Right-sided Double-lumen Endotracheal Tube Research Articles

The time-honored left pneumonectomy

With expanding experience in bronchial and vascular sleeve resections, pneumonectomy is avoidable in many cases, however, the thoracic surgeon will be presented with cases in his or her career for which resection is only possible by pneumonectomy. In their review, Kostoulas et al. provide a thorough review of surgical technique for left pneumonectomy, highlighting several key pearls and pitfalls. Similar to the authors’ technique, we begin every case with a flexible bronchoscopy to assure that an R0 bronchial resection margin is technically feasible. We similarly prefer a right-sided double-lumen endotracheal tube (ETT); however, the readers should understand that a left-sided bronchial blocker placed through a single lumen endotracheal tube is a possible alternative, and should pay close attention that is removed before clamping or dividing the left mainstem bronchus.

Endobronchial intubation in thoracic surgery: Which side should be preferred?

This study was undertaken to compare the clinical performance of right versus left double-lumen endotracheal tubes placed without using fiberoptic bronchoscopy in thoracic surgery operations. This was a retrospective review of patients who were operated on in our institution between January 2013 and February 2014. We analyzed clinical performance in terms of hypoxia, hypercapnia, and adequate deflation of the lungs with both left- and right-sided double-lumen endotracheal tubes. There were 80 patients with a mean age of 53.74 ± 15.59 years. Right-sided double-lumen tubes were used in 33 patients, and left-sided double-lumen tubes were used in 47. Perioperative hypoxi (p < 0.05), hypercapnia (p < 0.01), and inadequate deflation of the lung (p < 0.001) were found more frequently with the use of right-sided double-lumen endotracheal tubes. Arterial blood gas analyses in the post-anesthesia care unit showed that high pCO2 (>45 mm Hg), low pH (<7.36), and high lactate levels (>4 mmol L(-1)) were more frequent with right-sided double-lumen endotracheal tubes (p < 0.001). The incidence of atelectasis was greater (p < 0.001) and the duration of hospital stay was longer (p = 0.02) with the use of right-sided double-lumen endotracheal tubes. Right-sided double-lumen endotracheal tubes resulted in poorer clinical performance. Therefore, a left-sided double-lumen endotracheal tube should be preferred in thoracic surgery operations when an appropriate size of fiberoptic bronchoscope is not available.

Value of Lung Sonography to Control Right-Sided Double Lumen Endotracheal Tube Location

Value of Lung Sonography to Control Right-Sided Double Lumen Endotracheal Tube Location

Bronchial obstruction by tumor embolus of contralateral lung during pneumonectomy: report of a case

Bronchial obstruction due to a tumor embolus of the contralateral lung during pneumonectomy is an uncommon and fatal complication. According to previous cases, a bronchial balloon of double-lumen endotracheal tube (DLT) could prevent a dislodged tumor from traveling to the contralateral lung. We experienced a tumor embolism from the bronchus with cancer to the other bronchus despite applying DLT. A 59-year-old male with endobronchial lung cancer underwent a left pneumonectomy. One-lung ventilation was established by the right-sided DLT. After a left bronchial division, a sudden increase of peak airway pressure and reduction of the expired tidal volume to 50 ml was observed. Intraoperative fiberoptic bronchoscopy showed a near total obstruction of the right main bronchus due to tumor emboli. It was not possible to remove the tumor embolus through bronchoscopic suction and forceps. Therefore, we reopened the left bronchial stump and successfully extracted tumor embolus under bronchoscopic guidance.

Value of lung sonography to control of right-sided double lumen endotracheal tube location

Ponsonnard, S.; Gardet, E.; Bertin, F.; Marsaud, J. P.; Fuzier, R.; Nathan, N. Author Information

How to achieve successful lung separation

ABSTRACTRecent advances in surgical techniques for thoracic, cardiac, and oesophageal surgery have led to an increased use of lung separation techniques. Currently, double-lumen endotracheal tubes (DLT) and bronchial blockers (an Arndt wire-guided endobronchial blocker, a Cohen Flexitip endobronchial blocker, or the Fuji Uniblocker) are used.1–3 Achieving successful lung separation relies on knowledge of the anatomical distances of the airway, flexible fibreoptic bronchoscopy techniques, and familiarity with left and right-sided DLTs and bronchial blockers.In general, lung isolation techniques are designed to: facilitate surgical exposure for cases involving the thoracic cavity, to prevent contamination of the contralateral lung in cases where pus or haemorrhage is present, and to establish airway continuity such as in a patient who presents with bronchopleural fistula and requires mechanical ventilation. Specific indications with bronchial blockers include: patients with difficult airways, patients with ...

Results of the Study Comparing Devices Used for Lung Isolation Are Rather Concerning

Results of the Study Comparing Devices Used for Lung Isolation Are Rather Concerning

Margin of Safety in Positioning Double-lumen Endotracheal Tubes Using a Fiberoptic Bronchoscope in Korean Adult

Background: The margin of safety is the length of the mainstem bronchi, over which double-lumen endotracheal tubes (DLTs) can be moved and still be correctly positioned. A negative value of margin of safety means that DLTs may not be safe. We measured the length of the left and right mainstem bronchi and margin of safety in Korean adults. Methods: One hundred and fifty-six ASA I or II adult patients undergoing an elective surgery were examined. After induction of general anesthesia, we measured the lengths from the upper incisor to the tracheal carina, to the proximal margin of the left and right upper lobe bronchial opening using a fiberoptic bronchoscope. We calculated the lengths of the left and right mainstem bronchi and margin of safety using the measured lengths. Results: In Korean adults, the average margin of safety of left-sided DLTs of males and females was 2.4 1.0 cm and 1.9 0.7 cm and right-sided DLTs of males and females was 1.0 0.9 cm and 0.8 0.3 cm, respectively. The percentage of a negative value of the margin of safety in positioning right-sided DLTs was 10.4% in males and 8.6% in females. However, all values of the margin of safety in left-sided DLTs were positive. Conclusions: Using left-sided DLTs, regardless of the operative side, is better than right-sided DLTs because left-sided DLTs have a greater margin of safety in positioning. If we use right-sided DLTs, we should confirm the proper position of tubes using a fiberoptic bronchoscope.

Pro: Right-sided double-lumen endotracheal tubes should be routinely used in thoracic surgery

Pro: Right-sided double-lumen endotracheal tubes should be routinely used in thoracic surgery

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.

LUNG ISOLATION TECHNIQUES

Left-sided double-lumen endotracheal tubes should be the tube of choice for most cases in which lung isolation is required. A right-sided double-lumen endotracheal tube can be used effectively when a contraindication to placing a left-sided double-lumen endotracheal tube exists. The method of choice to select left-sided double-lumen endotracheal tubes is based on chest radiograph or CT scan measurements of the trachea or bronchus. Based on clinical reports, Univents or WEB blockers may be a better choice for patients with difficult airways who require one-lung ventilation or for when a selective lobar blockade is needed. For all selective intubation, the method of choice for proper tube placement and bronchial blockade is fiberoptic bronchoscopy with the patient in a supine position at first or in a lateral decubitus position later, or if a malposition occurs.

Right Versus Left Double-Lumens for Left-Sided Thoracic Surgery

In Response: We appreciate the interest and comments of Dr. Schulman regarding our study (1). Benumof (2) recommends that the nonoperated mainstem bronchus should be routinely intubated because intubation of the operative mainstem bronchus may interfere with the performance of surgery. The “ball valve obstruction” suggested by Dr. Schulman, and described by others (3–4), leads us to believe that this may be another advantage of a right-sided double-lumen endotracheal tube (R-DLT) for left-sided thoracic surgery. We did not observe this problem in the 20 patients who received left-sided double-lumen endotracheal tubes (L-DLT) for left-sided thoracic surgery (1). Furthermore, we have not experienced this problem in our thoracic surgical practice overall–approximately 400 thoracotomy and thoracoscopic cases per year. Factors that should be considered before selecting a R-DLT for the “ball valve problem” include size of the tumor and proximity to the tracheal bifurcation or mediastinum. We advocate the use of a L-DLT for a left-sided thoracic surgery, unless there are contraindications to its use, for example, an exophytic lesion that causes compression of the left mainstem bronchus, intraluminal tumor that arises from the left main bronchus, tracheobronchial disruption, left-sided pneumonectomy, left lung transplantation, or a descending thoracic aortic aneurysm that compresses the left main bronchus. We believe that the “ball valve problem” is probably rare, but always should be considered when double-lumen endotracheal tubes and one-lung ventilation are planned. Javier H. Campos MD* Kemp H. Kernstine MD†

Right Versus Left Double-Lumens for Left-Sided Thoracic Surgery

In Response: We appreciate the interest and comments of Dr. Schulman regarding our study (1). Benumof (2) recommends that the nonoperated mainstem bronchus should be routinely intubated because intubation of the operative mainstem bronchus may interfere with the performance of surgery. The “ball valve obstruction” suggested by Dr. Schulman, and described by others (3–4), leads us to believe that this may be another advantage of a right-sided double-lumen endotracheal tube (R-DLT) for left-sided thoracic surgery. We did not observe this problem in the 20 patients who received left-sided double-lumen endotracheal tubes (L-DLT) for left-sided thoracic surgery (1). Furthermore, we have not experienced this problem in our thoracic surgical practice overall–approximately 400 thoracotomy and thoracoscopic cases per year. Factors that should be considered before selecting a R-DLT for the “ball valve problem” include size of the tumor and proximity to the tracheal bifurcation or mediastinum. We advocate the use of a L-DLT for a left-sided thoracic surgery, unless there are contraindications to its use, for example, an exophytic lesion that causes compression of the left mainstem bronchus, intraluminal tumor that arises from the left main bronchus, tracheobronchial disruption, left-sided pneumonectomy, left lung transplantation, or a descending thoracic aortic aneurysm that compresses the left main bronchus. We believe that the “ball valve problem” is probably rare, but always should be considered when double-lumen endotracheal tubes and one-lung ventilation are planned. Javier H. Campos MD* Kemp H. Kernstine MD†

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

Right upper lobe obstruction with right-sided double-lumen endobronchial tubes: A comparison of two tube types

Twenty-nine patients undergoing left thoracotomy consecutively were intubated with right-sided double-lumen endotracheal tubes in the conventional “blind” fashion. The first 20 received Leyland red-rubber double-lumen tubes, and the subsequent nine received Mallinckrodt polyvinylchloride double-lumen tubes. The patency of the right upper lobe bronchial orifice was then assessed by flexible fiberoptic bronchoscopy. Right upper lobe obstruction occurred in 89% of the polyvinylchloride tube intubations and in 10% of the red-rubber tube intubations.