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Fibreoptic bronchoscopic positioning of double-lumen tubes
THORACIC ANAESTHESIA
Fibreoptic bronchoscopic positioning of double-lumen tubes
Learning objectives After reading this article you should be able to: C choose the correct double-lumen tube (DLT) for your patient and understand the differences in right and left bronchial anatomy C place a right or left DLT using a fibreoptic bronchoscope C troubleshoot difficulties associated with DLT placement using a fibreoptic bronchoscope
Karen A Foley Peter Slinger
Abstract Double-lumen tubes should be placed using a fibreoptic bronchoscope. This allows correct positioning of the bronchial lumen in the chosen mainstem bronchus. It also ensures that the blue bronchial cuff does not obstruct the side to be ventilated when it is inflated under direct vision. Fibreoptic bronchoscopy facilitates correct positioning of the ventilatory side slot of a right double-lumen tube over the right upper lobe bronchus. The anaesthetist must know the fibreoptic tracheo-bronchial anatomy to properly position left- and right-sided double-lumen tubes (DLTs) and should always reconfirm the position of a DLT with fibreoptic bronchoscopy after repositioning the patient. Maintaining orientation (anteriorposterior) during fibreoptic bronchoscopy is crucial to positioning a DLT, particularly after the patient has been turned to the lateral position. A fibreoptic bronchoscope can also be used as a guide to direct a doublelumen tube under direct vision into its correct position.
at the level of the carina or within the trachea itself. A right-sided DLT has an additional ‘eye’ or ventilatory side slot about 0.5 cm from the distal end of the endobronchial tip to allow for adequate ventilation to the right upper lobe (Figure 1). This anatomy can be reviewed on the website http://www. thoracicanesthesia.com.
Selecting the correct size of DLT A properly sized DLT is one in which the main body of the tube passes without resistance through the glottis and advances easily within the trachea and in which the bronchial component passes into the intended bronchus without difficulty. At our institution 35F and 37F are used in female patients and 39F and 41F are used in male patients, taking into account patient height. Before placing a DLT one needs to first check the integrity of both the tracheal and bronchial cuffs by inflating each with air. In the case of the colour-coded Rusch DLT (Figure 2), one should attach the connector arms (tracheal, white and bronchial, blue) to the ‘Y’ piece in the correct orientation such that the correct bronchial connector arm is directed to the correct lumen. In the case of a Mallinckrodt DLT there is no colour coding of the Y
Keywords Double-lumen tubes; fibreoptic bronchoscopy; lung isolation Royal College of Anaesthetists CPD matrix: 1C02, 3A01
Double-lumen tubes (DLT) are indicated for lung isolation in a range of surgical specialities including oesophageal, thoracic and vascular surgery. They are also indicated for use when lung isolation is desired in the critically ill patient who has pulmonary haemorrhage or a large lung abscess. The aim of placing a DLT is to allow the anaesthetist to selectively interrupt ventilation to a chosen lung or portion of a lung or to employ two different ventilation strategies for each lung. Double-lumen endotracheal tubes are the most commonly used tubes for lung isolation. The differences in design between a right and left DLT is determined by the differences in bronchial anatomy. The left main bronchus is approximately 5 cm long and divides into the left upper and left lower lobe bronchi. The right main bronchus is much shorter being approximately 2.5 cm in length with early division of the right upper lobe bronchus approximately 1.5e2 cm from the carina.1 Right bronchial anatomy can be unpredictable and the right upper lobe bronchus sometimes originates
Karen A Foley MB FCARCSI is Assistant Professor and Staff Anesthesiologist at Toronto General Hospital, University of Toronto, Canada. No Conflicts of Interest. Peter Slinger MD FRCPC is Professor of Anesthesia at the University of Toronto and Staff Anesthesiologist at Toronto General Hospital, Toronto, Canada. No Conflicts of Interest.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:11
Figure 1 The ventilating side slot of a right-sided Mallinckrodt doublelumen tube is visible in the lateral wall of the bronchial lumen distal to the blue bronchial cuff.
505
Ó 2014 Elsevier Ltd. All rights reserved.
THORACIC ANAESTHESIA
Figure 2 Rusch left double-lumen tube with colour coding of bronchial and tracheal arms.
we routinely bend the end portion of the DLT (stylet in situ) into a hockey stick shape, check the integrity of both cuffs, lubricate the end of the DLT adequately with gel and perform laryngoscopy with either a Macintosh blade or video-laryngoscope. We hold the DLT with the tip pointing to the right as we enter the mouth to avoid tearing the large tracheal cuff on teeth on the way in. After passing the tip of the tube just through the vocal cords, an assistant removes the stylet and the anaesthetist rotates the tube 90 degrees to the left and advances the tube further into the trachea to a depth of approximately 29 cm for an average height adult of 170 cm, less for a shorter patient.2 The laryngoscope is removed, the tracheal cuff is inflated, the connector arms are attached and the patient is hand ventilated. Bilateral ventilation is confirmed by listening over all lung fields with a stethoscope and by seeing an appropriate end tidal CO2 trace. The patient is then placed on the ventilator with high-flow O2. The tracheal port is opened and the fibreoptic bronchoscope is passed down through the tracheal lumen to observe the carina. The carina is identified by the flat posterior membraneous wall and anterior cartilaginous arches (Figure 4a). If the carina is not visualized it is most likely that the tube is too distal and so the tracheal cuff should be deflated and the tube pulled back under direct vision with the bronchoscope until the carina is observed. The bronchial lumen should now be observed to be in the left main stem bronchus. The bronchial cuff is inflated under direct vision with the bronchoscope to check that it does not herniate across the carina and occlude the other side. The correct position of the bronchial (blue) cuff is such that
connector. It can therefore be useful to place a piece of coloured tape around the connector arm which corresponds to the correct orientation of endobrochial DLT selected (left or right) for quick identification during the surgery (Figure 3).
Placing a left DLT With the universal availability of fibreoptic bronchoscopy, positioning of DLTs has become relatively simple. At our institution,
Figure 3 Mallinckrodt connector arms with identifying tape on the bronchial arm.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:11
506
Ó 2014 Elsevier Ltd. All rights reserved.
THORACIC ANAESTHESIA
Figure 4 The optimal position of a left-sided double-lumen tube. (a) Shows an unobstructed view of the entrance of the right mainstem bronchus when the fibrescope is passed through the tracheal lumen and the edge of the fully inflated endobronchial cuff is below the tracheal carina in the left bronchus. Note the longitudinal elastic bundles inferiorly in the trachea. These white lines which lie in the posterior membraneous wall of the trachea and bronchi are a useful landmark to orientate the bronchoscopist anterior e posterior. (b) Shows the take-off of the right upper lobe bronchus with the three segments (apical, anterior and posterior); this is a unique landmark to reconfirm the right bronchus. (c) Shows an unobstructed view of the left upper and left lower bronchus when the fiberoptic bronchoscope is advanced through the bronchial lumen. The longitudinal elastic bundles pass into the left lower lobe bronchus and are another useful landmark. (Diagram courtesy of Dr J. Campos) With kind permission from Springer Science þ Business Media: The Principles and Practice of Anesthesia for Thoracic Surgery, P. Slinger Ed., Chapter 16, Lung Isolation, J Campos, Fig. 16.6.
when inflated it should be minimally visible in the left mainstem bronchus with the fibreoptic bronchoscope looking at the carina. The bronchial port is then opened and the bronchoscope is passed down the bronchial lumen to assess the position of the tip of the bronchial lumen in relation to the left upper and lower bronchi. The tip of the bronchial lumen should sit at least 1 cm proximal to the secondary carina. If it is found that the tube needs to be pulled back at this stage to achieve this, then it is likely that the bronchial cuff will have changed position at the main carina. A smaller DLT may be required to meet these two criteria.
search is performed looking through the slot for the right upper lobe. This is normally found at the 3 to 4 o’clock position by rotating the scope and tube together in a clockwise direction and anteflexing the tip of the scope. If it is not seen, both cuffs of the DLT should be deflated by an assistant and the DLT slowly withdrawn, rotating the scope within the tube and maintaining the side slot in view at all times. Once the ventilatory side slot is positioned over the right upper lobe bronchus, both cuffs are reinflated and the tube is secured. A final check of tube position is made when the patient has been placed in the final operating position. Another method of placing a DLT using a fibreoptic bronchoscope is to pass the tip of the DLT just through the vocal cords, remove the stylet and then to pass the fibreoptic bronchoscope to the end of the bronchial lumen of the DLT thus using the bronchoscope as a guide so that the DLT is advanced under direct vision. This is also a useful technique to reposition a left DLT that had been initially placed into the right mainstem bronchus.
Placing a right DLT Positioning a right DLT is more challenging because of the anatomy of the right upper lobe. Correct orientation of the ventilatory side slot over the right upper lobe opening requires patience and skill. As before, laryngoscopy is performed and the tube rotated this time 90 degrees to the right after passing though the vocal cords (with stylet removed) and advanced. Again the fibreoptic bronchoscope is passed down the tracheal lumen first to determine that the right mainstem bronchus has indeed been intubated. The tracheal cuff is inflated and the position of the inflated bronchial cuff is visualized. The bronchoscope is now passed down the bronchial lumen into the right mainstem bronchus. The bronchus intermedius and right lower lobe bronchial division is easily visualized. Next the bronchoscope is withdrawn into the blue bronchial cuff of the DLT until it looks through the ventilatory side slot (Figure 5). A
ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:11
Troubleshooting Care must be taken when identifying the main carina at the time of initial placement of a DLT as sometimes a secondary carina may be mistaken for the main carina. This would result in poor emptying of the operative lung upon commencing one lung ventilation. Should this occur, perform fibreoptic bronchoscopy and if necessary, deflate both cuffs and withdraw the DLT under direct vision until the true carina is identified.
507
Ó 2014 Elsevier Ltd. All rights reserved.
THORACIC ANAESTHESIA
Figure 5 The optimal position of a right-sided double-lumen endotracheal tube. (a) Shows the take-off of the right upper bronchus with three segments (apical, anterior and posterior) when the fibreoptic bronchoscope emerges from the ventilatory side slot located in the bronchial lumen. (b) Shows an unobstructed view of the entrance of the left mainstem bronchus when the bronchoscope is passed through the tracheal lumen and the edge of the fully inflated bronchial cuff is below the tracheal carina in the right bronchus. (Diagram courtesy of Dr J. Campos) With kind permission from Springer Science þ Business Media: The Principles and Practice of Anesthesia for Thoracic Surgery, P. Slinger Ed., 2011, Chapter 16, Lung Isolation, J Campos, Fig. 16.5. REFERENCES 1 Campos JH. Update on tracheobronchial anatomy and flexible fiberoptic bronchoscopy in thoracic anesthesia. Curr Opin Anaesthesiol 2009; 22: 4e10. 2 Brodsky JB, Benumof JL, Ehrenwerth J, et al. Depth of placement of left double-lumen endobronchial tubes. Anesth Analg 1991; 73: 570e2. 3 Shih FC, Lee WJ, Lin HJ. Tracheal bronchus. Can Med Assoc J 2009; 180: 783.
A tracheal bronchus (TB) or a congenitally aberrant right upper lobe bronchus has a reported incidence of 0.1e2%.3 Ventilation of the right lung with deflation of the left would be best achieved with a single lumen tube positioned above the location of the aberrant bronchus and a left bronchial blocker. Deflation of the right side can usually be achieved with a left DLT. If this is insufficient or contraindicated a Univent tube with or without an additional Fogarty catheter to block the TB would be indicated. A
ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:11
508
Ó 2014 Elsevier Ltd. All rights reserved.
Fibreoptic bronchoscopic positioning of double-lumen tubes
Learning objectives After reading this article you should be able to: C choose the correct double-lumen tube (DLT) for your patient and understand the differences in right and left bronchial anatomy C place a right or left DLT using a fibreoptic bronchoscope C troubleshoot difficulties associated with DLT placement using a fibreoptic bronchoscope
Karen A Foley Peter Slinger
Abstract Double-lumen tubes should be placed using a fibreoptic bronchoscope. This allows correct positioning of the bronchial lumen in the chosen mainstem bronchus. It also ensures that the blue bronchial cuff does not obstruct the side to be ventilated when it is inflated under direct vision. Fibreoptic bronchoscopy facilitates correct positioning of the ventilatory side slot of a right double-lumen tube over the right upper lobe bronchus. The anaesthetist must know the fibreoptic tracheo-bronchial anatomy to properly position left- and right-sided double-lumen tubes (DLTs) and should always reconfirm the position of a DLT with fibreoptic bronchoscopy after repositioning the patient. Maintaining orientation (anteriorposterior) during fibreoptic bronchoscopy is crucial to positioning a DLT, particularly after the patient has been turned to the lateral position. A fibreoptic bronchoscope can also be used as a guide to direct a doublelumen tube under direct vision into its correct position.
at the level of the carina or within the trachea itself. A right-sided DLT has an additional ‘eye’ or ventilatory side slot about 0.5 cm from the distal end of the endobronchial tip to allow for adequate ventilation to the right upper lobe (Figure 1). This anatomy can be reviewed on the website http://www. thoracicanesthesia.com.
Selecting the correct size of DLT A properly sized DLT is one in which the main body of the tube passes without resistance through the glottis and advances easily within the trachea and in which the bronchial component passes into the intended bronchus without difficulty. At our institution 35F and 37F are used in female patients and 39F and 41F are used in male patients, taking into account patient height. Before placing a DLT one needs to first check the integrity of both the tracheal and bronchial cuffs by inflating each with air. In the case of the colour-coded Rusch DLT (Figure 2), one should attach the connector arms (tracheal, white and bronchial, blue) to the ‘Y’ piece in the correct orientation such that the correct bronchial connector arm is directed to the correct lumen. In the case of a Mallinckrodt DLT there is no colour coding of the Y
Keywords Double-lumen tubes; fibreoptic bronchoscopy; lung isolation Royal College of Anaesthetists CPD matrix: 1C02, 3A01
Double-lumen tubes (DLT) are indicated for lung isolation in a range of surgical specialities including oesophageal, thoracic and vascular surgery. They are also indicated for use when lung isolation is desired in the critically ill patient who has pulmonary haemorrhage or a large lung abscess. The aim of placing a DLT is to allow the anaesthetist to selectively interrupt ventilation to a chosen lung or portion of a lung or to employ two different ventilation strategies for each lung. Double-lumen endotracheal tubes are the most commonly used tubes for lung isolation. The differences in design between a right and left DLT is determined by the differences in bronchial anatomy. The left main bronchus is approximately 5 cm long and divides into the left upper and left lower lobe bronchi. The right main bronchus is much shorter being approximately 2.5 cm in length with early division of the right upper lobe bronchus approximately 1.5e2 cm from the carina.1 Right bronchial anatomy can be unpredictable and the right upper lobe bronchus sometimes originates
Karen A Foley MB FCARCSI is Assistant Professor and Staff Anesthesiologist at Toronto General Hospital, University of Toronto, Canada. No Conflicts of Interest. Peter Slinger MD FRCPC is Professor of Anesthesia at the University of Toronto and Staff Anesthesiologist at Toronto General Hospital, Toronto, Canada. No Conflicts of Interest.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:11
Figure 1 The ventilating side slot of a right-sided Mallinckrodt doublelumen tube is visible in the lateral wall of the bronchial lumen distal to the blue bronchial cuff.
505
Ó 2014 Elsevier Ltd. All rights reserved.
THORACIC ANAESTHESIA
Figure 2 Rusch left double-lumen tube with colour coding of bronchial and tracheal arms.
we routinely bend the end portion of the DLT (stylet in situ) into a hockey stick shape, check the integrity of both cuffs, lubricate the end of the DLT adequately with gel and perform laryngoscopy with either a Macintosh blade or video-laryngoscope. We hold the DLT with the tip pointing to the right as we enter the mouth to avoid tearing the large tracheal cuff on teeth on the way in. After passing the tip of the tube just through the vocal cords, an assistant removes the stylet and the anaesthetist rotates the tube 90 degrees to the left and advances the tube further into the trachea to a depth of approximately 29 cm for an average height adult of 170 cm, less for a shorter patient.2 The laryngoscope is removed, the tracheal cuff is inflated, the connector arms are attached and the patient is hand ventilated. Bilateral ventilation is confirmed by listening over all lung fields with a stethoscope and by seeing an appropriate end tidal CO2 trace. The patient is then placed on the ventilator with high-flow O2. The tracheal port is opened and the fibreoptic bronchoscope is passed down through the tracheal lumen to observe the carina. The carina is identified by the flat posterior membraneous wall and anterior cartilaginous arches (Figure 4a). If the carina is not visualized it is most likely that the tube is too distal and so the tracheal cuff should be deflated and the tube pulled back under direct vision with the bronchoscope until the carina is observed. The bronchial lumen should now be observed to be in the left main stem bronchus. The bronchial cuff is inflated under direct vision with the bronchoscope to check that it does not herniate across the carina and occlude the other side. The correct position of the bronchial (blue) cuff is such that
connector. It can therefore be useful to place a piece of coloured tape around the connector arm which corresponds to the correct orientation of endobrochial DLT selected (left or right) for quick identification during the surgery (Figure 3).
Placing a left DLT With the universal availability of fibreoptic bronchoscopy, positioning of DLTs has become relatively simple. At our institution,
Figure 3 Mallinckrodt connector arms with identifying tape on the bronchial arm.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:11
506
Ó 2014 Elsevier Ltd. All rights reserved.
THORACIC ANAESTHESIA
Figure 4 The optimal position of a left-sided double-lumen tube. (a) Shows an unobstructed view of the entrance of the right mainstem bronchus when the fibrescope is passed through the tracheal lumen and the edge of the fully inflated endobronchial cuff is below the tracheal carina in the left bronchus. Note the longitudinal elastic bundles inferiorly in the trachea. These white lines which lie in the posterior membraneous wall of the trachea and bronchi are a useful landmark to orientate the bronchoscopist anterior e posterior. (b) Shows the take-off of the right upper lobe bronchus with the three segments (apical, anterior and posterior); this is a unique landmark to reconfirm the right bronchus. (c) Shows an unobstructed view of the left upper and left lower bronchus when the fiberoptic bronchoscope is advanced through the bronchial lumen. The longitudinal elastic bundles pass into the left lower lobe bronchus and are another useful landmark. (Diagram courtesy of Dr J. Campos) With kind permission from Springer Science þ Business Media: The Principles and Practice of Anesthesia for Thoracic Surgery, P. Slinger Ed., Chapter 16, Lung Isolation, J Campos, Fig. 16.6.
when inflated it should be minimally visible in the left mainstem bronchus with the fibreoptic bronchoscope looking at the carina. The bronchial port is then opened and the bronchoscope is passed down the bronchial lumen to assess the position of the tip of the bronchial lumen in relation to the left upper and lower bronchi. The tip of the bronchial lumen should sit at least 1 cm proximal to the secondary carina. If it is found that the tube needs to be pulled back at this stage to achieve this, then it is likely that the bronchial cuff will have changed position at the main carina. A smaller DLT may be required to meet these two criteria.
search is performed looking through the slot for the right upper lobe. This is normally found at the 3 to 4 o’clock position by rotating the scope and tube together in a clockwise direction and anteflexing the tip of the scope. If it is not seen, both cuffs of the DLT should be deflated by an assistant and the DLT slowly withdrawn, rotating the scope within the tube and maintaining the side slot in view at all times. Once the ventilatory side slot is positioned over the right upper lobe bronchus, both cuffs are reinflated and the tube is secured. A final check of tube position is made when the patient has been placed in the final operating position. Another method of placing a DLT using a fibreoptic bronchoscope is to pass the tip of the DLT just through the vocal cords, remove the stylet and then to pass the fibreoptic bronchoscope to the end of the bronchial lumen of the DLT thus using the bronchoscope as a guide so that the DLT is advanced under direct vision. This is also a useful technique to reposition a left DLT that had been initially placed into the right mainstem bronchus.
Placing a right DLT Positioning a right DLT is more challenging because of the anatomy of the right upper lobe. Correct orientation of the ventilatory side slot over the right upper lobe opening requires patience and skill. As before, laryngoscopy is performed and the tube rotated this time 90 degrees to the right after passing though the vocal cords (with stylet removed) and advanced. Again the fibreoptic bronchoscope is passed down the tracheal lumen first to determine that the right mainstem bronchus has indeed been intubated. The tracheal cuff is inflated and the position of the inflated bronchial cuff is visualized. The bronchoscope is now passed down the bronchial lumen into the right mainstem bronchus. The bronchus intermedius and right lower lobe bronchial division is easily visualized. Next the bronchoscope is withdrawn into the blue bronchial cuff of the DLT until it looks through the ventilatory side slot (Figure 5). A
ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:11
Troubleshooting Care must be taken when identifying the main carina at the time of initial placement of a DLT as sometimes a secondary carina may be mistaken for the main carina. This would result in poor emptying of the operative lung upon commencing one lung ventilation. Should this occur, perform fibreoptic bronchoscopy and if necessary, deflate both cuffs and withdraw the DLT under direct vision until the true carina is identified.
507
Ó 2014 Elsevier Ltd. All rights reserved.
THORACIC ANAESTHESIA
Figure 5 The optimal position of a right-sided double-lumen endotracheal tube. (a) Shows the take-off of the right upper bronchus with three segments (apical, anterior and posterior) when the fibreoptic bronchoscope emerges from the ventilatory side slot located in the bronchial lumen. (b) Shows an unobstructed view of the entrance of the left mainstem bronchus when the bronchoscope is passed through the tracheal lumen and the edge of the fully inflated bronchial cuff is below the tracheal carina in the right bronchus. (Diagram courtesy of Dr J. Campos) With kind permission from Springer Science þ Business Media: The Principles and Practice of Anesthesia for Thoracic Surgery, P. Slinger Ed., 2011, Chapter 16, Lung Isolation, J Campos, Fig. 16.5. REFERENCES 1 Campos JH. Update on tracheobronchial anatomy and flexible fiberoptic bronchoscopy in thoracic anesthesia. Curr Opin Anaesthesiol 2009; 22: 4e10. 2 Brodsky JB, Benumof JL, Ehrenwerth J, et al. Depth of placement of left double-lumen endobronchial tubes. Anesth Analg 1991; 73: 570e2. 3 Shih FC, Lee WJ, Lin HJ. Tracheal bronchus. Can Med Assoc J 2009; 180: 783.
A tracheal bronchus (TB) or a congenitally aberrant right upper lobe bronchus has a reported incidence of 0.1e2%.3 Ventilation of the right lung with deflation of the left would be best achieved with a single lumen tube positioned above the location of the aberrant bronchus and a left bronchial blocker. Deflation of the right side can usually be achieved with a left DLT. If this is insufficient or contraindicated a Univent tube with or without an additional Fogarty catheter to block the TB would be indicated. A
ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:11
508
Ó 2014 Elsevier Ltd. All rights reserved.