|Journal Reviewed: Journal of Cardiothoracic and Vascular Anaesthesia
|Issues: June 1999: Volume 13: Number 3
|Abstracted by: Dr M J Akhtar MB BCh (Registrar, University of the
Summary of abstracts
One should always be aware of potentially devastating consequences
of anaesthetic interventions, even if such disasters are uncommon.
Today we briefly explore airway rupture in the setting of double
lumen tube placement, and then conclude with a rare aside.
You may also wish to briefly browse our editorial comment
1. Airway rupture from double-lumen tubes.
The actual incidence of airway rupture has probably been
under-reported. Red rubber tube material is more rigid. Re-sterilised red rubber
tubes have irregularities of the tube tip and are more often associated with airway
damage, especially when inserted forcefully during the intubation process. A carinal hook
if present can also injure the upper airway. When the poly-vinyl-chloride double lumen
tubes were introduced in 1980 it was believed that these tubes did not cause airway
injuries. Reports of airway injury from the poly-vinyl-chloride double lumen tubes
soon appeared however. In this article the risk factors for airway rupture with double
lumen tubes, complications of double lumen lube usage and the recommendations for double
lumen tube placement are discussed concisely. The medical literature published between
1972- 1998 was reviewed and where possible the foreign language publications were
translated into English and one of the original investigators was contacted for additional
Initial over-inflation of either the tracheal or bronchial cuff at
the time of tube placement may have accounted for the greatest number of injuries with red
rubber double lumen tubes as well as with poly-vinyl-chloride double lumen tubes. Movement
of the patient into the lateral decubitus position with both cuffs inflated increases the
chances of mucosal trauma. Red rubber double lumen tubes have low volume/ high
pressure cuffs and inflate asymmetrically after multiple uses and are associated with more
frequent airway injuries.
In the case of poly-vinyl-chloride double lumen tubes
manufacturers recommend the removal of the stylet of the bronchial lumen as soon as the
tip of the tube has passed the vocal cords. Actually the stylet have never been
implicated in any report of major airway injury. There is one report that recommends
retaining of the stylet throughout the process of the tube placement.
Large and medium size red rubber double lumen tubes were
associated with most of the airway injuries reported. In contrast the majority of the
airway injuries with the poly-vinyl-chloride double lumen tubes are associated with the
small size tubes.
Although airway injuries have been reported with all types of
pulmonary surgery with both red rubber double lumen tubes as well as with
poly-vinyl-chloride double lumen tubes, the most frequently reported surgery associated
with such injuries is oesophageal surgery.
Risk Factors for the
- "Too forceful an insertion"
- Frayed tube tip [red rubber double lumen tubes only]
- Tube too large for the bronchus.
- Tube advanced with the stylet in place (Questionable)
- Movement of the tube while both cuffs are inflated.
- Carinal hook damage.
- Too rapid an inflation.
- Too large a volume. (Small tube require larger volumes to achieve a
- Nitrous oxide distention.
- Asymmetric cuff distention pushing the tube tip into the airway
[red rubber double lumen tubes predominantly ]
|Pre-existing airway pathology
- Congenital airway wall abnormalities
- Airway wall weakness from tumor infiltration or infection.
- Airway distortion from mediastinal lymph nodes or associated tumor.
- Patients receiving steroids or suffering from leukemia or lymphoma.
- Hypotension with hypoperfusion to the airway.
Airway damage can present with an air leak causing
subcutaneous emphysema or cardiovascular instability from a tension pneumothorax.
Airway hemorrhage and aneurysmal dilation of the membranous wall can occur from
incomplete laceration of the airway with dissection of the adventitia. The signs of injury
may be delayed.
Bronchoscopy performed before extubation allows early diagnosis in
the cases where airway injury is suspected as immediate surgical intervention is essential
for favorable results.
Fitzmaurice and Brodsky's recommendations for the
safe placement of a double lumen tube Choose the largest poly-vinyl-chloride double lumen
tube that will safely fit the patients airway.
Remove the bronchial stylet once the tip of the tube is past the
Be extra cautious with patients who have tracheo-bronchial wall
pathological disease, leukemia, steroid therapy or hypoperfusion.
Advance the double lumen tube to the appropriate distance in the
bronchus (based on the patient height)
Inflate both cuffs slowly.
Use 3ml syringe to inflate the bronchial cuff.
Never over-inflate either cuff.
(Usually <3mls of air is adequate for the bronchial cuff if an appropriate size double
lumen tube is selected. If more air is needed, reassess the tube size and position.)
When nitrous oxide is used consider inflating both cuffs with
saline or an oxygen/nitrous oxide mixture.
When nitrous oxide is used measure the cuff pressures
intermittently. Keep the bronchial cuff pressure < 30cm of water
Deflate both cuffs before moving the patient
Deflate the bronchial cuff when lung isolation is not required.
During oesophageal surgery consider partial deflation of the cuff
when surgical dissection is near either cuff.
Test the integrity of the intubated bronchus at the completion of
Use a fiberoptic bronchoscope to determine the extent of any
||Airway rupture from double-lumen tubes
|Journal: J Cardiothorac Vasc Anesth, Vol 15, No 3,
|Article type: Literature Review
|Authors: Fitzmaurice, B. Brodsky, J.
2. Selecting the correct size
left double-lumen tube
It is important to select the correct size
of double lumen tube because most of the complications associated with double lumen tubes
results from selecting too small a tube. Small double lumen tubes are more easily
displaced as compared to large double lumen tubes, causing obstruction of the orifice to
the upper lobe. Other problems include the over-inflation of the bronchial cuff in order
to get a good seal. Overinflation can cause herniation of the cuff in to the carina
as well as airway rupture. Increased resistance to airflow during one lung ventilation
with small double lumen tubes can be another problem.
Appropriate size double lumen tube selection has been done by
- Width of the left main bronchus from the chest radiograph. (Only
visible in 50% of cases)
- Left bronchial diameter measured by the chest computed tomograph
The width of the trachea measured from the postero-anterior chest
radiograph can be used to predict the left bronchial size and can be very helpful in
selecting the appropriate size of double lumen tube quite accurately.
Jay B Brodsky et al. applied this method of selection of double
lumen tube on 487 patients. All patients were intubated successfully, the tubes
functioned properly and there were no complications.
Hannallah et al by using CT scans for choosing the appropriate
size double lumen tube found that in 75% of their patients they used a smaller size double
lumen tube (37 or 35 French) as compared to the Brodsky series, where only 3% required a
37 or a 35 french double lumen tube
choosing a left double lumen tube.
Measured tracheal width (mm)
Predicted left bronchus width
Double lumen tube Size
| greater than 18
||greater than 12.2
|16.1 to 18
|15.1 to 16
|less than 15
width (mm) as measured from the chest radiograph.
Predicted left bronchus width (mm) is 68% of the measured tracheal width.
Double lumen tubes of 35 french size are seldom
required for adult patients unless they have very small airways, but they can be used for
larger children. Mallinckrodt also offers 32-French double lumen tube. The author
has used a 32-French BroncoCath double lumen tube in three 10 year old children with
||Selecting the correct size left double-lumen
|Journal: J Cardiothorac Vasc Anesth. Vol 11, No 7,
|Article type: Letter to the editor
|Authors: Brodsky JB, Mackey S, Cannon WB.
Finally, we draw your attention to another letter from Prof. Brodsky,
this about the exotic problem of inserting a double lumen tube into
somebody with situs inversus, where the lung, heart and abdominal anatomy
is a mirror image of normal. The solution is obvious - put a left
double lumen tube down the right side!
Choice of Double-Lumen Tube in Kartagener's Syndrome.
The Journal of Cardiothoracic and Vascular Anaesthesia 11 (6)
1997 810 |
Habibi A, Brodsky JB.
The article on airway rupture by Fitzmaurice
and Brodsky is comprehensive, authoritative and well worth reading
in full. The authors clearly have a vast experience of double
lumen tube placement, and have researched the topic in detail.
The central theme, returned to again and again, is that
mismatch between cuff inflation and bronchial size is the main
contributor to injuries induced by double-lumen tubes, be they
red rubber or polyvinyl chloride. The tables reproduced above
list other factor that contribute to airway rupture, and more importantly a
comprehensive strategy for avoiding this anaesthetic catastrophe.
We recently had the pleasure of a brief visit from Prof Brodsky, whose comments
on double lumen tubes were most enlightening. His take home message was
that one should select the largest tube , for several reasons:
it is more difficult to advance such a tube too far, the greater diameter
lowers resistance and auto-PEEP, and because of the tighter fit, there is
less air in the cuff and less fiddling with the airway while trying to
achive a snug seal! Professor Brodsky's second communication
addresses the issue of determining the largest tube size. Fortunately,
the diameter of the left main bronchus is easily and reliably predicted
as 68% of the tracheal diameter measured off a PA chest x-ray. Likewise,
depth of placement of the tube should be dictated by the patient's height,
as there is a linear relationship between ideal depth of placement and
patient height. Simply shoving the double lumen tube in until it doesn't
go any further is now unacceptable. Note that patient size does not
necessarily correlate well with bronchial diameter, for example one sometimes
encounters a small woman with chronic obstructive airway disease who has
(We note parenthetically that the above refers of course to left double
lumen tubes. The rare placement of right DLTs is today limited to situations
where there is obstruction of the left main bronchus, a left broncho-pleural
fistula, unilateral (left) one lung transplant, and sleeve resection of
the left main bronchus. Note that Campos and colleagues disagree!
They have recently reported a series of patients (Anesth Analg 2000 Mar;90(3):535-40)
where modified left or right Mallinckrodt BronchoCaths were compared
for left-sided thoracic surgery. They found no difference between the two
as regards malpositions, number of fibreoptic bronchoscopic examinations,
time for adequacy of left lung collapse, or incidence right upper lobe collapse.
They did however note that right-sided tubes cost more and placement took
longer. Less than convincing protagonists of an increasingly outmoded practice).