Endobronchial Cuff Research Articles

Individualized rotation of left double lumen endobronchial tube to improve placement success rate: a randomized controlled trial

BackgroundIn conventional practice, the left double lumen tube (DLT) is rotated 90° counterclockwise when the endobronchial cuff passes glottis. Success rate upon the first attempt is < 80%, likely owing to varying morphology of the bronchial bifurcation.MethodsWe conducted a randomized controlled trial to compare 90° counterclockwise rotation versus individualized degree of rotation in adult patients undergoing elective thoracic surgery using left DLT. The degree of rotation in the individualized group was based on the angle of the left main bronchi as measured on computed tomography (CT). The primary outcome was the first attempt left DLT placement success rate.ResultsA total of 556 patients were enrolled: 276 in the control group and 280 in the individualized group. The average angle of the left main bronchi was 100.6±9.5° (range 72° to 119°). The first attempt left DLT placement success rate was 82.6% (228/276) in the control group versus 91.4% (256/280) in the individualized group (P=0.02, χ2 test). The rate of carina mucosal injury, as measured at 30 min after the start of surgery under fibreoptic bronchoscopy, was significantly lower in individualized group than control group (14.0% versus 19.6%, P=0.041). The individualized group also had lower rate of postoperative sore throat (29.4% versus 44.0%, P<0.001) and hoarseness (16.8% versus 24.7%, P＜0.05).ConclusionsIndividualized rotation of left DLT based on the angle of the left main bronchi on preoperative CT increased first attempt success rate in adult patients undergoing elective thoracic surgery.Trial registrationThe trial is registered at Chinese Clinical Trial Registry (ChiCTR2100053349; principal investigator Xiang Quan, date of registration November 19, 2021).

A bench study on the prevention of lung-to-lung aspiration with double-lumen endobronchial tubes and bronchial blockers

Effective lung isolation prevents lung-to-lung aspiration during thoracotomy for the management of hemoptysis. Double-lumen endobronchial tubes (DLT) and bronchial blockers are commonly used for lung separation during thoracic surgery. In this study, the fluid-sealing characteristics of the endobronchial cuffs of three different commercially available DLTs (Broncho-Cath with a polyvinylchloride cuff, Broncho-Cath with a polyurethane cuff, and Human Broncho with a silicone cuff) and two different bronchial blockers (Arndt and Coopdech bronchial blockers) were evaluated using a benchtop model. The lateral decubitus position for the surgical management of bleeding from the right lung was simulated. The artificial tracheobronchial tree was placed horizontally, with the left bronchus in the dependent position and the right bronchus in the non-dependent position. In the DLT experiments, the tracheobronchial tree was intubated with left-sided DLTs, and the endobronchial cuff was inflated to maintain the intracuff pressure at 25 cmH2O. In the experiments with bronchial blockers, each bronchial blocker was inserted into the right bronchus, and the endobronchial cuff was inflated to seal the main bronchus. A fluid leakage test around the endobronchial cuff was performed using three different types of DLT (size 35, 37, and 41 Fr, each) and two different types of bronchial blockers (9 Fr). The 5 mL of colored water was poured into the right bronchus to simulate the blood flow from the operative side, and the times to the first and 100% leakage around the endobronchial cuff were recorded. Each bronchial blocker showed significantly less leakage over time than the other DLTs (P < 0.05). Fluid was not fully leaked around the cuffs for 24 h with either bronchial blocker. The times to first and 100% leakage were not significantly different among different types of DLTs. The times to first and 100% leakage did not also differ among the three different sizes of each type DLT. There was no significant difference in the time to first leakage around the endobronchial cuffs between Arndt and Coopdech bronchial blockers. Bronchial blockers provided a more effective seal against lung-to-lung aspiration than DLTs in the lateral decubitus position for thoracotomy in the benchtop model.

Comparison of the accuracy of three methods measured the length of the right main stem bronchus by chest computed tomography as a guide to the use of right sided double-lumen tube

BackgroundThe variation of right main stem bronchus leads to the orifice of the right upper lobe bronchus may be obstructed or increase the incidence of malposition intraoperatively when the right sided double-lumen tube is used. Therefore, the aim of this study was to compare the accuracy of three methods measured the length of the right main stem bronchus via chest computed tomography as a guide to the use of right sided double-lumen tube.MethodsIn this study, 168 adult patients undergoing left sided thoracic surgery were included. All these patients were allocated to carina-proximal (C-P) group, carina-distal (C-D) group and carina-carina (C-C) group. The position of endobronchial cuff observed via Fiberoptic bronchoscopy after successful initial placement and after turning the patients to the lateral decubitus position, as well as the incidence of malposition of right sided double-lumen tube intraoperative were recorded to assess the accuracy of three methods in predicting the position of right sided double-lumen tube.ResultsThe distance between the carina to the proximal margin of the right upper lobe orifice, carina to the distal margin of the right upper lobe orifice and carina to the first right interlobar carina of the right upper lobe orifice were 17.2 ± 2.3 mm, 25.4 ± 3.7 mm and 28.5 ± 3.1 mm (P < 0.05). In the C-D group, the number of endobronchial cuffs seen to be herniating out of the carina, the number of bronchoscopies during initial placement and on the lateral position, the number of total malposition intraoperative and the number of reposition manoeuvres intraoperative were significantly less than the C-P group or the C-C group (P < 0.05).ConclusionsThe length of the right main stem bronchus measured by the carina to distal margin of right upper lobe orifice method was more accurate than the other two methods in guiding the use of right sided double-lumen tube.Trials registrationClinical Trials. gov. no. NCT04127903. Registered at https://register.clinicaltrials.gov on 16/10/2019.

Bronchial blocker as an aid in the management of endo-bronchial cuff malfunction of double-lumen tube during one-lung ventilation.

Bronchial blocker as an aid in the management of endo-bronchial cuff malfunction of double-lumen tube during one-lung ventilation.

A Randomized Controlled Study of the Use of Video Double-Lumen Endobronchial Tubes Versus Double-Lumen Endobronchial Tubes in Thoracic Surgery

To compare the incidence of fiberoptic bronchoscope (FOB) use (1) during verification of initial placement and (2) for reconfirmation of correct placement following repositioning, when either a double-lumen tube (DLT) or video double-lumen tube (VDLT) was used for lung isolation during thoracic surgery. A randomized controlled study. Single-center university teaching hospital. The study comprised 80 patients who were 18 years or older requiring lung isolation for surgery. After institutional review board approval, patients were randomized prior to surgery to either DLT or VDLT usage. Attending anesthesiologists placed the Mallinckrodt DLT or Vivasight (ET View Ltd, Misgav, Israel) VDLT with conventional laryngoscopy or video laryngoscopy then verified correct tube position through the view provided with either VDLT external monitor or FOB. Data collected included: sex, body mass index, successful intubation and endobronchial placement, intubation time, confirmation time of tube position, FOB use, quality of view, dislodgement of tube, and ability to forewarn dislodgement of endobronchial cuff and complications. FOB use for verification of final position of the tube (VDLT 13.2% [5/38] v DLT 100% [42/42], p < 0.0001), need for FOB to correct the dislodgement (VDLT 7.7% [1/13] v DLT 100% [14/14], p < 0.0001), dislodgement during positioning (VDLT 61.5% [8/13] v DLT 64.3% [9/14], p = ns), dislodgement during surgery (VDLT 38.5% [5/13] v DLT 21.4% [3/14], p = ns), and ability to forewarn dislodgement of endobronchial cuff (VDLT 18.4% [7/38] v DLT 4.8% [2/42], p = 0.078). This study demonstrated a reduction of 86.8% in FOB use, which was a similar reduction found in other published studies.

Prevention of lung-to-lung aspiration during emergency thoracic surgery: an experimental study.

BackgroundLung separation is essential for an emergency thoracic surgery for massive hemoptysis. When using a double lumen tube (DLT), a commonly adopted lung separation device during thoracic surgery, a water-tight seal of endobronchial cuff is crucial to prevent lung-to-lung aspiration of blood. In this study, we investigated the fluid sealing characteristics of the endobronchial cuff of a DLT and examined the effect of gel lubrication on the fluid leakage beyond the endobronchial cuff of DLT.MethodsAn artificial tracheobronchial tree was intubated with a DLT. In the first phase of the study, the intra-cuff pressure of endobronchial cuff of DLT was set to 25, 50, or 100 cmH2O (n = 7, each), and the non-dependent bronchus was filled with 5 ml of water. Fluid leakage to the dependent bronchus beyond the endobronchial cuff was collected for 6 h. The time until leakage was first detected and the time until 100% leakage occurred were measured. In the second phase, the endobronchial cuff was coated with either saline (group C, n = 10) or lubricant gel (group GEL, n = 10), and the same parameters were measured.ResultsIn the first phase of the study, the times to first leakage and 100% leakage at an intra-cuff pressure of 25 cmH2O were 21.0 (7.0 - 59.0) sec and 3.0 (2.0 - 4.0) min, respectively. Higher intra-cuff (50 and 100 cmH2O) resulted in longer time for the first leakage and 100% leakage, but the duration was not long enough for clinical purpose. In the second phase, all the DLTs in group C showed 100% fluid leakage during the 6-hour period. In contrast, in group GEL, fluid leakage beyond the endobronchial cuff was detected only in 50% of the DLTs and none of the DLT showed 100% fluid leakage during the study. Among the DLTs which exhibited fluid leakage, the time to first leakage was 252.0 (171.0-305.0) min and the leakage volume at the end of the study period was 0.3〔0.0-1.8〕ml.ConclusionsEndobronchial cuff of DLT cannot prevent fluid leakage beyond the endobronchial cuff, but lubricant gel coating on the endobronchial cuff can effectively reduce the lung-to-lung aspiration.

Failure to Prevent Fluid Leakage Past Endobronchial Cuff by Double Lumen Tube Made of Polyvinylchlorid

PURPOSE: Double-lumen tube (DLT) is commonly used for lung isolation. The bronchial cuff of DLT must achieve a water-tight seal to protect the lung from spoiling. The seal characteristics of endotracheal cuff depend on its material and shape, and a cuff made of polyvinyl chloride(PVC) cannot provide complete sealing during endotracheal intubation. The endobronchial cuffs of most modern disposable DLTs are made of PVC and thus the sealing characteristics can be a cause for concern. Thus, we performed an in vitro study to investigate the sealing characteristics of PVC- DLT.

Endotracheal cuff leakage: a simple solution for an occasionally serious problem

To the Editor: We describe a possible solution for managing a cuff leak of a double-lumen endotracheal tube (DLT) used for an open thoracotomy. After induction of general anesthesia, the trachea of a 69-yr-old patient was intubated uneventfully with clear visualization of the vocal cords. A 39Fr left-sided DLT (Mallinckrodt Broncho-Cath TM , Tyco Healthcare Group, Pleasanton, CA, USA) was used. The patient was positioned in a left lateral decubitus position, and the correct DLT position was bronchoscopically verified. Within 15 min of skin incision, a significant leak of the endobronchial cuff was identified. The cuff leak was managed with a nasal cannula connected to an oxygen flowmeter. One of the two nasal prongs was then connected to the pilot balloon of the defective cuff via a well-fitting three-way stopcock. The other nasal prong was connected to an iv extension tubing (Baxter Extension Set, Baxter Healthcare Corporation, Deerfield, IL, USA) (86 cm long, 2.4 mm internal diameter). The end of the tubing was placed into a water-filled bottle 20 cm under the water’s surface. We then carefully inflated the endobronchial cuff of the DLT with oxygen at a flow rate of 2 Lmin -1 . The cuff appeared to maintain adequate pressure. Lung isolation was confirmed by direct inspection of the surgical field, equalization of delivered and exhaled tidal volumes, and bronchoscopic inspection of the cuff. No clinical changes in vital signs or signs of aspiration were present during the remainder of the procedure, which was confirmed by x-ray postoperatively. The system lasted until the end of the surgical procedure 1.5 hr later.

Electrical impedance tomography to confirm correct placement of double-lumen tube: a feasibility study

BackgroundDouble-lumen tubes (DLTs) are frequently used to establish one-lung ventilation (OLV). Their correct placement is crucial. We hypothesized that electrical impedance tomography (EIT) reliably displays distribution of ventilation between left and right lung and may thus be used to verify correct DLT placement online. MethodsRegional ventilation was studied by EIT in 40 patients requiring insertion of left-sided DLTs for OLV during thoracic surgery. EIT was recorded during two-lung ventilation before induction of anaesthesia and after DLT placement, and during OLV in the supine and subsequently in the lateral position. EIT measurements were made before and after verification of correct DLT placement by fibreoptic bronchoscopy (FOB). ResultsEIT accurately displayed distribution of ventilation between left and right lung online. All cases (n=5) of initially misplaced DLTs in the contralateral right main bronchus were detected by EIT. However, EIT did not allow prediction of FOB-detected endobronchial cuff misplacement requiring DLT repositioning. Furthermore, after DLT repositioning, distribution of ventilation, as assessed by EIT, did not change significantly (all P>0.5). ConclusionsThis study demonstrates that EIT enables accurate display of left and right lung ventilation and, thus, non-invasive online recognition of misplacement of left-sided DLTs in the contralateral main bronchus. However, as distribution of ventilation did not correlate with endobronchial cuff placement, EIT cannot replace FOB in the routine control of DLT position.

The effectiveness of ARNDT endobronchial blockers in paediatric scoliosis surgery

Introduction: Although described for paediatric thoracic surgery (1), there is little data on the use of the Arndt endobronchial blocker in paediatric spinal deformity surgery. We present its successful application in these patients.Methods: Thirteen patients undergoing surgical correction of scoliosis involving a lateral thoracotomy anterior approach were suitable for lung isolation using an Arndt endobronchial blocker. Placement was via an armoured tracheal tube; the endobronchial blockers were 5 or 9 FG with low‐volume low‐pressure cuffs (spherical or elliptical balloons). Placement was by a paediatric anaesthetist trained in paediatric bronchoscopy and required a 2.2 or a 2.8 mm paediatric fibreoptic bronchoscope.Results: Patient ages ranged from 18 months to 18 years and weights from 9 kg to 71 kg. All had idiopathic or congenital scoliosis; one patient underwent a VEPTR procedure. In all 13 patients, placement was easily and promptly achieved with no incorrect placements, displacements (including after patient repositioning), or failures to isolate one lung. Median time of insertion was 5 min (with checks), speed of insertion increasing as experience improved. Inflation times for the blocker balloon ranged from 1.5 h to 5 h. There was no airway trauma; direct bronchial inspection revealed local erythema only. Saturations were supported with 5 cm CPAP to the isolated lung and one‐lung ventilation was well tolerated in all but one patient with acceptable airway pressures (&lt;35 cm water); this one patient required partial lung inflation (blocker in place, balloon not inflated) to maintain adequate saturations and airway pressures. The surgical field was excellent in all cases.Discussion: Complex paediatric spinal surgery may require lung collapse to improve spinal access, and is traditionally achieved using a double‐lumen tracheal tube. Difficulties can arise as the children are often small for age with potentially distorted airway anatomy and there are a limited number of double lumen tube sizes. This can lead to inadequate isolation, a poor surgical field, endobronchial cuff herniation or obstruction of left upper lobe (tube too small or too long). The careful use of the Arndt endobronchial blocker avoids all these problems and enables easy reliable and safe isolation. Potential complications include malposition, migration, and direct airway trauma, allied to the usual complications of one lung anaesthesia. In our series, there were no complications relating to its use and insertion was quick and straightforward.Conclusions: Lung isolation with the Arndt endobronchial blocker is both safe and very effective in paediatric spinal deformity surgery.Reference 1 Wald SH, Mahajan A, Kaplan MB et al. Experience with the Arndt paediatric bronchial blocker. Br J Anaesth 2005; 94: 92–94.

Con: Right-sided double-lumen endotracheal tubes should not be routinely used in thoracic surgery

THERE IS AN ongoing debate as to whether a right-sided double-lumen tube (DLT) should be routinely used in thoracic surgery. The word routine is stressed to distinguish from special situations. The first design of the DLT in 1949 by Carlens1 was designated for left main bronchus intubation.2,3 The takeoff of the right upper lobe (RUL) near the carina made it impossible for the right mainstem bronchus to accommodate the tube without RUL occlusion. Several years later, a DLT was designed by White for right mainstem intubation. The Robertshaw4 design has a ventilating port for the RUL, and the right endobronchial cuff is S-shaped, allowing the RUL ventilation slot to ride over the RUL orifice. In the left main bronchus, the distance between the carina and takeoff of the left upper lobe orifice is adequate to accommodate the tip of the bronchial lumen without occluding the left upper lobe orifice. That distance varies between men and women and has been extensively described by Benumof et al.5 In their study, the distance was determined to be between 5 and 6 cm in women and between 6 and 8 cm in men. In the right main bronchus, the distance between the RUL orifice and the carina is short, and there is a narrow margin of safety. Although there is wide anatomic variation of the distance, most often it is between 1 and 2 cm from the carina. In some cases, the takeoff is adjacent to the orifices of the middle and lower lobes.6-8 In addition, the takeoff of the RUL orifice may often be at the level of the carina or at the trachea. Adequate ventilation requires proper positioning of the DLT with the ventilation slot opening directly into the RUL bronchial orifice. This positioning may be difficult and time-consuming to achieve and is prone to a high incidence of RUL occlusion. It often requires multiple manipulations and tube rotations until the right-sided DLT adequately aligns with the RUL orifice. Fiberoptic confirmation requires a skilled and experienced operator and does not guarantee the absence of intraoperative dislocation resulting from surgical manipulation or changes in patient position. Positioning of the RDL tube blindly, without the use of fiberoptic bronchoscopy, is unacceptable.9-14 Clinical assessment of breath sounds of the RUL is difficult to appreciate, and it is not surprising that the right-sided DLT has low popularity among practicing anesthesiologists. To avoid the problems associated with right-sided DLTs, most clinicians select left-sided DLTs for procedures on the left and right sides. Fig 1 summarizes the issues of concern when a right-sided DLT is used and why, in the author’s opinion, it should not be routinely used during thoracic surgery.

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.

Bronchial Rupture by a Double-Lumen Endobronchial Tube During Staging Thoracoscopy

Bronchial Rupture by a Double-Lumen Endobronchial Tube During Staging Thoracoscopy

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

Predicting the Size of a Double-Lumen Endobronchial Tube Based on Tracheal Diameter

We assessed whether using the tracheal diameter to predict the correct size of the left double-lumen endobronchial tube (DLT) could be used for our generally smaller sized Asian patients. Sixty-six consecutive adult patients under anesthesia for elective surgery requiring the use of a DLT were studied. The size of the left-sided DLT used was based on the width of patients' trachea measured from the preoperative posterior-anterior chest radiograph. The placement of the DLT was standardized and confirmed with fiberoptic bronchoscopy. The correct size of the DLT was the largest size tube inserted into the left bronchus with a small air leak detectable when the endobronchial cuff was deflated but not exceeding the recommended resting volume when inflated for lung isolation. Using this method of choosing our DLT, we found that an oversized DLT was often chosen especially among our female Asian patients. The overall positive predictive values for the male and female patients were 77.3% and 45.5%, respectively. We postulate that this could be due to our criteria for correct DLT size or that our local Asian patients, especially the females, were smaller and shorter. Implications: This study assessed whether the correct double-lumen endobronchial tube size could be predicted from tracheal diameter measurements taken from the chest radiograph. We found that this method of choosing the double-lumen endobronchial tubes was not always reliable. (Anesth Analg 1998;87:158-60)

A new and simple maneuver to position the left-sided double-lumen tube without the aid of fiberoptic bronchoscopy.

The double-lumen tube (DLT) is the mainstay of one-lung ventilation (OLV). We sought to determine whether this new intubation maneuver using an endobronchial cuff pressure could be substituted for verification by fiberoptic bronchoscope (FOB) in most conditions requiring left-sided DLT. Seventy-nine patients requiring video-assisted thoracoscopic surgery for pneumothorax or mediastinal mass, or open thoracotomy for lung or esophageal cancer were enrolled in this study. We used 35F (n = 23), 37F (n = 51), or 39F (n = 5) disposable polyvinyl chloride DLTs (Broncho-Cath; Mallinckrodt Medical Ltd., Athlone, Ireland), depending on the height and gender of the patients. The DLTs were inserted deeply until resistance was felt. At that time, the pilot of the endobronchial cuff was connected to the Control-Inflator (VBM Medizintechnik GmbH, Sulz am Neckar, Germany) via a three-way stopcock. The bronchial balloon was inflated with 1.0-2.0 mL of air through the stop-cock until approximately 30 cm H2O of cuff pressure was obtained. The DLT was slowly withdrawn until the pressure of the Control-Inflator decreased to approximately half the peak pressure during the initial phase of removal. At that time, the bronchial balloon was deflated, and the DLT was advanced approximately 1.0 cm (1.5 cm for the 39F DLT); using FOB, its position was checked by an independent observer not involved in positioning the DLTs. The ideal position was defined as that in which the carina was located at the same level with the middle 5 mm between the proximal margin of the endobronchial balloon and the circumferential black mark. In 50 patients the position was ideal, and in 27 patients it was not ideal but was within the margin of the safety. There were only two failures. We conclude that if a FOB is unavailable or inapplicable, this simple and new maneuver may be used as a substitute during the positioning of DLTs. The correct position of the double-lumen tube is vital for one-lung ventilation, which has been confirmed with a fiberoptic bronchoscope. We devised a simple maneuver to position the double-lumen tube correctly without a fiberoptic bronchoscope.

A New and Simple Maneuver to Position the Left-Sided Double-Lumen Tube Without the Aid of Fiberoptic Bronchoscopy

The double-lumen tube (DLT) is the mainstay of one-lung ventilation (OLV). We sought to determine whether this new intubation maneuver using an endobronchial cuff pressure could be substituted for verification by fiberoptic bronchoscope (FOB) in most conditions requiring left-sided DLT. Seventy-nine patients requiring videoassisted thoracoscopic surgery for pneumothorax or mediastinal mass, or open thoracotomy for lung or esophageal cancer were enrolled in this study. We used 35F (n = 23), 37F (n = 51), or 39F (n = 5) disposable polyvinyl chloride DLTs (Broncho-Cath[trade mark sign]; Mallinckrodt Medical Ltd., Athlone, Ireland), depending on the height and gender of the patients. The DLTs were inserted deeply until resistance was felt. At that time, the pilot of the endobronchial cuff was connected to the Control-Inflator[registered sign] (VBM Medizintechnik GmbH, Sulz am Neckar, Germany) via a three-way stopcock. The bronchial balloon was inflated with 1.0-2.0 mL of air through the stopcock until approximately 30 cm H2 O of cuff pressure was obtained. The DLT was slowly withdrawn until the pressure of the Control-Inflator[registered sign] decreased to approximately half the peak pressure during the initial phase of removal. At that time, the bronchial balloon was deflated, and the DLT was advanced approximately 1.0 cm (1.5 cm for the 39F DLT); using FOB, its position was checked by an independent observer not involved in positioning the DLTs. The ideal position was defined as that in which the carina was located at the same level with the middle 5 mm between the proximal margin of the endobronchial balloon and the circumferential black mark. In 50 patients the position was ideal, and in 27 patients it was not ideal but was within the margin of the safety. There were only two failures. We conclude that if a FOB is unavailable or inapplicable, this simple and new maneuver may be used as a substitute during the positioning of DLTs. Implications: The correct position of the double-lumen tube is vital for one-lung ventilation, which has been confirmed with a fiberoptic bronchoscope. We devised a simple maneuver to position the double-lumen tube correctly without a fiberoptic bronchoscope. (Anesth Analg 1998;86:1271-5)

Airway troubles related to the double-lumen endobronchial tube in thoracic surgery.

Several case reports indicate critical respiratory complications in relation to the double-lumen endobronchial tube (DLT). A prospective survey for the airway problems in using the DLT is presented. One hundred adult patients undergoing thoracotomy for lung cancer were investigated. Tube malposition and airway obstruction were searched using a fiber-optic scope. The endobronchial cuff was positioned just below the trachcal carina while the trachea was intubated with a DLT (Rüsch). The distances of displacement, from the tracheal carina to the bronchial cuff, were measured during anesthesia using an epidural catheter, which had marks every 5 mm. The distances for correcting the tube position were measured at both the bronchial cuff and the level of the teethPaO2,PaCO2 andSPO2 were also measured. Malposition (displacement over 5 mm from the correct position) was found in 42 patients, and 40 of them were in a withdrawal direction, occurring at the postural change and during one-lung ventilation, especially during manipulation of the lung hilum. Correcting distances at the level of the teeth were 15.3-3-times longer than those at the bronchial cuff. Airway deformities and gradual withdrawal of the bronchial cuff were found in association with surgical manipulation. Obstruction occurred at the tips of the tracheal tube in four patients and the bronchial tube in six patients, and at the tip of both in two patients. Hypoxemia (PaO2<60 mmHg) occurred in four patients and hypercapnea (PaCO2>60 mm Hg) in two patients. Most of the DLT obstructions were associated with withdrawal malposition. Great attention to DLT displacement and airway deformity is advised.

The effects of endobronchial cuff inflation on double-lumen endobronchial tube movement after lateral decubitus positioning

Object: This study was designed to measure changes in tracheal and bronchial lumen distances from mainstem and secondary carina with lateral positioning, and to assess whether inflation of the endobronchial cuff before lateral positioning would further secure a double-lumen endobronchial tube (DLT) and reduce movement. Design: Prospective study. Setting: University-affiliated cancer center. Participants: Fifty adult patients scheduled for elective thoracic surgical procedures requiring the placement of a left DLT. Interventions: Patients were sequentially assigned to either the endobronchial cuff-inflated group or the deflated group during lateral positioning. After induction of general anesthesia, a left polyvinylchloride (PVC) DLT was placed and the position confirmed. In the supine position, the distance from the tip of the tracheal lumen to main carina was measured using a fiberoptic bronchoscope (FOB) passed through the tracheal lumen, and the distance from the bronchial lumen to secondary carina was measured with the FOB passed through the bronchial lumen. The patients were then positioned laterally and a second set of measurements taken. Overall movement was determined by increases and decreases in tracheal and bronchial distances obtained by subtracting supine values from lateral values. Measurements and Main Results: There was significant tracheal movement in 40 of 50 patients, with a mean of 0.92 ± 1.0 cm. This was predominantly in the upward direction, as seen in 35 of 50 patients. There was significant bronchial movement in 37 of 50 patients, with a mean of 0.92 ± 1.15 cm. Also, predominance in the upward direction was seen in 34 of 50 patients. Conclusions: DLTs move with lateral positioning, regardless of endobronchial cuff inflation. The movement is predominantly in the upward direction. Therefore, fiberoptic visualization in the supine position should be used only to confirm that the endobronchial lumen is placed on the appropriate side and the cuff is at least 1 cm inside the left mainstem bronchus. Final positioning should always be verified in the lateral position.

Intentional Occlusion of the Right Upper Lobe Bronchial Orifice to Tamponade Life-threatening Hemoptysis

Intentional Occlusion of the Right Upper Lobe Bronchial Orifice to Tamponade Life-threatening Hemoptysis