Positioning of double-lumen tubes based on the minimum peak inspiratory pressure difference between the right and left lungs in short patients: a prospective observational study

Does the periportal end of a double-lumen endobronchial tube need to be fixed to prevent dislocation of the cuffed end caused by a change in position? A randomized controlled trial

OBJECTIVE

This study aimed to evaluate the effects on the dislocation and misalignment of the cuffed end of a double-lumen endobronchial tube (DLT) when a patient moves from a horizontal to a lateral position without fixation.

METHODS

A total of 148 patients who had undergone video-assisted thoracoscope surgery were enrolled and randomly divided into two groups: a group in which the periportal end of the DLT was fixed with tape (group I; n = 74) and a group in which the periportal end of the DLT remained unfixed (group II; n = 74). Both groups were given an intravenous induction for double-lumen endobronchial intubation and then moved from a horizontal position to a lateral position, after which the alignment of the bronchial cuffed end of the DLT was assessed using a fiberoptic bronchoscope.

RESULTS

After lateral position, the dislocation rate of group I and group II was 44.6% and 20.2%, and the misalignment rate was 27.0% and 8.1%, respectively, the incidence of dislocation and misalignment was significantly lower in group II than in group I after the change to a lateral position (p < 0.05). After lateral position, the total rate of airway injury was 25.7% in group I and 5.4% in group II, the incidence of airway injury was significantly lower in group II than in group I (p < 0.05), as was the incidence of sore throat, hoarseness, and cough on postoperative day 1 (p < 0.05). The average outward dislocation of the periportal end of the DLT in group II was 1.5 cm.

CONCLUSION

A DLT without periportal fixation is less likely to be displaced and poorly aligned when the patient moves from a horizontal to a lateral position, which could facilitate intra-operative management and reduce the incidence of postoperative complications.

One-lung ventilation in obese patients undergoing thoracoscopic lobectomy for lung cancer

BACKGROUND

We evaluated the safety and feasibility of one-lung ventilation in obese patients undergoing thoracoscopic lobectomy and whether obesity affected peri- and postoperative outcomes.

METHODS

This was a retrospective single center study including consecutive patients undergoing thoracoscopic lobectomy between October 2019 and February 2022. Obese patients were statistically compared to a control group to evaluate any differences in relation to one-lung ventilation and peri- and postoperative outcomes.

RESULTS

Our study population included 111 patients; of these, 26 (23%) were included in the obese group, while 85 (77%) were included within the nonobese group. To obtain one-lung ventilation in nonobese patients, a double-lumen tube was more frequently used than a single-lumen tube with bronchial blocker (61% vs. 39%; p = 0.02), while in obese patients a single-lumen tube with bronchial blocker was used more than a double-lumen tube (81% vs. 19%, p = 0.001). Intergroup comparison showed that a double-lumen tube was the preferred method in nonobese patients, while a single-lumen tube with bronchial blockers was the strategy of choice in obese patients (p = 0.0002). Intubation time was longer in the obese group than in the nonobese group (94.0 ± 6.1 vs. 85.0 ± 7.0 s; p = 0.0004) and failure rate of first attempt at intubation was higher in the obese group (23% vs. 5%; p = 0.01). Obesity was not associated with increased intra-, peri- and postoperative complications and/or mortality.

CONCLUSIONS

One-lung ventilation is a feasible and safe procedure also in obese patients and obesity did not negatively affect peri- and postoperative outcomes after lung resection.

A Randomized Controlled Trial Comparing Novel Triple-Cuffed Double-Lumen Endobronchial Tubes with Conventional Double-Lumen Endobronchial Tubes for Lung Isolation

Placing a double-lumen endobronchial tube (DLT) in an appropriate position to facilitate lung isolation is essential for thoracic procedures. The novel ANKOR DLT is a DLT developed with three cuffs with a newly added carinal cuff designed to prevent further advancement by being blocked by the carina when the cuff is inflated. In this prospective study, the direction and depth of initial placement of ANKOR DLT were compared with those of conventional DLT. Patients undergoing thoracic surgery (n = 190) with one-lung ventilation (OLV) were randomly allocated into either left-sided conventional DLT group (n = 95) or left-sided ANKOR DLT group (n = 95). The direction and depth of DLT position were compared via fiberoptic bronchoscopy (FOB) after endobronchial intubation between the groups. There was no significant difference in the number of right mainstem endobronchial intubations between the two groups (p = 0.468). The difference between the initial depth of DLT placement and the target depth confirmed by FOB was significantly lower in the ANKOR DLT group than in the conventional DLT group (1.8 ± 1.8 vs. 12.9 ± 9.7 mm; p < 0.001). In conclusion, the ANKOR DLT facilitated its initial positioning at the optimal depth compared to the conventional DLT.

Successful blind lung isolation with the use of a novel double-lumen endobronchial tube in a patient undergoing lung transplantation with massive pulmonary secretion: A case report

RATIONALE

Precise lung isolation technique with visual confirmation is essential for thoracic surgeries to create a safe and clear surgical field. However, in certain situations, such as when patients have massive pulmonary secretion or when the fiberoptic bronchoscopy (FOB) is not applicable, lung isolation has been performed blindly.

PATIENT CONCERN

A 52-year-old woman, whose airway was unable to visualize with FOB due to massive pulmonary secretion, was presented for bilateral sequential lung transplantation. Extracorporeal membranous oxygenation, tracheostomy, and mechanical ventilation were applied to the patient for 39 days preoperatively as a bridge for lung transplantation.

DIAGNOSIS

Patient was diagnosed with an idiopathic pulmonary fibrosis and obesity.

INTERVENTION

Initially, height-based blind positioning with a conventional double-lumen endobronchial tube (DLT) failed to ventilate the patient properly, and the confirmation of DLT positioning with FOB was impossible due to massive pulmonary secretion. Therefore, a novel DLT (ANKOR DLT) that has one more cuff, located at a point between the distal opening of the tracheal lumen and the starting point of bronchial cuff, than conventional DLT was used for the lung isolation in the patient.

OUTCOMES

After the completion of lung graft, FOB finding showed that the ANKOR DLT was optimally positioned at the tracheobronchial tree of the patient, and its depth was 2.5 cm shallower than that of the conventional tube.

LESSONS

ANKOR DLT would be a feasible choice to achieve successful blind lung isolation when the use of FOB is impossible to achieve the optimal lung isolation.

Chest Computed Tomography Image for Accurately Predicting the Optimal Insertion Depth of Left-Sided Double-Lumen Tube

OBJECTIVE

The main objective of this study was to assess the feasibility and accuracy of measuring the distance between the vocal cord and carina using chest computer tomography (CT) as a guide for the intubation of a left-sided double-lumen tube (LDLT).

DESIGN

Single-center, prospective, randomized study.

SETTING

Local hospital in China.

PARTICIPANTS

Sixty adult patients undergoing elective thoracic surgery requiring an LDLT for one lung ventilation were enrolled in this study.

INTERVENTIONS

Patients were randomly allocated to the following 2 groups: blind intubation group (B group, n = 30) or chest computed tomography-guided group (C group, n = 30). The placement of the LDLT was accomplished using 1 of the 2 intubation methods. After intubation, an independent anesthesiologist evaluated the position of the LDLT and carina and bronchial injuries using fiber optic bronchoscopy. The number of optimal positions, the time for LDLT intubation, the time for fiber optic bronchoscope confirmation, and carina and bronchial injuries were recorded.

RESULTS

Sixteen of 30 intubations in the B group were in optimal position, whereas 27 of 30 intubations in the C group were in optimal position; the difference was statistically significant (p < 0.01). The time for intubation of the LDLT took 118.0 ± 26.2 seconds in the B group and 71.5 ± 8.7 seconds in the C group (p < 0.01). The time for position confirmation using fiber optic bronchoscope took 40.8 ± 15.8 seconds in the B group and 18.7 ± 7.9 seconds in the C group (p < 0.05). The incidences of carina and bronchial injuries were obviously lower in the C group (occurred in 3 of 30 cases) than in the B group (11 of 30 cases) p < 0.05. The incidences of postoperative sore throat and hoarseness showed no significant differences between the 2 groups (p > 0.05).

CONCLUSION

This study demonstrated that the method of measuring the distance between the vocal cord and carina according to the chest CT as a guide for the intubation of LDLT is more effective and more accurate than the blind intubation method.

A six-month evaluation of the VivaSight™ video double-lumen endotracheal tube after introduction into thoracic anaesthetic practice at a single institution

For a six-month period, all airway options used for non-emergent patients undergoing thoracic surgery requiring one-lung ventilation at a single institution were assessed after introduction of the VivaSight™ double-lumen endotracheal tube (VivaSight-DL), a novel double-lumen tube with an integrated camera. This device displays a continuous view of the position of the tube relative to the carina. A total of 72 patients had lung separation with the VivaSight-DL. Lung separation was achieved on first attempt without additional manipulation in 85% of cases. In only three cases (4%) was a fibreoptic bronchoscope required, in each instance to reposition the tube after intraoperative dislodgement. The VivaSight-DL represents a novel method of one-lung ventilation allowing rapid identification of intraoperative airway problems and reducing the need for fibreoptic bronchoscopy.