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Positioning the double-lumen endobronchial tube

¹ Seoul, Korea

To the Editor:

We read with interest an article by Fortier et al.¹ regarding new landmarks to improve the positioning of the left Broncho-Cath^TM double-lumen tube (DLT). Through the bronchial tube and by transparency across the wall, the position of the DLT was adjusted so that the carina is midway between the black radiopaque line and the top of the bronchial cuff.¹ Through the bronchial lumen, however, the DLT appears to be located deeper relative to the black radiopaque line because the line of vision through the fibreoptic bronchoscope is almost vertical. Thus, the bronchial cuff must have been placed more proximally than intended by the authors. Figure 3 of the article1 may be self-explanatory.

When a DLT is located within the margin of safety, defined as the difference between the length of the main bronchus and the length of the tube between the top of the bronchial cuff and the tip,² the DLT can be moved over the difference and still be correctly positioned. When the carina is at the level midway between the top of the bronchial cuff and the black radiopaque line, the tube length below the carina is about 35 mm, because the length of the bronchial tube of the DLT is 40 mm.³ The possibility of the bronchial tube tip not being within the acceptable range is < 2.5%,⁴ since, according to an in vivo fibreoptic bronchoscopic study,² the probability of occurrence of a less-than-35-mm left main bronchus is > 2 SD from the mean.⁴

It should be remembered that the new technique1 frequently works at the expense of the margin of safety, and that, though proximal displacements predominate, distal malpositions also occur during the positional change to the lateral decubitus.⁵ We suggest that fibreoptic bronchoscopy should be performed through both the tracheal and bronchial lumen of a DLT to check the position, and repeated after lateral positioning.

References

1 Fortier G, Coté D, Bergeron C, Bussières JS. New landmarks improve the positioning of the left Broncho-CathTM double-lumen tube-comparison with the classic technique. Can J Anesth 2001; 48: 790–4.[Abstract/Free Full Text]

2 Benumof JL. Separation of the two lungs (double-lumen tube and bronchial blocker intubation). In: Benumof JL (Ed.). Anesthesia for Thoracic Surgery, 2nd ed. Philadelphia: W.B. Saunders, 1995: 330–89.

3 Yahagi N, Furuya H, Matsui J, Sai Y, Amakata Y, Kumon K. Improvement of the left Broncho-Cath double-lumen tube (Letter). Anesthesiology 1994; 81: 781–2.

4 Bahk J-H, Oh Y-S. A new and simple maneuver to position the left-sided double-lumen tube without the aid of fiberoptic bronchoscopy. Anesth Analg 1998; 86: 1271–5.[Abstract]

5 Klein U, Karzai W, Bloos F, et al. Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia. A prospective study. Anesthesiology 1998; 88: 346–50.[Medline]

² Québec, Québec

We thank Bahk et al. for their interest in and comments on our article.¹ Our results demonstrated that when using our new landmarks, the final position of left modified double-lumen tube (LM-DLT) seems better than with the classic positioning. We observed less need to reposition the LM-DLT proximally after turning the patient to the lateral decubitus. This technique is a reproducible and easy method to obtain these results.

Despite the fact that the vision is not always direct, we try to obtain the most perfect line of vision by curving the fibreoptic bronchoscope (FOB) as far as we can to visualize the carina to assess the position of the LM-DLT following our landmarks. We would like to mention that Figure 3B of our publication is a schematic drawing and that the tip of the FOB should be deeper and curved in the LM-DLT to see the landmarks easily.

Our study found that the incidence of distal displacements and repositioning with our new technique is comparable to the classic technique. The new technique worked effectively at the expense of MoS (Table) but by only 2 mm. It seems quite acceptable to prevent difficult proximal repositioning of the LM-DLT after the patient has been turned laterally.

Reference

1 Fortier G, Côté D, Bergeron C, Bussières JS. New landmarks improve the positioning of the left Broncho-Cath^TM double-lumen tube-comparaison with the classic technique. Can J Anesth 2001; 48: 790–4.

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