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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
level of the carina or trachea. 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 (see Figure 1). This anatomy can be reviewed on the website www.thoracicanesthesia.com.
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 (anterioreposterior) during fibreoptic bronchoscopy is crucial to position 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 double-lumen tube under direct vision into its correct position.
Selecting the correct size 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 double-lumen tube 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 (see 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 tube there is no colour coding of the Y connector.
Keywords Double-lumen tubes; fibreoptic bronchoscopy; lung isolation
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 for example, pulmonary haemorrhage or a large lung abscess. The aim of placing a double-lumen tube 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 are 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 at the
Karen A Foley MB FCARCSI is a Thoracic Anesthesia Fellow 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, Canada. No conflicts of interest.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 12:12
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.
554
Ó 2011 Elsevier Ltd. All rights reserved.
THORACIC ANAESTHESIA
Figure 2 Rusch left double-lumen tube with colour coding of bronchial and tracheal arms.
Figure 3 The optimal position of a left-sided double-lumen tube. (a) 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 membranous wall of the trachea and bronchi are a useful landmark to orientate the bronchoscopist anterior e posterior. (b) 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) An unobstructed view of the left upper and left lower bronchus when the fibreoptic 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.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 12:12
555
Ó 2011 Elsevier Ltd. All rights reserved.
THORACIC ANAESTHESIA
Placing a left DLT
to be in the left mainstem 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 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.
With the universal availability of fibreoptic bronchoscopy, positioning of DLTs has become relatively simple. At our institution, 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 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 membranous wall and anterior cartilaginous arches (see Figure 3). 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
Placing a right DLT In positioning a right DLT, the position of the ventilatory side slot over the right upper lobe opening is an additional factor that requires further skill. As before, laryngoscopy is performed and the tube rotated this time 90 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.
Figure 4 The optimal position of a right-sided double-lumen endotracheal tube. (a) 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) 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.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 12:12
556
Ó 2011 Elsevier Ltd. All rights reserved.
THORACIC ANAESTHESIA
Next the bronchoscope is withdrawn into the blue bronchial cuff of the DLT until it looks through the ventilatory side slot (see Figure 4). A search is performed looking through the slot for the right upper lobe. This is normally found at the 3e4 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,
ANAESTHESIA AND INTENSIVE CARE MEDICINE 12:12
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. A
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, Ozaki GT. Depth of placement of left double-lumen endobronchial tubes. Anesth Analg 1991; 73: 570e2.
557
Ó 2011 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
level of the carina or trachea. 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 (see Figure 1). This anatomy can be reviewed on the website www.thoracicanesthesia.com.
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 (anterioreposterior) during fibreoptic bronchoscopy is crucial to position 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 double-lumen tube under direct vision into its correct position.
Selecting the correct size 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 double-lumen tube 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 (see 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 tube there is no colour coding of the Y connector.
Keywords Double-lumen tubes; fibreoptic bronchoscopy; lung isolation
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 for example, pulmonary haemorrhage or a large lung abscess. The aim of placing a double-lumen tube 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 are 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 at the
Karen A Foley MB FCARCSI is a Thoracic Anesthesia Fellow 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, Canada. No conflicts of interest.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 12:12
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.
554
Ó 2011 Elsevier Ltd. All rights reserved.
THORACIC ANAESTHESIA
Figure 2 Rusch left double-lumen tube with colour coding of bronchial and tracheal arms.
Figure 3 The optimal position of a left-sided double-lumen tube. (a) 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 membranous wall of the trachea and bronchi are a useful landmark to orientate the bronchoscopist anterior e posterior. (b) 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) An unobstructed view of the left upper and left lower bronchus when the fibreoptic 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.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 12:12
555
Ó 2011 Elsevier Ltd. All rights reserved.
THORACIC ANAESTHESIA
Placing a left DLT
to be in the left mainstem 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 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.
With the universal availability of fibreoptic bronchoscopy, positioning of DLTs has become relatively simple. At our institution, 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 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 membranous wall and anterior cartilaginous arches (see Figure 3). 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
Placing a right DLT In positioning a right DLT, the position of the ventilatory side slot over the right upper lobe opening is an additional factor that requires further skill. As before, laryngoscopy is performed and the tube rotated this time 90 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.
Figure 4 The optimal position of a right-sided double-lumen endotracheal tube. (a) 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) 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.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 12:12
556
Ó 2011 Elsevier Ltd. All rights reserved.
THORACIC ANAESTHESIA
Next the bronchoscope is withdrawn into the blue bronchial cuff of the DLT until it looks through the ventilatory side slot (see Figure 4). A search is performed looking through the slot for the right upper lobe. This is normally found at the 3e4 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,
ANAESTHESIA AND INTENSIVE CARE MEDICINE 12:12
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. A
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, Ozaki GT. Depth of placement of left double-lumen endobronchial tubes. Anesth Analg 1991; 73: 570e2.
557
Ó 2011 Elsevier Ltd. All rights reserved.