Position Of Double-lumen Tube Research Articles

Effect of intubation in lateral position on placement of a double-lumen tube in patients undergoing unilateral video-assisted thoracic surgery: a randomied clinical trial

Approximately one-third of patients who undergo double-lumen tube (DLT) intubation in the conventional supine position experience DLT malposition. No randomized study investigates the effect of DLT intubation in the lateral position. We therefore aimed to evaluate the effect of intubation in lateral position on placement of a DLT compared to supine intubation, and to test primary hypothesis that lateral DLT intubation could reduce the incidence of DLT malposition. We randomly allocated 108 patients undergoing video-assisted thoracic surgery to receive DLT intubation in the comfortable and surgically required lateral position (lateral group) or in the supine position (supine group) from October to December 2022. The primary outcome was the incidence of DLT malposition defined as movement >1.0cm to correct the DLT position. The secondary outcomes included intubation time, the frequency and duration of fibreoptic bronchoscopy, the need for re-intubation, intra-operative vital signs, and post-operative recovery. This trial is registered with the Chinese Clinical Trial Registry (ChiCTR2200060794). The incidence of DLT malposition was significantly lower in the lateral group (1/53 [2%]) than that in the supine group (16/53 [30%]; RR [95% confidence interval] of 0.06 [0.01-0.46]; P<0.001). Lateral DLT intubation decreased the intubation time, the frequency and duration of fibreoptic bronchoscopy. The incidence of hypotension, post-operative sore throat, and upper-arm discomfort was lower in the lateral group. Other secondary outcomes were similar between groups. Lateral DLT intubation reduced the incidence of DLT malposition for patients undergoing video-assisted thoracic surgery. These results support that lateral DLT intubation offers more benefits and may be a superior option compared to conventional supine intubation. National Natural Science Foundation of China and of Zhejiang Province.

Effect of intubation in the lateral position under general anesthesia induction on the position of double-lumen tube placement in patients undergoing unilateral video-assisted thoracic surgery: study protocol for a prospective, single-center, parallel group, randomized, controlled trial

BackgroundThe double-lumen tube (DLT) is an essential equipment for thoracic anesthesia and the precise position of DLT placement is particularly important for anesthesia and surgery. However, the incidence of DLT malposition remains high and it leads to lung isolation failure and hypoxemia during one-lung ventilation. This trial aims to explore the clinical application and efficacy of intubation in the lateral position under general anesthesia induction to reduce the incidence of DLT malposition in patients undergoing unilateral video-assisted thoracic surgery (VATS).MethodsIn this prospective, single-center, parallel group, randomized, controlled trial, we will recruit 108 patients, aged 18–80 years, scheduled for elective unilateral VATS with DLT intubation under general anesthesia, and they will be randomly assigned to two groups: a lateral DLT intubation group (group L) and a conventional supine DLT intubation group (group C). The left-sided DLT will be used to intubate in patients of both groups. The position of DLT will be confirmed and adjusted by using the fiberoptic bronchoscopy (FOB). The primary outcome is the incidence of DLT malposition observed via the FOB, and the secondary outcomes include the time of intubation, the frequency and duration of re-adjustments of DLT placement under FOB, whether to re-intubate, intraoperative vital signs, and postoperative recovery.DiscussionAccurate DLT positioning is crucially important for thoracic surgery, but the incidence of DLT malposition is still high in the present clinical practice of thoracic anesthesia. This trial aims to investigate whether lateral DLT intubation can reduce the incidence of DLT malposition, with more stable intraoperative vital signs and less postoperative complications.Trial registrationThe study protocol was registered at Chinese Clinical Trial Registry (http://www.chictr.org.cn) with registration number: ChiCTR2200060794 on June 11, 2022.

Recent advances in double-lumen tube malposition in thoracic surgery: A bibliometric analysis and narrative literature review.

Thoracic surgery has increased drastically in recent years, especially in light of the severe outbreak of the 2019 novel coronavirus disease (COVID-19). Routine "passive" chest computed tomography (CT) screening of inpatients detects some pulmonary diseases requiring thoracic surgeries timely. As an essential device for thoracic anesthesia, the double-lumen tube (DLT) is particularly important for anesthesia and surgery. With the continuous upgrading of the DLTs and the widespread use of fiberoptic bronchoscopy (FOB), the position of DLT in thoracic surgery is gradually becoming more stable and easier to observe or adjust. However, DLT malposition still occurs during transferring patients from a supine to the lateral position in thoracic surgery, which leads to lung isolation failure and hypoxemia during one-lung ventilation (OLV). Recently, some innovative DLTs or improved intervention methods have shown good results in reducing the incidence of DLT malposition. This review aims to summarize the recent studies of the incidence of left-sided DLT malposition, the reasons and effects of malposition, and summarize current methods for reducing DLT malposition and prospects for possible approaches. Meanwhile, we use bibliometric analysis to summarize the research trends and hot spots of the DLT research.

The anatomical landmarks for positioning of double lumen endotracheal tube using flexible bronchoscopy: A prospective observational study

BackgroundTo examine the tracheobronchial anatomy and its common variations after double-lumen tube (DLT) placement, and to determine the anatomical landmarks that can be easily identified by practitioners for DLT positioning. MethodIn total, 200 patients with American Society of Anesthesiologists I–II, who were aged 20–75 years and scheduled for video-assisted thoracic surgery (VATS), were prospectively enrolled. The types of DLT position in each patient was recorded [Type I, the DLT bronchial end was in the left main bronchus (LMB), and the primary carina could be observed; Type Ⅱ, the DLT bronchial end was in the right bronchus intermedius (RBI); and Type III, an unidentified trachea or bronchus wall was observed from the DLT tracheal lumen] and the main tracheobronchial tree images were collected using Flexible bronchoscopy (FB). ResultFive patients were excluded due to excessive bronchus secretions impacting image collection. Type Ⅰ, II, and III positions of DLT were detected in 134 (68.7%) patients, 28 (14.4%) patients, and 33 (16.9%) patients, respectively. Examples of the tracheobronchial tree, common features, and variations in each lung lobe were demonstrated using FB. Furthermore, image analysis showed that each superior segment orifice of the right lower lobe (RLL) and the left lower lobe (LLL) was less variable and recognizable, determining it an important anatomical landmark for DLT positioning. ConclusionThe tracheobronchial tree and its common variations after DLT placement were described. The superior segment orifice of the RLL and LLL can be considered as an important landmark for DLT positioning.

Double-lumen Tube Position Confirmation with Fiberoptic Bronchoscope after Turning Patients into Lateral Position: Is It Necessary?

Background: Our goal was to compare two common methods including auscultation and Fiber-Optic Bronchoscopy (FOB) in confirming the correct placement of Double-Lumen Tube (DLT).&#x0D; Methods: Seventy six patients were enrolled. After DLT insertion, clinical verification was made by auscultation, then FOB was applied. At lateral decubitus, the position of DLT was rechecked by auscultation, and then by FOB. The incorrect position including malposition and misplacement were compared between two routine methods of auscultation and FOB.&#x0D; Results: After blind intubation, 21.1% of DLTs were considered to be in an incorrect position. Meanwhile, FOB showed that 46.1% of DLTs were not placed correctly. Among all the patients, 53.9% of DLTs were in the optimal position. Misplacement was diagnosed in 35.5% and malposition in 10.5% of the patients. After positioning to the lateral decubitus, using auscultation, we found that 5.3% of tubes were dislocated, but according to FOB, it was 10.5%. The agreement coefficient between auscultation and FOB was 0.42 in the supine position and 0.64 in lateral position.&#x0D; Conclusion: Our results showed that although FOB needs more time to check the position of DLT, it should be used to confirm the exact position of DLT.

Airway Bleeding After Double-Lumen Tube Placement

A 78-YEAR-OLD, 45-kg, 165-cm woman, with a history of breast cancer treated with chemoradiation, and esophageal diverticulum, presented for robotic-assisted diverticulectomy. After anesthetic induction, a 37Fr left-sided, double-lumen tube (DLT) was placed without difficulty, and placement was confirmed with fiberoptic bronchoscopy. The tracheal tissue was noted to be mottled throughout. After the patient was placed in the left lateral decubitus position, the DLT position was confirmed once again, and single-lung ventilation was initiated, with inflation of the bronchial cuff with 2.5 mL of air and clamping of the tracheal limb. After entry and insufflation of the right chest, 3-5 mL of blood were noted to be emanating from the tracheal lumen, and the surgeon noted poor lung isolation. Fiberoptic evaluation noted sanguineous secretions, which, despite lavage, failed to identify an obvious cause of bleeding, and slow bleeding persisted. In an attempt to improve single-lung isolation, an additional 2 mL of air were added to the bronchial cuff. After addition of air to the bronchial cuff, bleeding ceased and no additional significant issues occurred during the rest of the surgical procedure. After completion of the surgery, bilateral lung ventilation was reinstated and the authors repositioned the patient supine. Given the lack of obvious bleeding source and the mottled appearance of the tracheal tissue, bronchoscopy was performed for pulmonary toilet and further evaluation. The DLT was exchanged for an 8.5-mm endotracheal tube under direct visualization. The following findings (Fig 1, Fig 2) were noted. What is the diagnosis? Fig 2Bronchoscopic view from the left main stem showing full thickness injury in the membranous portion of the bronchus. Anterior surface of esophagus is visible through defect (yellow star). View Large Image Figure Viewer Download Hi-res image

Use of bronchial blocker to facilitate left double-lumen tube placement.

Use of bronchial blocker to facilitate left double-lumen tube placement.

Lung sonography can improve the specificity of determination of left-sided double-lumen tracheal tube position in both novices and experts: a randomised prospective study.

ObjectiveLung sonography can be helpful to determine the position of a left-sided double-lumen tube (DLT). However, clinical experience is required for correct assessment. We investigated whether lung sonography can improve the diagnostic efficacy of determining the DLT position in novices and experts.MethodsIn this randomised prospective clinical study, 88 patients were allocated to two groups using auscultation or lung sonography for initial assessment of the DLT position. In each group, two repeated assessments were performed; the first was performed by a novice, and the second was performed by an expert. The final DLT position was confirmed by fibre-optic bronchoscopy. The primary outcome was the diagnostic efficacy (including overall accuracy, sensitivity, and specificity) in confirming the DLT position.ResultsIn both the novices and experts, the specificity of determining the DLT position was significantly higher with lung sonography than auscultation (60.0% vs. 21.7% and 66.7% vs. 37.5%, respectively). Additionally, the predictability of an incorrect position was similar between the novices and experts using lung sonography (area under the curve of 0.665 and 0.690, respectively).ConclusionsLung sonography can improve the diagnostic efficacy of detecting an incorrect DLT position in both novices and experts.

A simple blind placement of the left-sided double-lumen tubes.

One-lung ventilation (OLV) has been commonly provided by using a double-lumen tube (DLT). Previous reports have indicated the high incidence of inappropriate DLT positioning in conventional maneuvers.After obtaining approval from the medical ethics committee of First Affiliated Hospital of Anhui Medical University and written consent from patients, 88 adult patients belonging to American society of anesthesiologists (ASA) physical status grade I or II, and undergoing elective thoracic surgery requiring a left-side DLT for OLV were enrolled in this prospective, single-blind, randomized controlled study. Patients were randomly allocated to 1 of 2 groups: simple maneuver group or conventional maneuver group. The simple maneuver is a method that relies on partially inflating the bronchial balloon and recreating the effect of a carinal hook on the DLTs to give an idea of orientation and depth. After the induction of anesthesia the patients were intubated with a left-sided Robertshaw DLT using one of the 2 intubation techniques. After intubation of each DLT, an anesthesiologist used flexible bronchoscopy to evaluate the patient while the patient lay in a supine position. The number of optimal position and the time required to place DLT in correct position were recorded.Time for the intubation of DLT took 100 ± 16.2 seconds (mean ± SD) in simple maneuver group and 95.1 ± 20.8 seconds in conventional maneuver group. The difference was not statistically significant (P = 0.221). Time for fiberoptic bronchoscope (FOB) took 22 ± 4.8 seconds in simple maneuver group and was statistically faster than that in conventional maneuver group (43.6 ± 23.7 seconds, P < 0.001). Nearly 98% of the 44 intubations in simple maneuver group were considered as in optimal position while only 52% of the 44 intubations in conventional maneuver group were in optimal position, and the difference was statistically significant (P < 0.001).This simple maneuver is more rapid and more accurate to position left-sided DLTs, it may be substituted for FOB during positioning of a left-sided DLT in condition that FOB is unavailable or inapplicable.

Placement of VivaSightTMdouble lumen tube

Levy-Faber et al. compared the VivaSightTM double-lumen tube with a conventional double-lumen tube (DLT) in patients undergoing thoracoscopic lung surgery 1. We would like to add our experiences of the VivaSight 2 and respond to some points in the article. The authors state that the ‘external structure and dimensions of the VivaSight are identical to those of a conventional left-sided DLT’, and used a Mallinckrodt 37 F DLT (Covidien, Boulder, CO, USA) as their control. In our study, we noted that the external diameter of the 37 Fr VivaSight is greater (15 mm vs. 11 mm) due to the profile of the camera, which may have impeded the passage of the tube below the glottis in one of our patients, but also that the lateral profile of the two tubes was different, which could impede the passage of a flexible fiberscope through the bronchial lumen. In common with similar articles published on the VivaSight 3, 4, only the 37 Fr Vivasight was manufactured at the time of the evaluation. Currently, there are other sizes available 5. The authors do not state their criteria for the selection of the appropriate size tube for the patient. In our series, we found that the Brodsky criteria 6 would not necessarily predict the VivaSight size correctly for a given tracheal diameter. Whilst we agree with the authors that there may be a cost advantage in using the VivaSight due to decreased use of the flexible fibrescope (FOB), one cannot obviate its use completely. In our experience, the quality of the VivaSight camera view is variable and influenced by the slight anterior curve of the tube, such that the trachealis muscle cannot always be visualised. Massot et al. 4 reported that three patients in whom the Vivasight could not be placed correctly without the use of a FOB had to be excluded retrospectively from their evaluation. Koopman et al. described how secretions or tissue debris can obscure the view, and how the monitor camera could malfunction 5. Examination of the bronchial extremities might be necessary to relieve mucus plugs or other obstructions. The authors’ intubation times are based upon the time ‘until the DLT position was visually verified’, but clinical checks for correct positioning (chest auscultation and movement, absence of air leak.) were not assessed. They also comment that time to intubation in the control group included the time to use the FOB, leading to a particularly prolonged ‘intubation time’. In comparison, Schuepbach et al. 3 found that the mean time to correct placement by auscultation for the VivaSight vs conventional DLT was 63 s vs 97 s. Finally, the authors mention that continuous direct observation of DLT position avoids displacement of the tube, but do not comment on the number of intra-operative displacements in their article. In our series, displacement occurred in three out of seven cases and using the camera, the tube was replaced easily. Massot et al. described displacement in 40 of 77 patients 4.

A different fibre-optic device for double lumen tube position confirmation!

Sir, The review article ‘lung isolation, one-lung ventilation and hypoxaemia during lung isolation’ by Atul Purohit et al. in the September issue was an academic treat. We would like to report a novel and alternative device for confirming double lumen tube (DLT) position. The conventional method needs a paediatric fibre-optic bronchoscope (PFOB) which may not always be available.[1,2,3] We used a flexible fibre-optic uretero-renoscope (F-URS), which has an outer diameter (OD) similar to PFOB, to confirm the DLT position [Figure 1]. Figure 1 Double lumen tube loaded on fibre-optic uretero-renoscope A 24-old-year male patient was posted for the right upper lobectomy for aspergilloma in the right upper lobe cavity as a sequel to pulmonary tuberculosis. After induction of general anaesthesia, a 39 French left-sided DLT was inserted under direct laryngoscopic vision with capnographic confirmation. A “3-step” clinical method was followed to confirm position of left DLT: The tracheal cuff was inflated and air entry was confirmed bilaterally The bronchial cuff was inflated and the tracheal lumen was clamped proximally for the left lung isolation. Bronchial lumen of the DLT was ventilated and unilateral ventilation confirmed On releasing the clamp of the tracheal lumen, ventilation was resumed bilaterally. Hence, the DLT positioning was confirmed clinically.[3] The F-URS was then passed through the tracheal lumen of the DLT, which on exit showed the carina, the right main bronchus and absence of herniation of the bronchial cuff. The two left bronchi were seen on passing the F-URS through the bronchial lumen of the DLT.[1,2,3] The F-URS can confirm placement of right-sided DLT as the working length would be adequate to visualise the right upper lobe bronchus. The F-URS we used was the E Line Compact Flexible Uretero-renoscope®, manufactured by M/S Richard Wolf, Germany-8703.524; 8/9.8 Fr, with an OD of 2.67/3.27 mm and working length of 430 mm. It costs approximately Rs. 7.5–8 lakhs. The F-URS works on fibre-optic technology similar to a FOB and is used for urosurgery as a flexible fibre-optic scope. A 39 Fr DLT accepts a FOB with 3.9–4.2 mm OD, whereas a 37 Fr DLT accepts OD of 3.5–3.9 mm. The F-URS with OD of 2.67/3.27 mm easily accepts 37 and 39 Fr DLTs [Figure 2].[1,2] Figure 2 Comparing length of double lumen tube and fibre-optic uretero-renoscope Methods used for the confirmation of the DLT are clinical, FOB and recently ultrasonography (USG).[4] The clinical method as the sole confirmatory method is inaccurate in detecting malpositions of the DLT, and may present significant intra-operative problems during one-lung ventilation.[1,2] Using a FOB aids in confirming DLT position, repositioning if necessary during surgery, visualising the operated site before DLT removal and perioperative pulmonary toileting.[2,5] Its use may be limited by non-availability, also it does not confirm deflation of non-ventilated lung.[4,5] Confirmation of lung deflation can be done by lung USG by the lung sliding and lung pulse sign. USG is dependent on availability, cost of the machine and subjective assessment of the performer.[4] Hence, FOB remains the gold standard for confirming DLT position.[1,4,5,6] The presence of a super speciality urology facility in our institute ensured the presence of the F-URS. It has a smaller OD, larger working channel, active deflection and better fibre optics due to advanced technology. The indications for its use include diagnostic procedures, management of calculus disease and endoscopic management of upper tract tumours, endoureterotomy or endopyelotomy.[7] The sterilisation procedure for the F-URS is similar to other fibre-optic devices, and hence, it can be reused for urosurgery. We would like to emphasise that this was a one time use of the F-URS for confirmation of the position of DLT in the absence of PFOB, and we do not intend to use it on a regular basis. Hence, the warranty terms and conditions would not be affected. The limitation of this device would only be its non-availability in certain institutions. We would like to draw attention to the fact that application of fibre-optic technology to broader medical specialities can be used to the patients’ advantage. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A prospective comparative study to evaluate the utility of lung ultrasonography to improve the accuracy of traditional clinical methods to confirm position of left sided double lumen tube in elective thoracic surgeries.

Background and Aims:Traditional clinical methods like auscultation or inspection have been found to be inaccurate in confirmation of double-lumen tube (DLT) position. Lung ultrasonography (USG) reliably identifies the tidal movement (lung sliding) and the collapse of the lung (lung pulse). We intended to check whether the accuracy of clinical methods can be improved by the addition of USG in confirmation of left DLT (LDLT) position.Methods:A single centred, prospective, comparative study was conducted involving 70 patients undergoing thoracic surgeries requiring the use of LDLT. The patients were assigned to Group A - where LDLT position was assessed by using clinical methods alone, and Group B - where LDLT position was assessed by USG and clinical methods. The correct position was predicted when USG demonstrated the absence of lung sliding and the presence of lung pulse on the operative side, the presence of lung sliding on non-operative side, along with normal airway pressures and oxygenation. The final verification of LDLT position was done by direct observation of lung isolation by one surgeon who was blinded to the method of confirmation. Contingency tables were drawn to calculate sensitivity, specificity, positive predictive value, negative predictive value and accuracy of each method.Results:Compared to clinical methods alone, addition of lung USG improved sensitivity (75% vs. 88%), specificity (18% vs. 75%) and accuracy (57% vs. 85%) for correct prediction of LDLT position.Conclusion:USG is a useful addition to the armamentarium of anaesthesiologist for the confirmation of LDLT position.

Positioning of double-lumen tubes based on the minimum peak inspiratory pressure difference between the right and left lungs in short patients

Peak inspiratory pressures (PIPs) during one-lung ventilation (OLV) have served as a clinical marker that could indirectly verify the proper positioning of double-lumen tubes (DLTs). Patients of short stature are highly susceptible to initial DLT malpositioning. We investigated the usefulness of positioning left-sided DLTs using minimum PIP differences between the right and left lungs by comparing with the previously used method of auscultation without fibreoptic bronchoscopy (FOB). We also evaluated the difference in PIPs between the two lungs during OLV after the DLT was ideally positioned with FOB examination. Prospective, observational study. A university hospital. One hundred and two female patients of short stature (≤160 cm). Verification of DLT position was conducted by three sequential steps: auscultation; minimising the difference in PIP during each OLV; and verifying the resulting position by FOB. Fibreoptic bronchoscopic view results of DLT position followed by the position adjustment using the minimum PIP difference method. Repositioning the DLT using the minimum PIP difference led to clinically successful positioning of the DLT in 88% of patients and a more ideal placement of the tube than auscultation alone (69.6 vs. 11.8%, P <0.001). Additionally, the ideal position of DLTs verified by FOB showed that PIP differences were zero or ±1 mmHg in 93% of patients. Positioning the DLT based on the minimum PIP difference between the right and left lungs as a supplementation to routine auscultation serves as an easy and reliable method for DLT positioning and may improve the accuracy of DLT positioning as an adjuvant to FOB in short patients. Clinicaltrial.gov identifier: NCT01533012.

Neuromuscular Blocking Agents and Therapeutic Hypothermia Post Cardiac Arrest in the Intensive Care Unit: Knowledge to Practice

Transbronchial Migration of Double Lumen Tube during Lobectomy Proper positioning of double lumen tube (DLT) during thoracic surgery remains essential for successful lung separation and hence surgery. Bronchoscopic confirmation of DLT is the gold standard but the position of DLT is dynamically influenced by change in patient position and intraoperative manipulation. We report a case of displacement and transbronchial migration of DLT during right upper lobectomy.

Acquired abnormalities of tracheal geometry creating difficulties in positioning of double lumen tube

Acquired abnormalities of tracheal geometry creating difficulties in positioning of double lumen tube

Back To Blockers?

Back To Blockers?

Randomized Clinical Trial Comparing Double-Lumen Tube and EZ-Blocker for Single-Lung Ventilation

Background In several clinical situations, lung separation and single-lung ventilation (SLV) is essential. In these cases, the double-lumen tube (DLT) is the most widely used device. Bronchial blocker such as Univent or Arndt Blocker serves as an alternative. The EZ-Blocker® (EZ; AnaesthetIQ B.V., Rotterdam, The Netherlands) is a new device promising to exceed clinical performance of DLT. The aim of this study was to assess the clinical performance of EZ in comparison with conventional left-sided DLT. Methods Forty adult patients undergoing elective thoracic surgery requiring thoracotomy and SLV were included in this study. The patients were randomly assigned to one of two groups: EZ (combined with conventional 7.5 or 8.5 mm single-lumen tube) or DLT (37 or 39 Fr left-sided DLT). Time for intubation procedure and time to verification of the correct position of EZ or DLT using fibreoptic bronchoscopy (FOB) were recorded. After surgery, a thoracic surgeon rated the quality of collapse of the lung (1–3 on a three-level scale). Results Time for intubation using DLT 85.5 (54.8) s was significantly faster (P Conclusions Although time for intubation was longer with the EZ, the device proved to be an efficient and easy-to-use device. The EZ is a valuable alternative device to conventional DLT. Verification of the correct position of the EZ by FOB seems to be obligatory. This study was registered at http://www.clinicaltrials.gov (identifier: NCT01171560).

Corrigendum to 'Is flexible bronchoscopy necessary to confirm the position of double-lumen tubes before thoracic surgery?'[Eur J Cardiothorac Surg 2011;40:912-18

Corrigendum to 'Is flexible bronchoscopy necessary to confirm the position of double-lumen tubes before thoracic surgery?'[Eur J Cardiothorac Surg 2011;40:912-18

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.

Correct positioning of double-lumen tubes

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.