The clinical use of right-sided double-lumen tubes

Combination of computed tomography measurements and flexible video bronchoscope guidance for accurate placement of the right-sided double-lumen tube: a randomised controlled trial

OBJECTIVE

To compare the modified strategy for the right-sided double-lumen tube (R-DLT) placement using a combination of CT measurements and flexible video bronchoscopy guidance with traditional bronchoscopy technique.

TRIAL DESIGN, SETTING AND PARTICIPANTS

Double-blind, parallel randomised control trial at a tertiary care medical centre in China. 100 patients undergoing video-assisted thoracoscopic surgery and requiring R-DLT were randomly allocated to the control group and the intervention group.

INTERVENTION

The control group used the traditional bronchoscopy-guided technique. In the intervention group, the length and anteroposterior diameter of the right main bronchus (RMB) were measured on CT images to select the side and size of the Rüsch tube, and then a black depth marker was placed on the tube according to the difference between the length of the RMB and the bronchial cuff. Under the guidance of bronchoscopy, the depth marker should be placed parallel to the tracheal carina and a characteristic white line on the tube should be parallel to the midline of the tracheal carina.

MAIN OUTCOMES

The primary endpoint was the positioning of right upper lobe (RUL) ventilatory slot and RUL bronchial orifice. The secondary endpoints included intubation data and perioperative adverse events.

RESULTS

Compared with the control group, our modified strategy significantly increased the optimal and acceptable position rate (76% vs 98%, respectively; p<0.039), decreased the replacement rate (80% vs 94%; p=0.042), shortened the intubation time (101.4±7.3 s vs 75.2±8.1 s; p=0.019) and reduced the incidence of transient hypoxaemia (25% vs 6%; p=0.022), subglottic resistance (20% vs 6%; p=0.037), tracheobronchial injury (35% vs 13%; p=0.037) and postoperative RUL collapse (15% vs 2%; p=0.059).

CONCLUSION

This study demonstrates the superiority of our strategy and provides a new viable method for R-DLT placement.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR1900021676).

A method for addressing right upper lobe obstruction with right-sided double-lumen endobronchial tubes during surgery: a randomized controlled trial

BACKGROUND

A right-sided double-lumen tube (R-DLT) tends to obstruct the right upper lobe intraoperatively due to anatomical distortion during surgery. If the R-DLT is poorly matched with the patient's airway anatomy, it will not be possible to correctly replace the tube with a fiberoptic bronchoscope (FOB). In our study, we aimed to explore an efficient method for difficult repositioning caused by right upper lobe occlusion during surgery: repositioning the R-DLT from the right main bronchus into the left main bronchus. The current study was designed to assess the efficacy and safety of this method.

METHODS

Sixty adult patients scheduled to undergo left-sided thoracic surgery were randomly assigned to two groups. With the patient in the right lateral position during surgery, the R-DLT was pulled back to the trachea while being rotated 90° clockwise; it was then either rotated 90° clockwise for placement into the left main bronchus (Group L) or rotated 90° anticlockwise and returned to the right main bronchus (Group R) using FOB guidance. The primary outcomes included clinical performance, which was measured by intubation time, and the quality of lung collapse. A secondary outcome was safety, which was determined according to bronchial injury and vocal cord injury.

RESULTS

The median intubation time (IQR [range]) required for placement of a R-DLT into the left main bronchus was shorter than the time required for placement into the right main bronchus (15.0 s [IQR, 12.0 to 20.0 s]) vs 23.5 s [IQR, 14.5 to 65.8 s], P = 0.005). The groups showed comparable overall results for the quality of lung collapse during the total period of one-lung ventilation (P = 1.000). The numbers of patients with bronchial injuries or vocal cord injuries were also comparable between groups (Group R, 11/30 vs. Group L 8/30, P = 0.580 for bronchus injuries; Group R, 15/30 vs. Group L 13/30, P = 0.796 for vocal cord injuries).

CONCLUSIONS

Repositioning a R-DLT from the right main bronchus into the left main bronchus had good clinical performance without causing additional injury. This may be an efficient method for the difficult repositioning of a R-DLT due to right upper lobe occlusion during surgery.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-IPR-15006933 , registered on 15 August 2015.

Anaesthetic management of left main bronchial glomus tumour

Glomus tumours involving bronchus are rare. Surgical resection is the treatment of choice for this tumour, with excellent prognosis. The nature and location of tumour pose a significant challenge for perioperative anaesthetic management. However, there is a paucity of case reports on anaesthetic risks involved in case of a bronchial glomus tumour. We present a case of glomus tumour involving left main stem bronchus, subjected to bronchial sleeve resection. The various anaesthetic implications of this tumour type and airway management with right double lumen tube are discussed.

Efficacy of a New Blind Insertion Technique of Arndt Endobronchial Blocker for Lung Isolation: Comparison With Conventional Bronchoscope-Guided Insertion Technique-A Pilot Study

This study aimed to find other methods of blind insertion of Arndt endobronchial blocker (AEB) for lung isolation when a fiberoptic bronchoscope (FOB) is unavailable.We compared the effectiveness and safety of 3 insertion techniques of AEB: Gum elastic bougie (GEB)-, bougie combined with cricoid displacing (BCD)-, and fiberoptic bronchoscope (FOB)-guided insertion. Seventy-eight patients undergoing esophageal procedure and requiring left thoracotomy were randomly assigned to 1 of 3 groups: GEB group, BCD group, and FOB group. We recorded the successful placement of AEBs at first attempt, placement time, malposition of AEBs in supine and lateral decubitus position, the bronchus injury score, and other complications.The successful placement of AEB for the first attempt was 22/26, 25/26, and 26/26 patients in GEB, BCD, and FOB groups, respectively. The placement times in GEB and BCD groups were longer than those in the FOB group (P < 0.05). AEB malposition occurred in 1/26, 2/26, 1/26 patients after lateral decubitus position, and AEBs were repositioned in 5/26, 3/26, 1/26 patients by FOB due to poor lung isolation in GEB, BCD, and FOB groups, respectively. There was no difference for the bronchus injury scores and other complications among 3 groups (P > 0.05).Bougie and cricoid displacing-guided blind insertion of AEB seems to be a novel method, which is an effective and safe alternative when FOB was unavailable.