The effect of gel lubrication on cuff leakage of double lumen tubes during thoracic surgery*

Abstract

SummaryHigh-volume, low-pressure tracheal cuffs of disposable double lumen tubes may offer limited protection to the dependent lung if fluid leaks through folds in the inflated cuffs. This study was undertaken to determine the incidence of fluid leakage past the tracheal cuff and whether gel lubrication reduces the incidence. Fifty-five patients were randomly assigned to receive a double lumen tube with or without gel lubrication. The dependent lung was intubated. With the patient in the lateral position, methylthionium chloride was administered above the tracheal cuff via a pre-attached catheter. Fibreoptic bronchoscopy was performed to determine if dye had passed the tracheal cuff. Three patients were excluded. Dye leakage was seen in 12 ⁄ 27 and 3 ⁄ 25 patients in the unlubricated and lubricated group, respectively (p = 0.014). Gel lubrication significantly reduces fluid leakage past the tracheal cuff of a double lumen tube and should be considered for all thoracic surgical patients requiring one-lung ventilation. Post-thoracotomy pulmonary complications are the major cause of morbidity and mortality in patients undergoing lung resection [1] but their aetiology is not well understood. Intra-operative lung contamination may contribute to the development of pulmonary complications. For patients undergoing thoracotomy in the lateral position, the inflated tracheal cuff of a double lumen tube (DLT) is often the last barrier to lung contamination by oropharyngeal material, including refluxed gastric acid. Gastro-oesophageal reflux is relatively common during thoracotomy in the lateral position and the trachea proximal to the tracheal cuff of the DLT becomes contaminated with gastric acid in 8% of patients [2].Although gross contamination of the lungs with gastric contents is prevented by an adequately inflated tracheal cuff, modern high-volume, low-pressure (HVLP) cuffs may not completely protect the lungs from contamination [3,4]. Fluid leakage may occur along folds in adequately inflated HVLP cuffs [5]. It has been shown that the application of aqueous gel to the tracheal cuff of a single lumen tracheal tube reduces fluid leakage [6]. The incidence of fluid leakage past the tracheal cuffs of modern DLTs is not known. Design differences between double and single lumen tubes make it difficult to extrapolate data from studies of single lumen tubes to double lumen tubes. Unlike single lumen tubes, the main body of DLTs are not usually round in cross-section. The outer diameter of DLTs are usually much larger, relative to the trachea, than that of single lumen tubes. The outer diameter of the main body of a 41 FG left Mallinckrodt Ò , Broncho-Cath (Mallinckrodt Ò , Athlone, Ireland) double lumen tube is 14-15 mm. The tracheal cuff of a DLT is usually considerably longer than the tracheal cuff of a single lumen tube. We therefore conducted this randomised, double blind study in patients undergoing surgery in the lateral position to determine the incidence of dye leakage past the tracheal cuff of DLTs (Mallinckrodt Ò ,...

Tracheal fluid leakage in benchtop trials: comparison of static versus dynamic ventilation model with and without lubrication

“…Tube cuff lubrication has been used by several investigators during in vitro trials to imitate a close contact of the cuff surface with the tracheal mucosa and filling of microchannels (longitudinal folds) with mucosal fluid. In these models, cuff lubrication reduced or prevented fluid leakage past the cuff, results similar to those of our study [11,12]. The strength of the present study is the finding that cuff lubrication prevented fluid leakage even in those HVLP cuffs that have poor sealing characteristics.…”

“…Although earlier clinical studies [11,12] have reported a protective effect of gel lubrication in cuffed tubes against fluid leakage, the effect is only transient and is lost after 24-120 h. Because there is no reliable protection against subglottic leakage in clinical practice, gel lubrication should be avoided when investigating sealing qualities in HVLP tube cuffs by in vitro models. The difference in the sealing characteristics of tube cuffs becomes more conclusive and evident under the static unlubricated setup, which could facilitate tube selection for in vivo trials in the future.…”

Military anaesthesia

“…However, if the wider academic community and professional historians in particular are to recognise the value of these contributions, then the review process for historical papers must be every bit as rigorous as that to which clinical and research papers are subjected. We read with interest the study by Sanjay et al about the effect of gel lubrication on fluid leakage past the tracheal cuff of double lumen tubes [1]. The authors present a good case for gel lubrication reducing fluid leakage past the cuff.…”

“…Our monitoring system does not rely on comparing doctors with colleagues, but on comparing the performance of doctors with what can be achieved given an internationally recognised standard of risk-adjusted cardiac surgical performance (the logistic EuroSCORE) [1]. We believe therefore that our method is indeed criterion-based.…”

“…In his second paper on military influences on the development of anaesthesia [1], Metcalfe claims that 25% of those injured in the American Civil War received anaesthesia compared with only 8% of French soldiers in the Crimean War. This comparison is not valid, however, because the denominators for the two percentages are different.…”