube: Novel Approach for a Difficult Airway

Retromolar Placement of a Double-Lumen Tube: Novel Approach for a Difficult Airway

Sequential endobronchial use of the Aintree intubation and airway exchange catheters through LMA-ProSeal for double-lumen tube placement in a morbidly obese patient with right main stem bronchus tumour

Sequential endobronchial use of the Aintree intubation and airway exchange catheters through LMA-ProSeal for double-lumen tube placement in a morbidly obese patient with right main stem bronchus tumour

Difficult Double-Lumen Endotracheal Tube Placement Complicated by an Intraoperative Pneumothorax

Difficult Double-Lumen Endotracheal Tube Placement Complicated by an Intraoperative Pneumothorax

Double-lumen tube placement with the patient in the supine position without a headrest minimizes displacement during lateral positioning

The correct position of double-lumen tubes (DLTs) is customarily confirmed after tracheal intubation by bronchoscopy with the patient supine on a headrest. However, displacement of DLTs usually occurs during lateral positioning because of neck extension. This study was undertaken to determine whether displacement of DLTs could be minimized during lateral positioning if DLTs were positioned without a headrest. One hundred patients scheduled for thoracic surgery were randomized into two groups (n = 50 each). After tracheal intubation using a headrest, adjustment of DLT position was performed according to group assignment, i.e., either with the headrest in place or without the headrest. Using a bronchoscope, distances from the tracheal opening to the main carina and from the bronchial opening to the left bronchial carina were measured in both the supine and lateral positions. Displacement of DLTs [mean (standard deviation)] during lateral positioning was greater in the headrest group than in the no-headrest group [12.3 (6.5) mm vs 6.8 (5.5) mm, respectively, in the trachea; 11.6 (6.7) mm vs 6.0 (4.6) mm, respectively, in the bronchus; P < 0.001]. The incidence of significant displacement, defined as > 10 mm from initial correct position, was greater in the headrest group than in the no-headrest group (64% vs 28%, respectively, in the trachea; 58% vs 20%, respectively, in the bronchus; P < 0.001). Displacement of DLTs during lateral positioning appears to be caused primarily by extension of the neck. Correct adjustment of DLT position without a headrest in the supine position is an easy and effective method to minimize DLT displacement during lateral positioning.

Video Laryngoscopy Versus Direct Laryngoscopy for Double-Lumen Endotracheal Tube Intubation: A Retrospective Analysis

The authors hypothesized that video laryngoscopy (VL) facilitated double-lumen tube (DLT) insertion compared with direct laryngoscopy (DL). A retrospective analysis. An academic hospital. Patients older than 18 years of age undergoing thoracic surgery requiring DLT placement between 2005 and 2011. Patients without airway predictors of difficult intubation who were intubated under DL with Macintosh (DL-MAC, n = 40) or Miller (DL-MIL, n = 44) blades and VL with McGrath MAC (Aircraft Medical, Edinburgh, UK) and C-MAC (Karl Storz, Tuttlingen, Germany) laryngoscopes (n = 46) were included in the study. Patients who were intubated with both VL devices were grouped into a VL group. Patients in all 3 groups had comparable preoperative demographics. Mallampati scores and ease of manual ventilation after the induction of anesthesia were also similar in all groups. The Cormack Lehane (C-L) grade views were significantly higher in patients in the DL-MAC than in the DL-MIL and VL groups (p < 0.006). The number of intubation attempts was similar in all 3 groups; however, the percentage of intubation reported to be difficult was higher in the DL-MAC than in the other 2 groups (p = 0.014). No damage to the airway was found in any of the groups. DLT placement using VL appeared to overcome some of the limitations of DL-MAC but was similar to DL-MIL. The authors speculated that the ease of placement was related to the improved visualization of the vocal cords because there was a significantly greater number of C-L views 3 and 4 in the DL-MAC group as compared with the VL and DL-MIL groups. Hence, the authors advocate using VL, particularly when the laryngoscopist is inexperienced using DL-MIL for DLT placement.

A customized stylet for GlideScope® insertion of double lumen tubes

To the Editor, The double lumen tube (DLT) is the airway of choice to establish and maintain lung isolation. However, it can be challenging to secure the airway with a DLT in patients with a difficult airway because DLTs are larger, more rigid, and more difficult to place into the trachea than single lumen tubes. Recently, a high level of success was achieved using the GlideScope (GLS) to assist in positioning a single lumen tube (SLT) in situations where the airway was considered or proven to be difficult. The GLS has also been advanced for DLT placement in patients with difficult airways. In collaboration with Verathon Medical Canada ULC, we recently designed a new semi-rigid intubating stylet, the GlideRite DLT Stylet (GR-DLT-S) (Figure), which can be used for primary DLT intubation with the GLS. The GlideRite DLT Stylet (Verathon Medical Canada ULC, Burnaby, BC, Canada) is a reusable device which has been commercially available since March 2010 (In Canada, information on the device is available from CAREstream Medical Ltd., Langley, BC, Canada). We undertook a preliminary study to observe the efficiency of the GR-DLT-S for primary insertion of a DLT with the GLS in patients presenting a normal upper airway. After obtaining Research Ethics Board approval from our institution, 50 adult patients scheduled for thoracic surgery and requiring lung isolation were enrolled after written informed consent. Exclusion criteria included patients with anticipated difficult bag-mask ventilation of the lungs or anticipated difficult tracheal intubation according to the standard criteria, such as Mallampati class [ 3. Following application of routine monitors, pre-oxygenation, induction, and paralysis, tracheal intubation with the DLT was undertaken using both the GLS and the GR-DLT-S. Forty-nine (98%) patients received tracheal intubation using the combination of DLT/GLS/GR-DLT-S. The mean time required for intubation was 46.3 (32.3) sec. The number of attempts was one in 37 patients (74%), two in 11 patients (22%), and three in one patient (2%). None of the subjects experienced complications associated with DLT insertion. Three publications have described the use of the Glidescope to facilitate DLT tracheal intubation. In 2005, Hernandez et al. described the first use of the GLS to introduce a DLT. In 2008, Chen et al. described a failure to insert a DLT with the GLS. They used the GLS to introduce a SLT, and afterwards, they used a tube exchanger to replace the SLT with a DLT, also with the assistance of the GLS. Finally, Bustamante et al. described a case report where bending the malleable stylet and sequential rotation of the DLT enabled them to introduce the DLT successfully. These authors reported a dozen successful cases using this technique. Over the past five years, we had several cases where we failed to intubate the trachea with a DLT using a similar method. The failed cases involved patients with little room to maneuver the DLT due to a large tongue or a small mouth opening. In these cases, the malleable stylet was not sufficiently rigid to maintain the optimal tube curvature. Since the introduction of the GR-DLT-S, tracheal intubation with the DLT has been successful using this new device in more than 15 patients with either a proven or an anticipated difficult airway. In conclusion, based on our initial experience, we suggest that the GR-DLT-S is effective when used in J. S. Bussieres, MD (&) F. Martel, MD J. Somma, MD S. Morin, MSc N. Gagne, PhD RRT Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Quebec City, QC, Canada e-mail: jean.bussieres@anr.ulaval.ca

The importance of bronchoscopic anatomy for anesthesiologists

One-lung ventilation (OLV) is a sine qua non of thoracic surgery and requires knowledge and talent. Close familiarity with equipments used for OLV as well as bronchoscopy and respiratory tract anatomy is important for successful OLV. We aim to outline the bronchoscopic anatomy of the tracheobronchial tree and OLV equipment for anesthetists and thoracic surgeons in this review. The recorded preoperative and intraoperative bronchoscopic applications of the patients hospitalized in our Thoracic Surgery clinic for diagnosis and treatment have been evaluated from an anesthetist's perspective. Anatomic landmarks were identified in the bronchoscopic evaluation. Optimal and misplacement images of double-lumen tubes (DLT) and bronchial blockers (BB) used for OLV in our clinic were obtained via fiber optic bronchoscopy. While left lung isolation can be made more safely due to the anatomy of the left main bronchus, placement of both DLTs and BBs to the right main bronchus requires greater care. Success in OLV procedures would increase with anesthetists being well informed about the fiber optic bronchoscopic anatomy of the tracheobronchial tree and in close cooperation with the surgical team.

"Detachment of the carinal hook following endobronchial intubation with a double lumen tube"

BackgroundCarinal hooks increases difficulty at endotracheal intubation. Amputation of the carinal hook during passage and malpositioning of the tube to the hook are some of the potential problems related with left-sided Carlens double lumen tube (DLT). This article reports an amputation of the hook during a difficult selective intubation and aimed at calling the attention to complications associated with DLTs and the importance of fiberoptic bronchoscopy.Case presentationA 68 year-old woman was scheduled for right-sided thoracotomy in whom blind DLT insertion was performed. Narrowed trachea causes difficulty in rotating the DLT 90° counter-clockwise. After carinal hook was noticed upon visual inspection of the DLT, fiberoptic bronchoscopy was used to remove the missing part (with the use of forceps) from the right mainstem bronchus.ConclusionInsertion of DLTs with carinal hook is associated with technical problems and potentially life-threatening hazards have discouraged their use. Fiberoptic evaluation and repositioning solves most of the problems. Although amputation of the carinal hook has not been previously reported, clinicians should be alert. This case report emphasizes the utility of the fiberoptic bronchoscopy in the operating theatre for placement, positioning and inspection of the carinal hook DLT.

Is flexible bronchoscopy necessary to confirm the position of double-lumen tubes before thoracic surgery?☆

Flexible bronchoscopy is recommended to confirm correct placement of double-lumen tubes used for thoracic anesthesia. However, there is still controversy over routine bronchoscopic confirmation of their position. This study aimed to verify the usefulness of flexible bronchoscopy for confirming the position of double-lumen tubes after blind intubation. During a 9-month period, consecutive patients undergoing elective oncologic thoracic surgery were prospectively enrolled in the study. All patients were intubated with a left disposable polyvinyl chloride double-lumen tube. Immediately after intubation, clinical verification was made by the anesthesiologist. Then, the endoscopist performed flexible bronchoscopy with a 2.8-mm diameter Olympus(®) video bronchoscope, and verified the position of the double-lumen tube, before positioning the patient. The double-lumen tube was in optimal position, if the bronchial cuff was immediately below the tracheal carina, and there was a clear view of the left subcarina, with unobstructed left upper and lower bronchi. Misplacement of the double-lumen tube was diagnosed when the tube had to be moved (in or out) for more than 0.5 cm to correct its position. Critical malposition meant a double-lumen tube dislocated in the trachea or in the right bronchi, requiring immediate re-intubation under bronchoscopic guidance. A total of 144 patients (44 women (42%) and 60 men (58%), with a mean age of 51 years (range 25-77 years)) were enrolled in the study. Surgical procedures included 37 right-sided and 31 left-sided thoracotomies, 22 video-assisted thoracoscopic surgeries (VATSs) (16 right-sided and six left-sided), one median sternotomy, six mediastinotomies, and seven miscellaneous procedures. In 66 (63%, 95% confidence interval 53.2-71.8%) cases, there was complete agreement between the anesthesiologist and the endoscopist. The latter diagnosed misplacement of the double-lumen tube in 33 (32%, 95% confidence interval 22.8-40.7%) patients and critical malposition in five (5%, 95% confidence interval 0.7-8.9%) cases. After blind intubation, 37% of double-lumen tubes required repositioning by means of flexible bronchoscopy, despite positive evaluation made by the anesthesiologist. Our data suggests that initial bronchoscopic assessment should be made with the patient still in the supine position, and confirms that flexible bronchoscopy is useful in verifying the correct position of double-lumen tubes or adjusting possible misplacements, before starting thoracic surgery.