Is it time to abandon routine blind insertion of the Double Lumen Tube?

Amruta Desai DO, MPH, MBA1, HyunSuk Lee MD1,2 and Dhamodaran Palaniappan MD1,2
Department of Anesthesiology, University of Connecticut School of Medicine, Farmington, CT1; Department of Anesthesiology, Hartford Hospital, Hartford, CT2

INTRODUCTION

• Endobronchial double lumen tubes (DLT) are utilized commonly for lung isolation during thoracic
surgery.

• The conventional technique used in DLT placement includes attempting a direct laryngoscopy,
removing the stylet once the bronchial cuff is past the glottis, rotating the tube to either left or right,
then inflating the tracheal cuff and verifying correct placement by a fiberoptic bronchoscope or less
commonly by clinical or radiological examination (figure 2).

• This blind technique used in DLT insertions can on rare occasions cause iatrogenic tracheobronchial
injury secondary to DLT’s large external diameters, use of stiff stylets, and proceduralist inexperience. A
tracheal injury, however rare, is critical as it requires quick diagnosis and appropriate intervention to
minimize the severe morbidity or mortality associated with this complication.

• One such case of a tracheal injury associated with a blind DLT insertion by the proceduralist involved
and further management is discussed here along with suggestions to minimize such complications in
the future.

CASE

• We describe a case of a 79yoF with adenocarcinoma of left upper lobe scheduled for left upper
lobectomy by VATS approach.

• ASA Physical Status: III

• PMHX: atrial fibrillation, coronary artery disease, chronic obstructive pulmonary disease, diabetes mellitus, hypertension, hyperlipidemia, glaucoma, hypothyroidism, lumbar spinal canal stenosis.

• PSHx: coronary artery bypass graft, c-section, cataract extractions, lung biopsy

• Previous Anesthesia issues: PONV

• Allergies: celecoxib, clarithromycin, codeine, rofecoxib, erythromycin

• Social Hx: former smoker- 3ppd x 24 yrs

• Medications: amlodipine, low dose ASA, atenolol, benicar, symbicort, glipizide, synthroid, metformin, pradaxa, pravastatin

• Vital Signs: BP 154/84 mmHg | Pulse 83 | Temp 99 °F (37.2 °C) (Oral) | Resp 22 | Ht 1.67 m (5’ 6″) | Wt 72.12 kg (160 lb) | BMI 25.68 kg/m2 | SpO2 96%

• Diagnostic Data:

• EKG: atrial fibrillation, ventricular rate = 73, no significant ST-T changes
• Echo (2011): normal EF, mild AV sclerosis and mild MR
• CT Thorax without contrast: Lobulated ground-glass lesions bilateral upper lobes. Left upper lobe has a mixed attenuation lesion, measuring 3 x 2.6 cm in maximal dimension.
• H/H: 12.6/38.9, Platelet count: 196, BUN/Cr: 16/0.8, Na/K: 138/3.9

ANESTHETIC MANAGEMENT

Intraop:

• Monitors: ASA Standard monitors and right radial arterial line. Pre-induction vital signs: Art BP:200/80, HR: 100 (afib), SpO2:100%.

• Induction of Anesthesia: After preoxygentation, IV induction was performed with 100mcg of fentanyl, 200mg of propofol and 50mg of rocuronium. Easy mask ventilation.

• DLT Insertion: The proceduralist involved performed a direct laryngoscopy with Mac #3, Grade II view, a left 37F DLT was passed through the cords without difficulty. Stylet removed. On further advancement of DLT after counterclockwise rotation of DLT, resistance was met at approximately 24 cm mark. The tracheal cuff inflated, end tidal CO2 was obtained on positive pressure ventilation with SpO2 at 100%. The fiberoptic bronchoscope (FOB) was passed through the bronchial lumen and unable to see the tracheal anatomy. FOB passed via tracheal lumen and it was seen that the tip of the DLT was abutting the soft tissue of the trachea and a superficial laceration of membranous trachea was noted. FOB then passed again through the bronchial lumen, DLT was pulled back, carina and left bronchus were identified. DLT was then carefully advanced over the FOB in left bronchus. After establishing one lung ventilation in right lateral decubitus position, VATS left upper lobectomy was performed. Airway Relook: At the end of the case, patient was repositioned supine. DLT removed.

• A single lumen #8 tube was gently and carefully inserted into the trachea. A flexible bronchoscopy was performed by thoracic surgeon to assess the airway. A full-thickness injury of the membranous trachea was noted few centimeters above the carina, and 2-3 cm below the vocal cords. Under fluoroscopic guidance, the proximal and distal extent of the laceration was noted. An 18 x 60 mm tracheal stent was deployed. Follow up bronchoscopy showed that the stent to be seated well and completely occluded the laceration.

• Pos-op: Patient was extubated in the OR and transferred to the SICU. Left Redo Thoracoscopy was performed under general anesthesia on POD #1 for increased left chest tube drainage and symptomatic anemia. Patient was brought to OR, intubated carefully with #8 mm single lumen tube. Tube inserted just to glottic aperture and FOB placed through it and ETT advanced under direct visualization. Tracheal stent in good position. Left sided bronchial blocker placed under direct visualization with FOB. Patient tolerated left thoracoscopy and evacuation of hematoma. Post procedure, patient was transferred to SICU intubated. Patient was eventually extubated & discharged to home on POD #10.

• Stent Removal: Stent removed on POD # 50 under GETA with FOB (figure 3).

DISCUSSION

• Tracheobronchial injury during DLT placement, a rare but serious complication, occurs with an incidence of about 0.2%.3 Between 1998 and 2010, only six reported cases of tracheobronchial injury were published.3. Common sites of injury include distal trachea and/or left main bronchus, likely secondary to a preference of left sided DLTs.3 These injuries usually occur as a longitudinal defect within the membranous portion of the trachea.3

• Major risk factors include an inexperienced clinician, repetitive attempts, inappropriate use of the stylet, an over inflated cuff, inappropriate selection of tube size, abnormal location of the tube, sudden movement of the patient, excessive coughing, weakened membrane structure of the trachea due to steroid or radiation therapy, and hx of COPD or tracheomalacia. Other factors include obesity, short stature, age older than 50, and being female.3

• Management of the airway during the repair of a tracheal rupture requires safe ventilation and adequate surgical access. Methods of ventilation which minimize further injury include jet ventilation, high frequency positive pressure ventilation, distal tracheal intubation, spontaneous respiration, and cardiopulmonary bypass. A bridging technique can be performed for mechanical ventilation during repair of a tracheal rupture. The tube can be advanced distal to the ruptured site with a minimally inflated cuff, which will not create pressure on the damaged tissue. At this time, a small amount of air leakage is acceptable and will allow for surgical access.3

• After treatment of a tracheal injury, early extubation is recommended as there is the possibility of damage to the mucosal layer of the trachea secondary to the movement of the endotracheal tube and the pressure of the cuff. Although, in many instances, some patients need to remain intubated in order to retain adequate venDlaDon.3

• This rare but serious complication associated with blind DLT insertion could be eliminated by using FOB to guide DLT placement as shown in figure 4. A. Remove stylet once bronchial cuff passes through the glottis, place FOB through the bronchial lumen and identify carina, left bronchus. B. Scope is withdrawn, and positioned just above the tip of bronchial lumen. C. The tracheal cuff is then deflated, and tube is advanced with the scope into the left main-stem bronchus just above the secondary carina. D. FOB is
passed through the tracheal lumen to check the position of the bronchial cuff and the opening of the right main-stem bronchus.2 Another option is to insert FOB through bronchial lumen, place FOB just above secondary carina and advance DLT over the scope to the desired location.

• Routine FOB guided DLT insertion technique in our opinion can minimize serious tracheal injury as opposed to blind insertion.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REFERENCES
• 1. Morgan, G. E., Mikhail, M. S., & Murray, M. J. (2005). Clinical anesthesiology (5th ed.). Chapter 25.

• 2. Shields, T. W. (2009). General thoracic surgery. Chapter 17. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

• 3. Kim, J., Lim, T., & Bahk, J. Tracheal laceration during intubation of a double-lumen tube and intraoperative fiberoptic bronchoscopic evaluation through an LMA in the lateral position -A case report-. Korean Journal of Anesthesiology, 2011, 60(4), 285. doi:10.4097/kjae.
2011.60.4.285

• 4. Hartman, W. R., Brown, M., & Hannon, J. Iatrogenic Left Main Bronchus Injury following Atraumatic Double Lumen Endotracheal Tube Placement. Case Reports in Anesthesiology, 2013, 1-3. doi:10.1155/2013/524348