Endobronchial Lumen Research Articles

USE OF VIDEO LARYNGOSCOPE FOR DIFFICULT AIRWAY MANAGEMENT IN THORACIC SURGERY: A CASE STUDY

We present the clinical case of a 76-year-old male with the following medical history: Active smoker (2 packs/day),moderate obesity, moderate COPD. arterial hypertension, mellitus diabetes 2, dyslipidemia. Lacunar stroke without neurological damage, infrarenal abdominal aortic aneurysm of 40 mm, under follow-up in policlinic of Vascular Surgery, 1st degree atrioventricular block, under follow-up by Cardiology. Normal Echocardiography. PET-CT: Hypermetabolic pulmonary nodule in RUL, suggestive of cancer. FUNCTIONAL TESTS: Moderate obstructive pattern. FEV1 2.20 (72%), FEV1/FVC 58. DLCO 5.80 (64%). AIRWAY EXPLORATION: Retrognatia, Mallampati III, significant cervical stiffness, thick neck and degree of movement of head and neck < 80°. Case Management: Placement of thoracic epidural catheter (T5-T6) prior to induction for analgesic control during intraoperative and postoperativeperiod. Non-invasive blood pressure monitoring, 5-lead ECG, temperature, peripheral oxygen saturation (SpO2), Bispectral Index (BIS) and Train-of-four (TOF). In the presence of predictors of possible difficult airway and ventilation, material is prepared for management of possible difficult airway Pre-oxygenation with face mask and FiO2 1 until EtO2 85 mmHg is reached. Rapid sequence induction was performed with intravenous midazolam, fentanyl, propofol and 1,2 mg/kg of rocuronium. After reaching TOF 0, direct laryngoscopy was initially performed but a Cormark-Lehane (CL) III was observed.Indirect laryngoscopy was then performed with a McGrath video laryngoscope with a n°4 disposable blade, showing a CL I. Subsequently, an 11 Fr airway exchange catheter was introduced through the vocal cords into the trachea; then, the proximal end of the airway exchange catheter was inserted into the endobronchial lumen of the 37Fr Vivasight DL, to permet its insertion into the trachea guided by this airway exchange catheter under the vision of the McGrath videolaryngoscope. Once the VivaSight DL was inserted into the trachea, the airway exchange catheter was removed and the VivaSight DL tube was turned left 90° and was inserted successful into the left main bronchus guided by embedded camera of this special type of DLT. Anesthesia maintenance was performed with inhalated sevoflurane and continuous intravenous infusion of remifentanil and rocuronium. Epidural elastomer of levobupivacaine 0.125% at 7 ml/h. Controlled ventilation is maintained in volume control mode, with Tidal Volume (TV) at 7 ml/kg ideal weight in two-lung ventilation and 5 ml/kg ideal weight in one-lung ventilation. Alveolar Recruitment Maneouvres (ARM) after intubation and at start of one-lung ventilation (OLV) were performed. Good mechanics and adequate gas exchange throughout the procedure, with no episodes of desaturation. After completion of surgery, reversal of neuromuscular blockade was achieved with sugammadex at 2 mg/kg. After checking TOF ratio> 90% and adequate level of consciousness, optimal respiratory mechanics and a 100% SpO2, extubation was performed without incident. He was transferred to the intensive care unit for post-surgical control during the first 24 hours.

Unexpected difficult intubation with a double-lumen tube in a case of asymptomatic vallecular cyst.

Vallecular cyst (VC) can cause difficult intubation. If a double-lumentube (DLT) has to be placed, difficulty in tracheal intubation becomes more complicated. The gum elastic bougie (GEB) is a widely used device for facilitating tracheal intubation.However, there is not enough study with DLT to make a predictionfor success of GEB-guided intubation. Here, we aimed to describe our approach during unexpected difficult intubation due to VC in a patient required DLT insertion. We emphasize that, in case of confronting a patient with asymptomatic VC as a cause of difficult intubation, a successful DLT intubation is possible by sliding endobronchial lumen of DLT over pediatric GEB.

Non-ventilated lung deflation during one-lung ventilation with a double-lumen endotracheal tube: a randomized-controlled trial of occluding the non-ventilated endobronchial lumen before pleural opening.

Lung deflation during one-lung ventilation (OLV) is thought to be faster using a double-lumen endotracheal tube (DL-ETT) than with a bronchial blocker, especially when the non-ventilated lumen is opened to allow egress of air from the operative lung. Nevertheless, ambient air can also be entrained into the non-ventilated lumen before pleural opening and subsequently delay deflation. We therefore hypothesized that occluding the non-ventilated DL-ETT lumen during OLV before pleural opening would prevent air entrainment and consequently enhance operative lung deflation during video-assisted thoracoscopic surgery (VATS). Thirty patients undergoing VATS using DL-ETT to allow OLV were randomized to having the lumen of the operative lung either open (control group) or occluded (intervention group) to ambient air. The primary outcome was the time to lung collapse evaluated intraoperatively by the surgeons. The T50, an index of rate of deflation, was also determined from a probabilistic model derived from intraoperative video clips presented in random order to three observers. The median [interquartile range] time to lung deflation occurred faster in the intervention group than in the control group (24 [20-37] min vs 54 [48-68] min, respectively; median difference, 30 min; 95% confidence interval [CI], 14 to 46; P < 0.001). The estimated T50 was 32.6 min in the intervention group compared with 62.3 min in the control group (difference, -29.7 min; 95% CI, -51.1 to -8.4; P = 0.008). Operative lung deflation during OLV with a DL-ETT is faster when the operative lumen remains closed before pleural opening thus preventing it from entraining ambient air during the closed chest phase of OLV. www.clinicaltrials.gov (NCT03508050); registered 27 September 2017.

Clinico-etiological profile of patients presenting with hemoptysis diagnosed by fiber optic bronchoscopy - A study done in tertiary care centre of central Karnataka

Introduction: Hemoptysis is a common complaint among patients attending chest clinics. Clinical profile and etiology may vary depending upon patient population studied. Fiber optic bronchoscopy (FOB) is a useful diagnostic tool in such cases to establish accurate diagnosis. Aim: To study the clinical and etiological profile of patients presenting with hemoptysis at our tertiary care centre. To define the diagnostic yield of FOB in these patients. Materials and Methods: Institutional based observational prospective study was conducted on 60 patients who presented with hemoptysis to the department of pulmonary medicine at our tertiary care centre. All patients underwent FOB after thorough clinical, radiological and laboratory evaluation. Results: Mean age of the patients studied was 43.93 ± 13.20 yrs, predominant were male 38(63.3%). Sputum production in 42 patients (70%) was the most common associated symptom followed by dyspnea 34(56.7%) and fever 20(33.3%). On FOB, congestion of the endobronchial lumen was seen in 44 (73.3%), ectasia in 16 (26.6%), bleeding site was localized in 30 (50%) patients. Broncho alveolar lavage (BAL) was positive for Acid fast bacilli in 12 (20%), bacterial culture in 6 (10%) and fungal elements in 2 (3.33%) patients. Endobronchial biopsy (EBB) diagnosed lung malignancy in 10(16.7%) patients. Conclusion: Bronchiectasis was the most common cause of hemopytsis followed by pulmonary tuberculosis. FOB resulted in diagnosis of three-fourths of the patients analysed in our study with a positive yield of 76.6%. Keywords: Hemoptysis, Etiological profile, Fiberoptic bronchoscopy (FOB).

Bronchoscopic Observation of Endobronchial Tumor Cells

A 68-year-old woman presented with cough and dyspnea. Chest x-ray film and computed tomography revealed atelectasis in the right upper lobe. She had a history of a bladder neoplasm, which was treated by cystectomy and chemotherapy. Flexible bronchoscopy revealed a polypoid tumor in the right upper lobe bronchus, protruding into the right main bronchus. Further, we observed the surface of the tumor by using the endocytoscopy system. The endocytoscopy system showed oval-shaped tumor cells with prominent nuclei on the surface of the tumor with a methylene blue dye staining. Biopsied specimen of the tumor demonstrated foci of metastatic urothelial carcinoma. These cancer cells were similar to the cell images of endocytoscopy system. This technology may have the potential to provide pathologic diagnosis during bronchoscopy.

Bronchoesophageal Fistula

Bronchoesophageal fistula (BEF) is an undesirable consequence of esophageal cancer. A BEF is encountered in 5% to 15% of patients with esophageal cancer. It is generally a life-threatening complication because of the development of recurrent pulmonary infection and sepsis. We present a case with esophageal cancer and acquired BEF. The fistula allowed herniation of the esophageal wall into the endobronchial lumen, causing significant obstruction of the airway lumen, findings not reported previously.

Clinical Application of Direct Bronchial Ultrasound to Visualize and Determine Endobronchial Tumor Margins for Surgical Resection

We describe the first experience of direct bronchial (epi-bronchial) ultrasound to visualize and determine the endobronchial tumor margins for surgical resection. An ultrasound probe was applied onto the membranous portion of the right main bronchus directly over a pedunculated tumor. The tumor was visualized due to the water content, with a total loss of signal (air-tumor interface) at the tumor edge. A sterile marker was used to outline the air-tumor interface. Traditionally, surgical technique involves palpation of the tumor with an incision to inspect the endobronchial lumen determining the position of the pedicle, thus estimating the amount of airway to resect. Using direct bronchial ultrasound, the right main palpated margin was 0.5-cm proximal to the ultrasound margin, which correctly identified the tumor margin. The upper lobe palpated margin was 1 cm proximal to the ultrasound margin, which correctly identified the tumor margin. In the intermediate bronchus, the palpated and ultrasound margin were the same and correct. By using the air-tumor interface, epi-bronchial ultrasound scanning can accurately demarcate the base of endobronchial tumors for surgical resection and reconstruction.

Foreign-body excretion through the bronchial stump after extrapleural pneumonectomy

Foreign-body excretion is a bioresponse of the human body. Bronchial foreign bodies commonly occur through aspiration or inhalation. We present a rare case of the excretion of a foreign body through the bronchial stump 19 months after pneumonectomy. A 52-year-old man had a high fever and chest discomfort. He underwent a left extrapleural pneumonectomy for malignant pleural mesothelioma 19 months earlier. He received postoperative chemotherapy, which consisted of 4 cycles of cisplatin, doxorubicin, and cyclophosphamide, and sequential radiation therapy for the entire hemithorax of 56 Gy in total.1Sugarbaker D.J. Strauss G.M. Lynch T.J. Richard W. Mentzer S.J. Lee T.H. et al.Node status has prognostic significance in the multimodality therapy of diffuse malignant mesothelioma.J Clin Oncol. 1993; 11: 1172-1178Crossref PubMed Scopus (200) Google Scholar, 2Sugarbaker D.J. Grarcia J.P. Richards W.G. Harpole Jr, D.H. Healy-Baldini E. DeCamp Jr, M.M. et al.Extrapleural pneumonectomy in the multimodality therapy of malignant pleural mesothelioma Result in 120 consecutive patients.Ann Surg. 1996; 224: 288-294Crossref PubMed Scopus (196) Google Scholar Blood count showed luekocytosis, and chemistry showed an increased C-reactive protein level. Chest radiography showed no abnormal lesions except for left-side opacity after pneumonectomy. Computed tomography of the chest and the abdomen showed no evidence of recurrence of malignant pleural mesothelioma. Culture of thoracentesis fluid showed no growth of microorganisms. Bronchoscopic examination revealed a foreign body, a whitish cottony material, at the left main bronchial stump (Figure 1). Endoscopic extraction with forceps identified a hemostat of oxidized cellulose (Figure 2). After the extraction, a blue suture was translucently identified in the mucosa of the bronchial stump. Bronchopleural fistula was not seen during or after the extraction. Culture of the material revealed Haemophilus species. After the removal of the infected foreign body, the patient recovered quickly and has been doing well for 3 years.Figure 2Oxidized cellulose extracted with forceps broncho-scopically.View Large Image Figure ViewerDownload (PPT) The bronchial stump at the left extrapleural pneumonectomy was hand sutured with interrupted polypropylene sutures (3-0 Prolene; Ethicon Inc, Somerville, NJ) and reinforced with a pedicled intercostal muscle by using the same polypropylene sutures for bronchus. On the next day, the patient underwent a re-exploration of the thorax as a result of the excessive blood loss. After hemostasis was obtained, cotton-type oxidized cellulose (Oxycel; Sankyo Co, Tokyo, Japan) was inserted into the mediastinum as a hemostat. Bronchoscopic examination 4 weeks after the pneumonectomy showed normal findings at the bronchial closure. For 19 months of postoperative follow-up, the patient had been without any symptoms of bronchopleural fistula, and chest radiography had never shown an air-fluid level in the left thorax. The bronchial stump should have been airtight since the extrapleural pneumonectomy. In the literature most foreign bodies found in the airway are the result of aspiration or inhalation. On the other hand, several bronchial foreign bodies that were not inhaled have been reported. Migration of shrapnel from the pulmonary parenchyma into a bronchus 64 years after the injury was reported.3Bogedain W. Migration of shrapnel from lung to bronchus.JAMA. 1984; 251: 1862-1863Crossref PubMed Scopus (11) Google Scholar Two foreign bodies with uncommon ways of entry were removed with a bronchoscope: one was a bullet that eroded in the right lower bronchus after having penetrated through a wound in the chest wall, and the other was a fragment of circular saw lodged in the right main bronchus after penetration through a wound in the neck.4Aprigliano F. Bronchial foreign bodies: an uncommon way to entry.Ann Otol Rhinol Laryngol. 1990; 99: 695-697PubMed Google Scholar Recent literature also described expectoration of titanium staples in 3 patients many months after volume-reduction surgery for pulmonary emphysema.5Oey I. Waller D.A. Metalloptysis: a late complication of lung volume reduction surgery.Ann Thorac Surg. 2001; 71: 1694-1695Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Jackson and Jackson6Jackson C. Jackson C.L. Bronchoesophagology. WB Saunders, Philadelphia (PA)1950Crossref Google Scholar mentioned that foreign bodies, especially metallic ones that cause little specific reaction, can reach the bronchi through penetration of the chest wall. However, few nonmetallic foreign bodies migrating into the airway have been reported. Our patient appeared to have excreted a hemostat of oxidized cellulose from the thoracic cavity into the endobronchial lumen through the sutures of the bronchial stump. The foreign-body reaction of cellulose has been known to be mild in in vivo experiments.7Miyamoto T. Takahashi S. Ito H. Inagaki H. Noishiki Y. Tissue biocompatibility of cellulose and its derivatives.J Biomed Mater Res. 1989; 23: 125-133Crossref PubMed Scopus (304) Google Scholar Although the mechanisms of the migration remain unknown, we would provide evidence of a rare nonmetallic foreign body in the airway through the bronchial stump.

A double-lumen tube technique for selective lobar isolation

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

Lymph node trafficking and antigen presentation by endobronchial eosinophils.

Because eosinophils recruited into the airways in allergic diseases are exposed to inhaled allergens, we evaluated whether eosinophils within the endobronchial lumen can function in vivo as antigen-presenting cells for inhaled antigens. We recovered eosinophils from the airways after aerosol antigen challenge in sensitized mice or from the peritoneal cavities of IL-5 transgenic mice and fluorescently labeled these cells ex vivo. These labeled cells, instilled intratracheally into normal mice, migrated into draining paratracheal lymph nodes and localized to T cell-rich paracortical areas. The homing of airway eosinophils to lymph nodes was not governed by eotaxin, because CCR3(-/-) and CCR3(+/+) eosinophils migrated identically. Airway eosinophils, recovered after inhalational antigen challenge in sensitized mice, expressed MHC class II and costimulatory CD80 and CD86 proteins and functioned in vitro as CD80- and CD86-dependent, antigen-specific, antigen-presenting cells. Moreover, when instilled into the airways of antigen-sensitized recipient mice, airway eosinophils recovered after inhalational antigen challenge stimulated antigen-specific CD4(+) T cell proliferation within paratracheal lymph nodes. Thus, eosinophils within the lumina of airways can process inhaled antigens, traffic to regional lymph nodes, and function in vivo as antigen-presenting cells to stimulate responses of CD4(+) T cells.

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.

Atelectasis of Right upper Lobe after Left Thoracotomy under General Inhalation Anesthesia

Acute airway obstruction during endotracheal anesthesia is embarrassing and critical situation which requires early diagnosis and immediate management. A 57-year-old man was scheduled for right pneumonectomy for a destroyed lung by fibroatelectatic changes and pleural calcification of right lung. We experienced high arterial PCO2 and inspiratory resistance during Left - Sided Double Lumen Endobronchial anesthesia in the left decubitus position. We exchanged tube after failure of suction and found airway obstruction due to mucous plug attached to the bevel of the endobronchial lumen. (Korean J Anesthesiol 1997; 32: 127∼130)

Bronchial Cuff Inflation Technique for Proper Positioning of Double-lumen Endobronchial Tube

Background: Accurate placement of double-lumen endobronchial tube(DLT) is essential for successful one-lung anesthesia. This study was performed to evaluate the effectiveness of bronchial cuff inflation technique for accurate placement of DLT. Methods: One hundred and five patients undergoing elective thoracotomy which required the use of DLTs were studied. Following induction of anesthesia, the tip of the left-sided DLT was advanced just past the vocal cords, the stylet in the endobronchial lumen was removed and the tube was rotated 90 degrees counterclockwise. After rotation of DLT, the bronchial cuff was inflated with air(4-6 ml) and the tube was advanced until resistance to further passage was encountered. After deflating of the bronchial cuff, the tube was advanced 2 cm more distally. The fiberoptic bronchoscopy was then introduced into the tracheal lumen of the tube and the tube's position was evaluated. Results: In the 100 patients out of 105 patients, the tube was inserted into the left side bronchus correctly. In the 77 patients(77 %) out of 100 patients, the position of DLTs was evaluated as ideally placed. In the l6 patients(16 %), the tube was evaluated as too deeply inserted into the appropriate bronchus and in the other 7 patients, the tube was too shallow. But only one patient needed repositioning. Conclusions: Bronchial cuff inflation technique may be useful for accurate placement of DLT for the one-lung anesthesia in the situation without fiberoptic bronchoscope. (Korean J Anesthesiol 1996; 31: 330-333)

Spontaneous pneumothorax in early pregnancy: Successful management by thoracoscopy

Spontaneous pneumothorax in early pregnancy: Successful management by thoracoscopy

Con: Proper Positioning of a Double-Lumen Endobronchial Tube Can Only Be Accomplished With the Use of Endoscopy

T HE GREAT advantage of double-lumen tubes (DLTs) in thoracic surgery is that either or both lungs can be ventilated independently while isolating each lung. Unfortunately, because of problems with their accurate placement, many anesthesiologists do not use these tubes as often as they should. Since a misplaced DLT can result in hypoxemia, airway trauma, and unsuitable surgical conditions, many experts recommend that endoscopy always be performed to ensure their proper positioning. In my opinion, if you choose the appropriate DLT and understand the information easily obtained by carefully listening to breath sounds during their placement, fiberoptic bronchoscopy is seldom, if ever, needed. The three most common positioning complications associated with DLTs are not passing the tube sufficiently far down into the bronchus, intubation of the wrong bronchus, and passing the tube too deep into the correct bronchus resulting in upper lobe obstruction. All these problems can be easily recognized without bronchoscopy by using the following simple technique for DLT placement.’ Following induction of anesthesia, the tip of the DLT is advanced just past the vocal cords, the stylet in the endobronchial lumen is removed, and the tube is rotated 90” in the direction of the bronchus to be intubated. Since most anesthesiologists prefer a left-sided DLT for either right or left thoracotomy, the steps for left endobronchial intubation will be described. The tube should be advanced until moderate resistance to further passage is encountered. Both the tracheal and endobronchial cuffs are then inflated with air. It is essential that a large DLT be used. Men should be intubated with a 41F and most women with a 39F polyvinylchloride (PVC) DLT. Only 1 to 2 mL of air should be needed for the bronchial cuff. If more than 3 mL of air is required to seal the bronchus, the bronchial cuff is either herniating above the carina or may be completely in the trachea. A bronchoscope is not needed to recognize a tube that is not deep enough. The patient should be ventilated with both cuffs still inflated. With a clear PVC DLT, moisture should appear in both lumens. The chest wall is observed for equal movement and is auscultated with special attention for any differences in breath sounds over the left upper and lower lung fields. Next, the tracheal lumen should be occluded with a surgical clamp. Breath sounds should now be heard only over the intubated left lung. If breath sounds are present bilaterally, the tube is far too high in the trachea. If breath sounds are heard only over the right lung while ventilating through the endobronchial lumen, the tube is down the wrong side. This problem is easily remedied by deflating both cuffs, pulling the tube back until its tip is above the carina, and rotating it to the left while again advancing it until resistance is encountered. The left endobronchial lumen should then be clamped and the patient ventilated. Breath sounds should be heard only over the right lung. If there is now difficulty ventilating through the tracheal lumen with a marked resistance to air flow with both cuffs inflated, the tube is either too far into the left bronchus or still not deep enough. At this point, the tube’s position can be determined, without bronchoscopy, by deflating only the endobronchial cuff while continuing to ventilate only through the tracheal lumen with the left (endobronchial) lumen occluded. If the tube is too deep into the left bronchus, breath sounds will now be heard only on the left (Fig 1). If the tube is not deep enough into the bronchus, breath sounds will now be heard bilaterally (Fig 2). Both cuffs should be deflated and the DLT advanced or withdrawn depending on the results of the previous maneuver. Once this sequence of steps is understood, a DLT can be quickly, safely, and accurately positioned in less than a minute. It is important that

Rate of gas absorption during atelectasis.

Rate of gas absorption during atelectasis.