Margin of Safety in Positioning Modern Double-lumen Endotracheal Tubes

Benumof, Jonathan L.; Partridge, Brian L.; Salvatierra, Cairo; Keating, John L.

doi:10.1097/00000542-198711000-00018

Cited by 296 publications

(134 citation statements)

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“…The margin of safety in positioning left-sided DLTs is the length of the left mainstem bronchus minus the distance between the proximal margin of the bronchial cuff and the tip of the bronchial lumen. 11 In this study, significant displacement of DLTs was defined as a migration of [ 10 mm from initial correct position regardless of its direction. In both groups, there was no case of significant inward displacement of DLTs after lateral positioning.…”

Section: Discussionmentioning

confidence: 99%

Double-lumen tube placement with the patient in the supine position without a headrest minimizes displacement during lateral positioning

Seo

Hong

Lee

et al. 2012

Can J Anesth/J Can Anesth

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Double-lumen tube placement with the patient in the supine position without a headrest minimizes displacement during lateral positioning La mise en place d'une sonde à double lumière chez un patient en decubitus dorsal sans appuie-tête minimise le risque de déplacement au cours du passage en decubitus latéral Abstract Purpose The correct position of double-lumen tubes (DLTs) is customarily confirmed after tracheal intubation by bronchoscopy with the patient supine on a headrest. However, displacement of DLTs usually occurs during lateral positioning because of neck extension. This study was undertaken to determine whether displacement of DLTs could be minimized during lateral positioning if DLTs were positioned without a headrest. Methods One hundred patients scheduled for thoracic surgery were randomized into two groups (n = 50 each). After tracheal intubation using a headrest, adjustment of DLT position was performed according to group assignment, i.e., either with the headrest in place or without the headrest. Using a bronchoscope, distances from the tracheal opening to the main carina and from the bronchial opening to the left bronchial carina were measured in both the supine and lateral positions. Results Displacement of DLTs [mean (standard deviation)] during lateral positioning was greater in the headrest group than in the no-headrest group [12.3 (6.5) mm vs 6.8 (5.5) mm, respectively, in the trachea; 11.6 (6.7) mm vs 6.0 (4.6) mm, respectively, in the bronchus; P \ 0.001]. The incidence of significant displacement, defined as [ 10 mm from initial correct position, was greater in the headrest group than in the no-headrest group (64% vs 28%, respectively, in the trachea; 58% vs 20%, respectively, in the bronchus; P \ 0.001). Conclusion Displacement of DLTs during lateral positioning appears to be caused primarily by extension of the neck. Correct adjustment of DLT position without a headrest in the supine position is an easy and effective method to minimize DLT displacement during lateral positioning (ClinicalTrials.gov number, NCT01413347). RésuméObjectif La bonne position des sondes a`doubles lumie`res (DLT) est d'ordinaire confirme´e par bronchoscopie apre`s intubation trache´ale chez un patient en decubitus dorsal avec appuie-teˆte. Cependant, ces sondes se de´placent habituellement au cours d'un changement de position en decubitus late´ral en raison d'une extension du cou. Cette e´tude a e´te´entreprise pour de´terminer si le de´placement des DLT pouvait eˆtre minimise´au cours d'un passage en This article is accompanied by an editorial, please see Can J Anesth 2012; 59: this issue.

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Section: Discussionmentioning

confidence: 99%

Double-lumen tube placement with the patient in the supine position without a headrest minimizes displacement during lateral positioning

Seo

Hong

Lee

et al. 2012

Can J Anesth/J Can Anesth

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“…8 For several reasons, the DLT moves relative to the tracheobronchial tree when the patient is turned to the lateral position. First, the carina probably shifts when the patient is moved from the supine to the lateral chest-open position.…”

Section: New Landmarks In Positioning L-dltsmentioning

confidence: 99%

“…8 Le DLT se déplace par rapport à l'arbre trachéobronchique pour plusieurs raisons quand le patient est tourné en décubitus latéral. Premièrement, il est probable que la carène bouge lorsque le patient est déplacé du décubitus dorsal en position latérale à thorax ouvert.…”

Section: Nouveaux Points De Repère Pour Le Positionnement Des Dlt Gauunclassified

Correct positioning of double-lumen tubes

Bussières

Slinger

2012

Can J Anesth/J Can Anesth

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“…soulignaient la petite marge d'erreur laissée par les SDL droites comparativement aux gauches (1-4 mm vs 16-19 mm, respectivement) : « les sondes à double lumière gauches sont nettement préférables aux sondes à double lumière droites parce qu'elles offrent une marge de sécurité de positionnement bien plus étendue… ». 13 À cette époque, étant donné que les anesthésiologistes avaient en général uniquement accès à des SDL en PVC en Amérique du Nord et étant donné que les SDL gauches étaient clairement supérieures, la tendance clinique a basculé à nouveau vers la position où elle se situe actuellement, soit vers l'utilisation de sondes gauches à chaque fois que cela est possible. The clinical use of right-sided double-lumen tubes 297…”

Section: L'utilisation Clinique Des Sondes à Double Lumière Droitesunclassified

“…At approximately the same time, the cadaver studies by Benumof et al highlighted the small room for error of right vs left DLTs (1-4 mm vs 16-19 mm, respectively), ''…left-sided double-lumen tubes are much preferable to right-sided double-lumen tubes because they have a much greater positioning margin of safety…''. 13 At this time, since anesthesiologists in North America usually had access solely to PVC DLTs and since left-sided DLTs were clearly superior, the clinical pendulum swung back to where it currently rests, i.e., to the use of left-sided tubes whenever possible.…”

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confidence: 99%

The clinical use of right-sided double-lumen tubes

Slinger

2010

Can J Anesth/J Can Anesth

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Right-sided double-lumen tubes (DLTs) have a bad reputation. Many experts in the field of thoracic anesthesia regard them as being difficult to position, having a small margin of safety for correct placement, and being prone to intraoperative malpositioning. 1 However, in a randomized prospective study, Campos et al. compared the use of right vs left DLTs in two groups of 20 patients having left thoracotomies. 2 In this small study, there were no significant differences between the two types of DLTs with respect to the relevant aspects of clinical performance, including the time for left lung collapse and the incidence of inadvertent right upper lobe collapse. There was a tendency for rightsided tubes to become malpositioned intraoperatively, but in all cases this difficulty was corrected easily by fibreoptic bronchoscopy. In a more recent retrospective report, the anesthetic records of 961 thoracic procedures were examined at one teaching institution where the usual practice was to use a DLT contralateral to the side of surgery, i.e., a rightsided tube for left-sided surgery. 3 There were no differences in the incidences of hypoxemia, hypercarbia, or high airway pressures between patients managed with left or right DLTs. The current sales of DLTs in North America show a 10:1 preference for left-vs right-sided tubes (personal communication with Covidien, Mansfield, MA, USA), suggesting that the majority of anesthesiologists tend to use left DLTs whenever possible. Given the evidence that right DLTs may function as well as left DLTs, and in view of the fact that it is necessary to use a right DLT in certain select cases, 4 perhaps it is time to reconsider their use for routine airway management in thoracic surgery.To appreciate our current clinical practice in thoracic anesthesia, it is useful to understand how we arrived at where we are today. Both the spectrum of patients and the equipment available for lung isolation have changed drastically from the origins of lung isolation in the 1930s. At that time, thoracic surgery was essentially for complications of infectious diseases, e.g., abscesses, bronchiectasis, hemoptysis, etc., which were often due to tuberculosis. The anesthesiologist's major priority was to protect the dependent lung from contamination with the infected secretions from the operative lung. The initial methods of lung isolation involved placement of a modified endotracheal tube as a single-lumen endobronchial tube in the mainstem bronchus of the non-operative lung. These tubes were placed by a rigid bronchoscope through the singlelumen tube and rigid bronchoscopy was a standard skill of the pioneers of thoracic anesthesia. 5 Selective intubation of the contralateral lung became an established principle. In 1949, Carlens, a respirologist, introduced a red rubber leftsided DLT designed to be placed with topical anesthesia in awake patients with tuberculosis who were having splitlung broncho-spirometry as a part of their workup for possible lung resection. 6 This DLT was quickly adopted by the tho...

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Margin of Safety in Positioning Modern Double-lumen Endotracheal Tubes

Cited by 296 publications

References 0 publications

Double-lumen tube placement with the patient in the supine position without a headrest minimizes displacement during lateral positioning

Double-lumen tube placement with the patient in the supine position without a headrest minimizes displacement during lateral positioning

Correct positioning of double-lumen tubes

The clinical use of right-sided double-lumen tubes

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