Use of bronchial blocker to facilitate left double-lumen tube placement

Sir,

A 46-year-old, 166 cm tall female with coronary artery disease was posted for coronary artery bypass grafting (CABG) through left thoracotomy. After anesthesia induction, 37F left double-lumen tube (DLT) (BronchoCath, Mallinckrodt, USA) was placed under direct laryngoscopy. On auscultation, there was absence of air entry on the right side when bronchial lumen was clamped and with audible breath sounds on left side suggesting the placement of bronchial lumen of left DLT in the right bronchus which was confirmed with bronchoscope. An attempt to place the DLT under bronchoscopic guidance was not successful as the left bronchial tip slid into right bronchus when rail-roading the DLT. The DLT was withdrawn completely and a bronchial blocker (BB) was passed into the tracheal lumen of the DLT until its tip was just seen protruding through the tracheal lumen. This combination of left DLT and BB was inserted under direct laryngoscopy. After the bronchial cuff passed through the glottis, the DLT was rotated 90° counterclockwise and advanced. At the point when tracheal cuff crossed the vocal cords, the BB was advanced by 1 cm and inflated with 3 ml of air. Then the DLT with BB inflated was inserted to a depth of 29 cm [Figure 1]. Finally, the BB was deflated and removed. The tracheal and bronchial cuff of the DLT were inflated and connected to the ventilator circuit. Chest auscultation revealed correct placement of DLT and was further confirmed with bronchoscope. Lung isolation was adequate and the patient underwent uneventful CABG. At the conclusion of surgery, DLT was exchanged with standard endotracheal tube and the patient was shifted to intensive care unit for further management. A backup plan for the above described technique is to replace the DLT with single-lumen endotracheal tube and to place the BB under bronchoscopic guidance into the left bronchus.

Figure 1.

Illustrative sketch showing the relative position of BB cuff and DLT in tracheo-bronchial tree. (a) BB cuff within tracheal lumen of DLT, (b) BB cuff advanced into trachea, (c) BB cuff in trachea inflated with air and (d) BB cuff acting as a scaffold to facilitate the placement of bronchial lumen of left DLT in the left bronchus. Abbreviations- BB: Bronchial blocker, DLT: Double-lumen tube

Left-sided DLTs have greater margin of safety for correct positioning because the left main bronchus is longer than right main bronchus.[1] The placement of left DLT usually consists of rotation of the DLT by 90° to the left once the bronchial cuff passes the glottis and is then advanced blindly into the left bronchus.[2] With blind technique, the DLT may be misdirected into the right bronchus because the right bronchus is wider and has less angulation with trachea compared to left bronchus.[3] Misplacement into right bronchus inhibits ventilation/deflation of right upper lobe and can worsen oxygenation during one-lung ventilation[4] Also, the repeated action of re-positioning the misplaced tube can inflict tracheo-bronchial injuries. Several techniques have been described to facilitate first pass successful placement of left DLT. Seo et al.[5] suggested augmentation of curved tip of left DLT to reduce right bronchial misplacement. However, it is generally not preferred to modify an airway device in a way different from the original manufacturer's version and there may be difficulty in removal of stylet with the left bronchial lumen excessively angulated. Fibreoptic (FOB) guided placement of left DLT to reduce misplacement has been described.[6] However, the disadvantages are that it requires considerable technical expertise and small calibre FOBs are too fragile to guide DLTs with risk of damage to FOB during manipulation.

In our technique, the inflated cuff of the BB facilitated placement of the bronchial lumen of left DLT in the left bronchus by acting as a scaffold. There are certain limitations to our technique. There may be resistance during passage of DLT after bronchial cuff inflation which can be resolved by reducing the volume of air in the BB cuff. Secondly, there is risk of BB cuff rupture and mucosal/carinal injury. Finally, FOB is required to confirm the optimal placement of DLT. Before embarking on this technique, the cost-benefit analysis needs to be considered. To conclude, the combined use of BB and DLT as a rescue technique to prevent misdirection of bronchial lumen of left DLT into the right bronchus may be an option in certain cases.

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Conflicts of interest

There are no conflicts of interest.