Double-Lumen Endotracheal Tube Placement: Knowing Depth of Insertion Firsthand May Make a Difference

Abstract

SURGICAL PROCEDURES performed in the thoracic cavity, such as pulmonary resection, lung transplantation, spine surgery, descending aorta repair, and esophagectomy, require collapse of the lung on the ipsilateral side of the surgery to facilitate exposure and create optimal surgical conditions. 1-6 As a consequence, anesthesiologists need to be furnished with proper devices (lung isolation devices) and equipment (fiberoptic bronchoscopy) necessary to create conditions feasible for surgery with one-lung ventilation (OLV). Major technologic advances have been made in airway devices to facilitate lung isolation and OLV such as the bronchial blocker, the conventional double-lumen tracheobronchial tube (DLT), and the VivaSight video DLT (ETView Ltd, Misgav, Israel). 7-12 There still is much debate and controversy as to choice of airway device to create OLV and size of device, particularly as it pertains to DLTs. 13-15 In contemporary anesthesia practice, however, the conventional left-sided DLT (LDLT) is the preferred device for lung isolation and OLV because of its ease of insertion, reliability, better efficacy of lung isolation, and cost efficiency. 1-7 In all practical matters, the LDLT is safe for lung isolation, with less than 1% incidence of major complications, mainly from incorrect selection of size. 15 Nevertheless, it has been associated with malposition and dislodgement, which are influenced by multiple factors attributed to the patient (sex, height, and weight); surgery (patient positioning, right or left surgery); operator (experience and equipment used); and the DLT itself (depth of insertion, DLT size, and cuff inflation). 2-7,15 The LDLT is an airway device composed of a proximal endotracheal lumen and a distal endobronchial lumen in a sideby-side fashion. Commonly used LDLTs in adults are sizes 35 French (Fr), 37 Fr, 39 Fr, and 41 Fr, which have external bronchial diameters of 11.7 mm, 12.3 mm, 13.0 mm, and 13.7 mm, respectively. 9 Traditionally, the LDLT is placed in a blind fashion using direct laryngoscopy. After the LDLT is

Lung Isolation in the Setting of a Tracheostomy Stoma: Anesthesiologists Beware!

“…Commonly used airway management techniques for one-lung ventilation (OLV) in the setting of a tracheostomy stoma include bronchial blocker insertion through a cuffed low-pressure tracheostomy tube; bronchial blocker insertion through a single-lumen tube (SLT) placed through either the tracheostomy stoma or orotracheally; double-lumen tube (DLT) insertion through a tracheostomy stoma or orotracheally; placement of an EZ-Blocker (Teleflex, Wayne, PA) through either the tracheostomy stoma or orotracheally; and endobronchial placement of a SLT contralateral to the surgical hemithorax. 3 The safety, efficacy, and feasibility of the previously mentioned approaches for lung isolation in the setting of a tracheostomy stoma in situ are yet to be determined.…”

“…It may be useful to select a SLT based on the internal diameter of the bronchus, which can be measured on chest computed tomography. 3 The DLT, which is the most commonly used airway device for lung isolation in patients with normal airways, 3 is used less commonly in tracheostomy patients because of its large external diameter, which can cause tracheostomal injury and airway bleeding. When the decision is made to use a DLT, placing it through the stoma comes with significant challenges.…”

“…They also contest that the right bronchus may become injured because of inadvertent overinflation of the SLT cuff. In a previous publication regarding tracheobronchial anatomy, 3 we clearly described the right mainstem bronchus anatomy. In men, the distance from the tracheal carina to the takeoff of the right upper lobe bronchus is an average of 2 cm, whereas it is approximately 1.5 cm in women.…”

Preintubation Adult Fiberoptic Bronchoscope Assessment—An Effective Way to Know Depth of Insertion of Double-Lumen Tube

“…We read with great interest the study "Chest computed tomography image for accurately predicting the optimal insertion depth of left-sided double-lumen tube" by Liu et al 1 and an editorial, "Double lumen endotracheal tube placement-knowing depth of insertion firsthand may make a difference," by Essandoh et al 2 Authors of the study measured distance from vocal cords to carina using computed tomography (CT) scan, which was used to guide double-lumen tube (DLT) insertion. With this method, they could achieve satisfactory position of the DLT in 90% of patients within a significantly shorter time as compared to blind insertion of the DLT.…”

“…We read with great interest the work from Jellish and Oftadeh about peripheral nerve injury after cardiac surgery. 1 Their article well summarizes the known nerve lesions related to cardiac surgery, together with the pathophysiology and clinical workup. Among the possible iatrogenic lesions, which can affect patients undergoing cardiac surgery, a significant role is played by diaphragmatic dysfunction due to phrenic nerve injury.…”