Chapter 20

Lung Isolation Devices

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Indications for Lung Isolation
Thoracic Procedures
A def lat ed lung provi des better operati ng condi ti ons and reduced
trauma duri ng thoracic procedures.
Control of Contamination or Hemorrhage
A lung i solati on devi ce can prevent infected materi al from one
lung from contami nati ng the other lung (1). When hemorrhage
occurs i n one lung, an i solation device allows the unaff ected lung
to be venti lat ed (2,3,4,5,6,7,8,9,10,11).
Unilateral Pathology
A bronchopleural or bronchocutaneous fi stula may have such a
low resi stance t o gas flow that most of t he ti dal volume passes
through i t, maki ng i t i mpossi ble to adequately venti late t he other
lung (12,13,14). Large cysts or bul lae may rupt ure under posi ti ve
pressure, making it mandat ory that they be excluded from
venti lati on. Another i ndication for l ung separati on is when lungs
have markedly di fferent compli ance or ai rway resi stance such as
that whi ch occurs followi ng si ngle-lung transplantation or
uni lat eral i njur y (15).
The best method of producing lung i solati on i n a gi ven situati on
wi l l depend on several fact ors, i ncluding the indi cati on for lung
i solation, patient variables, avai lable equipment, and the ski ll and
traini ng of the anesthesi a provider.
Anatomical Considerations
The right mai nstem bronchus is shorter, strai ghter, and has a
larger di ameter than t he left. It takes off from the trachea at an
angle of 25 degrees in adults. The left mai nstem bronchus
di verges from the medi an plane at a 45-degree angle. These
angles are slight ly larger in chi ldr en (16). The right upper lobe
bronchus takeoff i s very close to the ori gin of the ri ght mai nstem
bronchus. These anat omical features mean t hat it i s usually
easi er to i ntubate the ri ght mai nstem bronchus than the left, but i t
i s more di ffi cult to place a tube i n the ri ght mai nstem bronchus
wit hout obstructi ng the upper lobe ori fi ce.
Double-lumen Tubes
The double- lumen tube ( DLT, DLET) is the devi ce most
commonly used t o provide lung i solation.
Description
A DLT is essenti al ly two si ngle-lumen tubes bonded toget her and
desi gnated either as right- or left-sided, dependi ng on which
mainstem bronchus the tube i s desi gned to fi t. The tracheal
lumen is desi gned to t erminate above the cari na. The di st al
portion of the bronchial lumen is angled to fit i nto the appropri ate
mainstem bronchus.
The internal lumen of each tube i s D-shaped wi th the straight
si de of the D i n the mi ddle of the tube. The resi stance of each
lumen of a 35 to 41 French (Fr) DLT has been f ound to be
comparable to t he resist ance of a si ze 6 to 7 mm int ernal
di ameter single-lumen tracheal tube (17).
The bronchi al cuff f or right-sided tubes vari es i n shape,
dependi ng on the manuf acturer. On some tubes, t he cuff has a
slot to allow venti lati on of the right upper lobe. Some ri ght-sided
DLTs have two bronchi al cuffs wi th an opening for the ri ght upper
lobe bet ween them. The resti ng volume and compli ance of
bronchial cuffs vari es between di ff erent si zes and brands of DLTs
(18,19). Most manufacturers color the bronchi al cuff blue. They
also use blue marki ngs on the pi lot balloon and/or the i nflati on
devi ce for the bronchi al cuff.
A f ew DLTs have a cari nal hook t o ai d i n proper placement and
mini mi ze tube movement aft er placement. Potenti al problems
wit h carinal hooks i nclude i ncreased dif fi culty duri ng i ntubati on,
trauma to the ai rway, malposi ti on of the tube because of the
hook, and int erference wi th bronchial closure duri ng
pneumonectomy. The hook can break off and become lost i n the
bronchial tree.
Most manuf acturers place a radi opaque marker at t he bottom of
the tracheal cuff or at t he end of the tracheal lumen. Other marks
may be placed above and/or below the bronchi al cuf f. Some have
a radi opaque line runni ng the length of the tube.
Disposable DLTs are supplied in steri le packages, which include
a stylet, connectors, and suction catheter(s). A means to supply
continuous posi ti ve ai rway pressure (CPAP) may be i ncluded wi th
the tube or can be purchased separately.
The connector (20) allows both lumens to attach t o a breat hing
system at the same ti me.
Sizing
Adult DLTs commonly come i n si zes 35, 37, 39, and 41 Fr. The
French scale i s the external diameter of the tracheal segment
ti mes t hree. Some manufact urers also provi de 26, 28, and 32 Fr
tubes for younger pati ents. Unfortunat ely, the French gauge
marki ngs are of li mited value i n determi ning the most important
measurement-the di ameter of the bronchi al segment.
There are maj or vari ati ons between manuf acturers in the
di mensi ons of the bronchi al segment of DLTs of the same
nomi nal si ze and even among tubes of the
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same si ze from t he same manufacturer (21,22,23, 24). An
Internati onal Technical Speci fi cati on has recommended that
outside circumference of the bronchial segment be desi gnated i n
mi lli met ers (25). The di ameter of the bronchi al segment wi th the
cuff inf lated may not i ncrease wi th tube si ze (26).
Margin of Safety
The margi n of safet y f or a DLT i s t he length of the
tracheobronchi al tree between the most di stal and proxi mal
acceptable posi ti ons (27,28). The margi n of safety wi l l depend on
the length of the lumen i nto which the cuff i s placed and the
length of the cuff . If the cuff i s short or the mainst em bronchus
long, the margi n of safet y wi ll be greater.
Left-sided Tubes
The outermost accept able posi ti on for a left-si ded DLT i s when
the bronchi al cuff is just below the carina. If the tube were more
proximal, the bronchial cuff could obstruct t he trachea and/or the
contralateral (ri ght) mainstem bronchus. In thi s case, the seal
bet ween the two lungs would be lost. The most acceptable di stal
posi ti on i s when the the bronchi al segment ti p i s at t he proximal
edge of the upper lobe bronchi al ori fi ce. More di stal inserti on
would result in obstructi on of the upper lobe bronchus.
The average lengt h of the left bronchus from t he carina to the
takeoff of the upper lobe bronchus i s 5.6 cm. Thi s leaves a
relatively smal l margin for placement, as t here could be up t o 3. 5
cm of movement wi th neck flexion and extensi on (29). There is
great variabi lit y i n t he length of the bronchi al segment of left-
si ded DLTs currently avai lable (30).
Right-sided Tubes
The margi n of safet y i s defined di fferently for ri ght-sided tubes. A
ri ght-si ded DLT i s acceptably posi tioned if t he right upper lobe
venti lati on openi ng or the space bet ween the two cuffs i s ali gned
wit h the right upper lobe orifice. Thus, t he margi n of safety i s t he
length of the venti lation openi ng minus the diamet er of t he
ori fi ce. The margin of safet y for right-sided tubes is consi derably
less than f or left-sided tubes.
Specific Tubes
Carlens Double-lumen Tube
The Car lens DLT (Fi gs. 20. 1, 20.2) is i ntended to be i nserted i nto
the left mainst em bronchus. It has a carinal hook (spur). Thi s
tube may be especi ally useful wit h massi ve hemoptysis when
verification of tube placement i s especial ly diffi cult (31).

View Figure

Figure 20.1 Carlens double-lumen tube. A: The
connector has ports for fiberscope insertion or suctioning
and areas where a clamp can be applied to occlude gas
flow. B: Note the carinal hook and the blue bronchial
cuff.

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View Figure

Figure 20.2 Carlens tube in place.

White Double-lumen Tube
The White DLT (Fi g. 20.3) is desi gned to fit the right mainstem
bronchus. It has a carinal hook. The cuff for the ri ght mai nstem
bronchus i s circumferenti al superior to the openi ng t o the upper
lobe bronchus and conti nues dist ally behi nd the opening.
Robertshaw Right Double-lumen Tube
The bronchi al portion of the Rober tshaw ri ght DLT (Fi g. 20.4) i s
angled at 20 degrees (32). The bronchi al cuf f has a slotted
openi ng i n i ts lateral aspect (Fig. 20.5). The bronchi al cuff is
proximal to the slot on the lat eral surface and extends
tangenti all y toward the medi al surface.
Robertshaw Left Double-lumen Tube
The Robertshaw left DLT is shown i n Fi gures 20.6 and 20.7. The
angle of the bronchial porti on i s 40 degrees (32). The average
length of the bronchi al segment is 23 mm for si zes 35/37 and 25
mm for si zes 39/ 41 (30).
Broncho-Cath Right-sided Tube
The Broncho-Cat h ri ght-si ded t ube has a bronchi al cuff that is
roughly the shape of an S, or slanted doughnut. The cuff edge
nearest the right upper lobe bronchus is closer to the trachea
than the part of the cuff touchi ng the medi al bronchi al wall ( Figs.
20.8, 20.9). A slot i n t he t ube j ust beyond the cuff corresponds to
the openi ng of t he upper lobe bronchus (27). The end of t he
bronchial segment has no bevel (33).
The shape of t he right bronchial cuff allows the venti lati on slot t o
ri de off the ri ght upper lobe ori fi ce, increasi ng the margi n of
safety. One study found that when this tube was i nserted bli ndly,
ri ght upper lobe obstruction occurred i n 89% of cases (34).
Placement usi ng fiberopti c endoscopy resulted i n much better
posi ti oning (35).

View Figure

Figure 20.3 White double-lumen tube. (Picture courtesy
of Teleflex Medical.)

Broncho-Cath Left-sided Tube
On the Broncho-Cath left-sided DLT (Fi g. 20.10), the bronchi al
portion of the tube i s at an angle of approxi mately 45 degrees
(33,36,37). The bronchi al porti on has a curved ti p. The bevel was
removed in 1994 but reintroduced in 2001 (33,38). The average
length of the bronchi al segment is 30 t o 31 mm (30). The tube is
avai lable wi th or wi thout a cari nal hook.
Sher-I-Bronch Right-sided Double-lumen
Tube
The Sher-I-Bronch ri ght-sided DLT has two cuff s on the bronchi al
segment, one proxi mal and one di stal to the upper lobe
venti lati on slot. The slot is 13 to 14 mm long (Figs. 20.11, 20.12).
One study found that poor lung i solation was more common when
this tube was used (39). A case has been reported i n whi ch the
tube tip became trapped i n the right upper lobe bronchus (40).

View Figure

Figure 20.4 Robertshaw right double-lumen tube in
place.

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View Figure

Figure 20.5 Robertshaw right double-lumen tube in
place.

Sher-I-Bronch Left-sided Double-lumen Tube
The bronchi al segment of t he Sher-I-Bronch lef t-sided DLT
di verges from the mai n tube at an angle of 34 degrees. The
average length of the bronchi al segment is 35 mm (30). The
bronchial segment has a bevel (30). One st udy found that the
bronchial cuff on this tube requi red si gnificant ly higher pressures
to achi eve one- lung isolati on than cuffs on other DLTs (41).
Silbroncho Double-lumen Tube
The Si lbroncho DLT (Fi g. 20.13) i s made of si li cone, whi ch i s
softer than polyvi nylchlori de (PVC). The tube does not contai n
latex. The bronchi al segment is wi re-rei nforced di stal to t he
tracheal cuff. Thi s al lows it to be flexi ble and prevents ki nki ng.
The wi re rei nforcement also makes tube posi ti on easy to
determi ne on x-ray. The bronchi al cuff i s smal l and near the end
of the tube. It is avai lable i n si zes 33, 35, 37, and 39 Fr.

View Figure

Figure 20.6 Robertshaw left double-lumen tube.
(Courtesy of Rusch, Inc.)


View Figure

Figure 20.7 Robertshaw left double-lumen tube.

Techniques
Tube Choice
Right versus Left
When surgery is performed on the ri ght lung, a left-sided DLT
should be used (42,43, 44). Because the margin of saf ety i n
posi ti oning a right-si ded DLT is so smal l, some prefer to use a
left-si ded DLT whenever possi ble for left lung surgery (28,45).
Duri ng left pneumonectomy, i mmedi ately bef ore the left mai nstem
bronchus i s clamped, the DLT can be pul led from the bronchus
and used for venti lati ng the ri ght lung. A disadvantage of thi s
techni que is the ri sk of blood and secreti ons movi ng from t he
operati ve (left) bronchus t o the nonoperati ve bronchus. Other
possi ble problems i nclude the tube becomi ng dislodged or
sutured i n place duri ng surgery. A ball-valve obstructi on may
occur as a result of secreti ons or medi asti nal pressure pushing
the tracheal lumen agai nst the tracheal wal l (46). A left DLT may
not provide opti mum conditions for ventilati ng the residual lung
after left upper lobectomy (47).
A right-si ded DLT should be used when i t is i mportant to avoi d
mani pulati on/i ntubati on of the left main bronchus (e.g., an
exophytic lesion), when the left mai n bronchus is narrowed or the
left mainst em bronchus i s so cephalad t hat the bronchi al lumen
wi l l not enter t he
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left mainst em bronchus, left pneumonectomy, left lung
transplantati on, left mainstem bronchus stent in place or when
there i s tracheobronchi al disrupti on on the left (43,48,49,50,51).

View Figure

Figure 20.8 Broncho-Cath right double-lumen tube.
Newer versions have no bevel at the end of the bronchial
segment. (Courtesy of Mallinckrodt Medical, Inc.)

Before placi ng a right DLT, the patient' s chest x-ray or comput ed
tomography scan can be closely examined to i denti fy a right
upper lobe bronchus t akeoff, which would make it di fficult to use
a right DLT. A left DLT should be placed in the ri ght mai nstem
bronchus i n Kartagener' s syndrome, which includes complete
si tus inversus and a longer-than-normal ri ght mainstem bronchus
(52).

View Figure

Figure 20.9 Broncho-Cath right double-lumen tube. The
bronchial cuff has the shape of an S or a slanted
doughnut, with the edge of the cuff nearest the right
upper lobe bronchus closer to the trachea than the part of
the cuff touching the medial bronchial wall. A slot in the
tube beyond the cuff corresponds to the opening of the
right upper lobe bronchus. Newer versions have no bevel
on the bronchial segment.

Size
Selecti ng an appropriately si zed DLT for a gi ven patient i s cri ti cal
to mi ni mi ze the frequency of compli cations (53).
A DLT that i s too small may fai l to provi de lung i solati on or may
require bronchi al cuff volumes and pressures that could produce
mucosal i schemi a or bronchial rupture. Using too smal l a DLT
can result in the tube advanci ng t oo f ar i nto the bronchus, a
hi gher level of autoPEEP (posi ti ve end-expi ratory pressure), or
barotrauma (54,55). An undersized tube may be more likely to be
di splaced. Venti lati on and suctioni ng are more diffi cult wi th a
small t ube.
Usi ng a large DLT wi l l result i n less resistance to gas f low,
faci li tate sucti oni ng and passage of a fi berscope, and reduce the
ri sk of advanci ng the DLT too far i nto t he bronchus but may
result i n trauma (56). Inabi li ty to i nsert a larger tube through the
larynx or past the cari na or i ntrinsi c or extri nsic obstruction in the
mainstem bronchus to be intubated may necessi tate use of a
smaller tube.
A t ube i s oversi zed i f the bronchi al lumen wi l l not fi t i nto the
bronchus or there is no ai r leak wi th the bronchial cuff deflated
(22,38,57,58,59,60). It is too small i f the bronchi al cuff i nflati on
volume is greater than the resti ng cuff volume. Not more than 3
cc of air i n the bronchial cuff should be requi red to creat e a seal.
When there i s a hi gh risk that f lui ds wi ll seep past the bronchial
cuff, a smal ler DLT should be used (61).
In adults, the di mensi ons of the cri coid ri ng best defi ne those of
the main bronchi (23). In chi ldren, age but
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not weight i s a predi ct or of bronchi al diameter, and the right main
bronchial di amet er is si gnificant ly larger than the left (62).
Suggested si zes for DLTs i n chi ldr en are shown in Table 20.1.
Tubes from different manufacturers vary in si ze and may not fi t
this table.

View Figure

Figure 20.10 Broncho-Cath left double-lumen tube.
(Courtesy of Mallinckrodt Medical, Inc.)


View Figure

Figure 20.11 Sher-I-Bronch double-lumen tubes. A:
Left-sided tube (top). Right-sided tube (bottom). B:
Close-up of right bronchial segment, showing opening to
the right upper lobe. (Courtesy of Sheridan, Inc.)


View Figure

Figure 20.12 Sher-I-Bronch right double-lumen tube.
Note the two cuffs proximal and distal to the opening to
the right upper lobe.

The opti mal si ze of DLT is easi ly selected i f the di ameters of the
patient' s mai n bronchus and the DLT tip are known. The di amet er
of the DLT bronchial lumen should be 1 to 2 mm smal ler t han the
i ntubated bronchus (22). The di ameter of t he mai nstem bronchus
i n any given pati ent can be di fficul t to determi ne. There are
consi derable variati ons i n mainstem bronchial di ameters. Age,
sex, gender, wei ght, and hei ght have relatively weak predi ctive
value when selecting the proper DLT (22,60).
TABLE 20.1 Sizes of Double-lumen Tubes for Children
Age (years) Double-lumen Tube (French)
8 to 10 26
10 to 12 26 to 28
12 to 14 32
14 to 16 35
From Hammer GB, Fitzmaurice BG, Brodsky JB. Methods for single-lung
ventilation in pediatric patients. Anesth Analg 1999;89:14261429.

The si ze of the mai nstem bronchus may be determi ned by
measuri ng t he wi dth of the pati ent' s bronchus from a chest x-ray
or computed tomographi c scan (22,54,60,63, 64,65, 66,67, 68).
Unfortunately, i t is not possi ble to accurately measure bronchi al
width on many chest x-rays, and the correlation between the
tracheal and bronchi al si ze may not be reli able enough t o
determi ne the proper si ze DLT from the si ze of the trachea
(56,59,63,69,70,71,72). Reli abi li t y may be i ncreased by
measuri ng t he tracheal di ameter both anteropost ally and
medi olaterally (73). The lung transplant pati ent may have a
si gnificantly di fferent si zed bronchus than would have been
predicted from the si ze of the trachea (56).
Preparing the Double-lumen Tube
The tracheal and bronchi al cuffs should be inf lated and checked
for leaks and symmetrical cuff i nf lation, maki ng certai n that each
i nflati on tube i s associat ed wi th the proper cuff. The cuffs and
stylet should be lubri cated wi th a water-soluble lubri cant and t he
stylet placed
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i nside the bronchi al lumen, making certai n that i t does not extend
beyond the ti p. The connector should be assembled so t hat it can
be quickly fi tted to the tube and breathi ng system af ter
i ntubation.

View Figure

Figure 20.13 A: The Silbroncho double-lumen tube. B:
The bronchial segment is wire-reinforced distal to the
tracheal cuff.

Insertion
The DLT is advanced through the larynx wi th t he angled tip
di rected ant eri orly. After the bronchial cuff has passed the cords,
the tube i s turned 90 degrees so that t he bronchi al porti on poi nts
toward t he appropri ate bronchus. If the tube is to be placed in the
left mainst em bronchus, the head and neck should be rotated to
the ri ght before rotati ng and advancing the tube (74). Leaving the
stylet i n place for the enti re int ubati on procedure rather than
removi ng i t once the bronchi al cuff has passed the vocal cords
may result i n more rapi d and accurate placement (75). However,
some recommend that the st ylet be removed j ust after the tube
passes the vocal cords to prevent trauma (76).
A DLT is most accurately placed by i nserti ng a fi berscope int o
the bronchi al lumen and directi ng i t into t he appropri ate bronchus
under di rect vi sion (77,78,79,80,81,82). Concurrent di rect
laryngoscopy may be requi red to elevate the supraglotti c ti ssues
to faci lit ate passi ng t he DLT through the glotti c openi ng after the
fi berscope i s i n the trachea (83). This ensures that the correct
bronchus i s i ntubated on the fi rst attempt and avoids i nserti ng
the tube too deeply or the tube becoming ki nked i n the upper
lobe bronchus (40).
A DLT wi th a carinal hook should be inserted wit h t he bronchial
segment concave anterior ly unti l the bronchi al cuff passes t he
cords. It should t hen be rot ated 180 degrees so that the hook i s
anteri or and advanced unti l the hook passes the vocal cords. The
tube i s then advanced unti l the hook engages the cari na. The
hook can be ti ed closely to the tube wi th a slip knot to faci litate
passage through t he larynx and then unti ed.
Inserting the bronchi al portion i nto the bronchus can be
performed bli ndly after inserti on t hrough the vocal cords. In some
cases (e. g., bronchorrhea, bleedi ng), bli nd placement may
succeed where the fi beroptic techni que does not (79).
With blind inserti on, the correct depth of i nserti on may be di fficult
to determine. However, this method may be useful where rapi d
lung i solation or col lapse is necessary. In adults, there i s a
correlati on bet ween the i deal depth of i nserti on of left DLTs and
patient hei ght but not wei ght or age (24,84,85,86,87). The ideal
dept h of i nsertion can be esti mated from the chest x-ray
(84,85,86). Advanci ng the t ube wit h the bronchi al cuff parti ally
i nflated unti l an i ncrease i n resist ance i s felt (or only one si de of
the chest moves and compli ance i s reduced) may prevent
i nserting the tube too deeply (88,89,90,91). The bronchi al cuff i s
then def lated and the tube advanced a di stance equal to the
length of the bronchi al cuff plus 1 to 1.5 cm to place i t just
beyond the cari na (92,93). Depth of i nsertion may be esti mated
by moni toring bronchi al cuff pressure (94).
Since the t ube usual ly moves upward wit h positioni ng, some
clini ci ans recommend t hat the tube should i nitial ly be inserted
more deeply than would be the i deal posi ti on (36,38,95,96).
Others believe that the danger of t rauma i s i ncreased i f the tube
i s i ntentional ly placed too deeply (97).
If the patient i s anatomical ly di fficult to i ntubate, a single-lumen
tracheal t ube may be placed by any of t he means that faci litate
di fficult i ntubati ons (98). An exchange catheter can t hen be
i nserted i nto the single-lumen tube and the DLT i nserted over the
catheter after the si ngle- lumen tube has been wi thdrawn (99).
The WuScope (Chapter 18) has been successful ly employed to
place a DLT i n a pati ent who was di fficult to int ubate (100). A
DLT can be placed by usi ng a li ghted st ylet ( Chapter 19) in the
bronchial lumen (101) or a retrograde i ntubati on techni que (102).
Awake fiberopti c bronchi al int ubati on wi th a DLT has been
reported (103). A DLT may be introduced over a gum elastic
bougi e (45,104,105,106). It may be helpful to pass the bougie
through the openi ng for the ri ght upper lobe ori fi ce on ri ght DLTs
(105).
A DLT may be i nserted through a t racheostomy (107,108).
Cuff Inflation
Once the tip is thought to be i n a mai nstem bronchus, the
tracheal cuff should be i nflated i n a manner si mi lar to t hat of a
tracheal t ube (109,110). It is more di ffi cult to i nflate the bronchi al
cuff correctly. An overinf lated bronchial cuff is more li kely to
herniate i nto the trachea, cause the carina to be pushed t oward
the opposi te side, or result i n narrowi ng of the bronchi al segment
lumen. Inflati ng t he bronchi al cuff beyond its resti ng volume may
result i n dangerously hi gh pressure (18,111).
The bronchi al cuff should be i nflated wi th small i ncremental
volumes unti l an airti ght seal is just attai ned (109,112). The t otal
volume should be less than 3 mL (41). One techni que i s to
i mmerse the proxi mal tracheal lumen i n water during venti lati on
vi a the bronchial lumen. The bronchial cuff is inf lated unti l no
bubbles are seen escapi ng during posi ti ve-pressure inspi rati on
(110,111) (Fi g. 20.14). Variations of this are to connect a bal loon
(113) or a capnograph (111) to t he tracheal lumen. Another
method is to apply suction to the tracheal lumen (110). Absence
of bronchial seal wi ll cause the reservoi r bag i n a breathi ng
system that i s connected to the bronchi al lumen to collapse.
Inflati ng t he bronchi al cuff to an ai rtight seal may not prevent t he
spread of blood or secreti ons (61). The bronchi al cuff may also
be inf lated with wat er (114).
Confirming Position
Confi rming proper tube posi ti on is essenti al because the tube
may not perform properly if i ncorrectly
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posi ti oned. Positi on should be checked after i nserti on, after
repositioni ng t he pati ent, and before beginni ng one-lung
venti lati on, as t hese tubes oft en move during pati ent posi ti oni ng
or surgi cal manipulati ons
(97,115,116,117, 118,119,120,121, 122,123). The most frequent
DLT movement is duri ng lateral decubi tus positioni ng. Whi le
movement i s usuall y out ward, di stal migrati on may also occur.
DLT posi ti on should be confirmed whenever there i s evi dence of
malfuncti on.

View Figure

Figure 20.14 Inflating the bronchial cuff. With the
tracheal cuff inflated, the bronchial cuff is slowly inflated.
Right: A bronchial cuff leak is indicated by bubbles when
the end of the tracheal lumen is placed under water. Left:
With a seal, no bubbles appear.

Auscultatory Techniques
Unfortunately, auscult ati on detects DLT malpositi on only part of
the ti me because breat h sounds can be transmi tted from one
regi on of the lung to adjacent areas (124,125,126,127). Studi es
have shown t hat a si gnificant percentage of DLTs thought to be
posi ti oned sati sfact ori ly by auscultati on were found to be
i nappropriately positioned on subsequent fi beropti c examination
(116,120,128). A DLT may function sati sf actori ly although not in
an ideal posi ti on. Another problem wi th auscult ati on i s that once
the patient i s prepped and draped, the chest i s no longer
avai lable f or auscultation. One study found that auscultatory
placement was not associ ated with an increased i nci dence of
compli cations duri ng one- lung venti lati on (39).
Clamping Method
Left-sided Tubes
With only the tracheal cuff inf lated and the tracheal lumen
connected to the breathi ng system, both lungs should be
auscultated i n the axi l lar y regions and upper lung fields to detect
di fferences. The bronchi al cuff should then be i nflated and both
lumens connected to the breathi ng system. Auscult ati on should
then be repeated.
Next, t he attachment bet ween the breathing system and t he
tracheal lumen should be occluded and the tracheal lumen
opened to atmosphere. Breath sounds should be heard only over
the left lung. If breath sounds are heard bi lateral ly, the tube i s
too hi gh i n the trachea. Both cuffs should be def lated and the
tube advanced. If breath sounds are heard only over the ri ght
lung, the bronchi al lumen i s on t he ri ght si de. If this is the case,
both cuffs should deflated, the t ube wi thdrawn unti l i ts distal end
i s above the cari na, rotated, then reinserted. The steps outli ned
should be repeated.
The attachment bet ween t he breathi ng system and the bronchi al
lumen should then be clamped and the pati ent venti lated through
the tracheal lumen. The bronchi al lumen should be opened t o
atmosphere. Breath sounds should be heard only over the ri ght
lung. If there i s marked resist ance to venti lati on, the tube i s
ei ther too far i nto the left bronchus or is not deep enough. The
posi ti on can be determi ned by defl ati ng the bronchial cuff whi le
continui ng to venti late through t he tracheal lumen wi th the
bronchial lumen clamped. If the ti p i s too deep in the left
bronchus, breath sounds wi l l be heard only on the left si de. If the
tube i s not deep enough i n the bronchus, breath sounds wi ll be
present bi laterally. The tracheal cuff also should be deflated and,
dependi ng on where breath sounds were heard, the tube pulled
back or advanced. Both cuffs should be reinf lated and the
auscultatory sequence repeated.
Right-sided Tubes
Auscultation of a right-si ded DLT i s simi lar to that of a lef t-sided
tube. It is especi ally i mportant to confi rm venti lati on of t he right
upper lobe.
P.643


Single Connector Method
An alternati ve techni que i s t he si ngle connector techni que in
whi ch a single connector is used to venti late each lung i n turn by
si mply transferring the distal end of the DLT from one lumen to
the other, eli minating the need for repeat ed clampi ng and
unclampi ng (126). Thi s has the advantage of bei ng si mpler and
requiri ng fewer steps and may result in reduced ri sk of creati ng a
potenti ally harmf ul ball-valve eff ect in a parti ally obstructed lobe
or lung by detecting it ear li er.
Aft er the DLT is advanced to the desi red depth, a single
connector from the breat hing system is attached to the bronchial
lumen. While performi ng manual venti lati on, the bronchi al cuff i s
i nflated to create an airti ght seal. Auscultation i s used to confi rm
that the i ntended lung i s bei ng venti lated. The connector is then
transferred from the bronchi al lumen to the tracheal lumen. The
tracheal cuff is inf lat ed to create an ai rtight seal, and it i s
confirmed that t he proper lung is venti lated. The connector i s
then transf erred to the bronchi al l umen and short venti lati ons
performed whi le li steni ng over the apex of the lung for vesi cular
breath sounds. If these are not heard, the single connector i s
detached from the bronchial lumen and a double connector i s
connected to the t wo lumens.
Flexible Endoscopic Techniques
Flexible endoscopy i s the most accurate met hod for determi ning
DLT posi ti on (120,129,130, 131,132). Many recommend that thi s
should be the standard of care (81,131,133,134, 135,136). Others
believe that t he fi beropti c scope i s helpful but not essenti al
(95,124,137,138, 139). There is general agreement that fi beropti c
endoscopy i s al ways needed for right-si ded DLTs. Fi beropti c
methods to confi rm the positi on of the DLT may not work in the
presence of blood or secreti ons (140). Whenever there i s any
doubt, thi s method should be used to check t he posi ti on. A
further advantage is that i t can be used to remove blood or
secreti ons. It can also be used after the patient i s prepped and
draped i f a question ari ses wi th regard to proper t ube placement.
Left-sided Tubes
A fiberscope is placed i n the tracheal lumen through the open
end of the tube or through a port in the connector that is speci ally
desi gned for thi s purpose. As the fiberscope is advanced, the
carina should come i nto view. The top surface of t he blue
bronchial cuff should be seen below t he carina in the left
mainstem bronchus. The bronchial cuff should not herniate over
the carina, nei ther should t he carina be pushed t o the ri ght. An
unobstructed vi ew of t he noni ntubated right mainstem bronchus
should be obtai ned.
The fi berscope should then be advanced t hrough the bronchi al
lumen to check for narrowing of the lumen at t he level of the cuff
and an unobstruct ed vi ew of the di stal bronchi al tree.
Right-sided Tubes
Looki ng down the tracheal lumen, the bronchi al cuff' s upper
surface should be seen below the cari na in the right mai nstem
bronchus. The fiberscope i s then placed in the bronchi al lumen.
The right mi ddle lower lobe bronchial carina should be seen
below the end of the tube. The endoscopist should be able t o
look i nto the ri ght upper lobe ori fi ce by flexi ng the tip of the
fi berscope superior ly.
Bronchospirometry
Pressure-volume and flow-volume loops are discussed i n Chapter
23. Changes i n compli ance or resi stance may mean that t he DLT
i s not correct ly placed
(141,142,143,144,145,146, 147,148,149,150). If a DLT is
advanced into the trachea wit h t he bronchi al cuff partial ly
i nflated, compli ance is reduced when the tube i mpacts the
bronchus (92).
Chest X-ray
Chest x-ray may be usef ul to confi rm tube position when a
fi berscope i s not avai lable or cannot be used. However, it i s less
precise than the fi beroptic bronchoscopy and is cost ly, time
consumi ng, and awkward to perform.
Stabilizing the Tube
Once correct tube position is confi rmed, the tube should be
secured i n place. Speci al fi xati on methods have been
recommended (151). Duri ng positi oni ng, the tube should be held
at the level of the inci sors and the head i mmobi li zed i n a neutral
or slight ly flexed posi tion to prevent the tube from migrati ng i nto
an incorrect posi ti on.
Intraoperative Care
The bronchi al cuff should be kept def lat ed (unless the lung needs
to be isolated to prevent spread of blood or i nfecti on) unti l t he
lung needs to be col lapsed t o mi ni mi ze damage to the bronchi al
mucosa (38). Lung collapse wi ll be most rapi d i f lung separati on
i s i nitiated at end-expirati on. Sucti on i s of li mi ted uti li ty because
the gas trapped i n t he lung i s di st al to collapsi ble airways. If
despi te best efforts complete lung separati on cannot be
accomplished and gas is i ntroduced i nto the ipsi lateral lung wi th
each breat h, then conti nuous sucti on may be helpful to evacuate
the gas as i t enters t he lung (38). Bronchial cuff pressure should
be moni tored and adj usted to the mi nimum necessar y t o achi eve
an airti ght seal.
A useful technique when the bronchial lumen i s i n the surgical ly
operated lung is to pass a suction catheter through the bronchial
lumen when t he lung i s def lat ed and to leave i t unti l ready for
rei nflation (152). Thi s may prevent the bronchi al lumen from
becoming obstructed by blood or mucus.
P.644


Replacing a Double-lumen Tube with a
Single-lumen Tube
If mechani cal venti lati on needs to be conti nued at the conclusi on
of a case i n whi ch a DLT was used, i t is usual ly desi rable t o
replace the DLT wi th a standard tracheal tube. Personnel who
are cari ng for the pati ent i n the postoperative peri od are not
usual ly fami li ar wi th a DLT. After pneumonectomy, when al l of the
patient' s venti lati on i s conducted through one lumen of the DLT,
the small di ameter of the lumen may make i f di ffi cult for the
patient t o breathe spontaneously. With hi gh mi nut e venti lati on,
this can lead t o auto-PEEP (17). Pressure-support venti lati on
(Chapter 12) can be used to decrease the i mposed work of
breathi ng duri ng spontaneous venti lati on i f replaci ng the DLT
cannot be performed. Sucti oning through a DLT is di fficult.
In most cases, the procedure is si mply t o remove the DLT and
i nsert a si ngle-lumen tube i n i ts place. If the pati ent was di fficult
to i ntubate or ci rcumstances make vi suali zi ng the larynx di fficult,
other techni ques should be consi dered. One techni que would be
to i nsert an airway exchange catheter into the tracheal lumen
before t he DLT is removed. Speci al extra-long exchange
catheters are needed for the exchange. After the DLT has been
removed, t he si ngle- lumen tube is then advanced over the
catheter (153,154). Oxygen insuffl ation via the catheter wi l l
reduce t he i ncidence of hypoxemi a.
Another techni que has been descri bed (155). At the conclusi on of
the case, bot h cuffs are deflated and t he DLT wi thdrawn unti l the
bronchial lumen i s above the cari na. The bronchi al cuff i s then
i nflated and t he lungs venti lat ed t hrough the bronchi al lumen.
The tracheal lumen i s clamped, and an opening i s created in the
wall of t he tracheal lumen. A si ngle- lumen tube i s t hen sli pped
over a fi berscope, and the fi berscope i s advanced through t he
hole i n the tracheal lumen and i nt o the trachea. The openi ng i n
the DLT i s extended, and the DLT is slowly removed. The
fi berscope i s t hen removed.
Hazards Associated with Double-lumen
Tubes
Many of t he hazards associat ed wi th single-lumen tracheal t ubes
(Chapter 19) can also occur wi th DLTs.
Difficulty with Insertion and Positioning
Inserting a DLT may be ti me consumi ng. When there i s severe
hemorrhage, thi s can be a maj or problem. Multi ple inserti ons and
repositioni ngs i ncrease the risk of trauma. While they are very
useful i n adults and older chi ldren, they are of ten too large f or
small chi ldren. They are often di ffi cult to positi on and usually
must be replaced with a si ngle-lumen tube at the end of surgery.
The rigi di ty and wi dth of t he DLT can make int ubati on
compli cated. The tube does not all ow preshaping before
i ntubation, and the large wi dth makes it di fficult to pass the DLT
through a tracheostomy stoma, small ai rway, or nasal passage.
Tube Malposition
Certai n physi cal condi ti ons may make it di fficult or impossi ble for
a DLT to be correct ly placed (156,157). Preoperative fi beroptic
endoscopy may detect many of these problems. Even i f a correct
posi ti on i s achieved i ni ti al ly, head movement, a change i n body
posi ti oning, or surgical mani pulati on may result i n t ube
malposi ti on. Displacement duri ng posi ti oni ng can be decreased
by usi ng a neck brace (123,158). Malpositioni ng is increased
when anesthesi a providers have li mited experience i n lung
i solation (159).
If DLT malposi ti on i s suspected, fiberopti c t echniques are clearly
advantageous i n defi ning the problem and afford a means of
vi sual correcti on. Whi le some have reported that monit ori ng
carbon di oxide waveforms helps t o detect DLT displacement
(160,161), capnography does not reli ably i ndicate DLT
misplacement (142, 148,149,162).
Consequences
Functional i ndicati ons of misplacement include the fol lowi ng:
Unsatisfactory Lung Collapse
An obstructi on i n the unventi lated lumen can prevent the
unventi lated lung from deflati ng. If the lung cannot be col lapsed,
operati ng ti me wi l l be increased, and t he surgical result may be
compromised. Another cause may be a tumor fragment i n t he
ai rway (163).
Obstruction to Lung Inflation
If the bronchi al cuff i s not below t he carina, i t may obstruct the
trachea and ri ght mainstem bronchus. Wi th right-si ded tubes,
misalignment of the port for the ri ght upper lobe can result i n
obstruction. If the bronchi al cuff on a left-si ded DLT is too deep,
i t may obstruct the upper lobe bronchus.
Gas Trapping
Gas trappi ng or expi rat ory obstructi on may be t he result of a one-
way valve effect that al lows inf lati on but not deflati on. If
unrecogni zed, i t can result in cardi orespi ratory embarrassment
and/ or lung parenchymal damage.
Failure of Lung Separation
If the ai rway to a bronchopleural fi stula cannot be i solated from
that to t he normal lung, barotrauma may develop with posi ti ve-
pressure venti lati on, or the ai r leak through t he fist ula may be so
large that venti lati on of t he normal lung i s compromi sed. An
i ncompletely protected dependent lung may be flooded wi th blood
or secreti ons.
Possible Malpositions
Bronchial Lumen in the Wrong Mainstem
Bronchus
In some cases, the bronchi al porti on wi l l enter the opposi te
P.645

lung. This is usual ly easy to detect and correct by usi ng
fi beropti c endoscopy (115). In some cases, i t may be best to
leave the bronchial lumen i n t he operati ve bronchus and i solat e
the operati ve lung by clampi ng t he bronchi al li mb and usi ng t he
tracheal lumen for venti lati on (118,122). This may be appropri ate
for right lung surgery but not for surgery on t he left lung, since
the ri ght upper lobe bronchus would almost certai nly be
occluded. An alternati ve option i s to withdraw the tube unti l it i s
i ntratracheal and to use a bronchi al blocker (see below) to block
the operati ve lung.
It may be possi ble for the surgeon to assist i n correct ly placi ng
the tube once the chest is open (164). If it i s det ermined that t he
tube i s i n t he wrong bronchus, both cuff s are def lat ed, and the
tube i s wi thdrawn into t he trachea. The surgeon then compresses
the bronchus, and the anesthesi a provider advances t he t ube i nto
the correct si de wi th surgi cal guidance. The cuffs are then
rei nflated.
Bronchial Portion Inserted too Far into the
Appropriate Bronchus
If a left-sided DLT i s i nserted t oo deeply, the problem may be
that the tube i s too smal l (156,165,166,167). It wi l l result i n
obstruction of the upper lobe. In some pati ents, a left-sided DLT
placed so that the bronchial cuff i s j ust distal to the cari na sti ll
may cause left upper lobe obstruction. A high peak ai rway
pressure duri ng one- lung venti lati on should suggest thi s
malposi ti on (135).
Tube too Proximal in the Airway
If the tube i s not suffici ently advanced i nto the bronchus, the
bronchial cuff may protrude int o the trachea. The need to i nj ect
more than 3 mL of ai r into the bronchial cuff to achieve a seal
should alert t he user that the tube may be malpositioned. The
bronchial segment may sli p out of its bronchus, especi al ly duri ng
changes i n the pati ent' s position. In many cases, no untoward
sequelae wi ll occur. However, ther e may be obstruction of gas
flow to the other lung and i nabi li ty to isolate the surgi cal lung.
Tip of Bronchial Lumen above the Carina
The ti p of the bronchial lumen may be above t he carina because
of a tracheal lesi on that prevents t he t ube from bei ng advanced
farther. Wi th thi s malposition, there wi ll be unsatisf actor y lung
def lati on and fai lure of lung separation.
Incorrect Placement with Respect to the Upper
Lobe Bronchus
Malposi ti on wi th respect to t he upper lobe bronchus is
particular ly a problem wi th ri ght-sided tubes (34). Even with a
left-si ded tube, it i s possible t o obstruct the upper lobe bronchus
(129,168). The result of such a malposi ti on is usuall y hypoxemi a
and fai lure of the upper lobe t o def late satisfactori ly. A case has
been reported where the bronchial lumen entered the right upper
lobe bronchus (40).
Asymmetric Bronchial Cuff Inflation
The inf lat ed bronchial cuff can cause t he ti p of the bronchi al
lumen to face int o the bronchial wall, produci ng one-way valvular
obstruction that allows lung inf lati on but not deflati on (169,170).
Hypoxemia
In many i nstances, hypoxemia duri ng one- lung venti lati on i s at
least part ly the result of a malposi tioned DLT (171). For thi s
reason, whenever hypoxemi a occurs, tube posi ti on should be
reassessed and adj usted if necessary. Even wi th correct
posi ti oning, hypoxemi a can result from blood conti nui ng to f low
through the unventi lated lung (shunti ng) after one-lung venti lati on
has begun.
Another cause of hypoxemi a i s the presence of a tracheal
bronchus arisi ng from t he lateral tracheal wall (166,172,173,174).
If a DLT i s used, t he tracheal bronchi al openi ng must be checked
after the tube is placed. In some of these cases, a bronchi al
blocker may be a better choi ce f or one-lung venti lati on.
Another mechani sm that can produce hypoxemi a i s ambi ent
pressure venti lati on of the nonventi lated lung. Attachi ng an
oxygen source at ambient pressure to the opening to the
nonventi lated lung may help t o pr event hypoxi a
(175,176,177,178). Thi s may also enhance collapse of the
nonventi lated lung.
If hypoxemi a i s a problem despi te proper tube posi ti on, CPAP
can be applied to the nondependent lung (179). Some DLT
manufacturers i nclude a CPAP devi ce wi th each DLT, or they
may be purchased separately (Fig. 20. 15). Other measures to
i mprove oxygenati on i nclude dependent lung PEEP, occasi onal
venti lati on of t he nondependent lung (one breath every 5 to 10
minut es), i nsuff lati on of 2 to 3 L/minute of oxygen t o the
nonventi lated lung, and clampi ng of the pulmonary arter y before
clampi ng t he bronchus. Jet venti lati on of the nondependent lobes
that are not bei ng removed by usi ng an airway exchange catheter
may be used to i mprove oxygenati on (180).
Obstructed Ventilation
Many cases of obstruction are the result of a malpositioned tube.
In addi ti on, inf lating the bronchi al cuff can cause narrowing of the
bronchial lumen (129,156) or may cause the cari na to be
di splaced lateral ly, produci ng obst ruction of the other mainstem
bronchus (181). A defective tube or connector may cause
obstruction (182,183).
Other causes of bronchi al obstruct ion have been reported. In one
case, the bronchial cuff was left def lated unti l one-lung
venti lati on was to begin, and necrotic tumor mi grated into the
bronchus of the dependent lung, causi ng obstruction when one-
lung venti lati on was begun (184). The bronchi al lumen can
become t wisted (185). A carinal hook may obstruct the openi ng of
the tracheal lumen (186).
P.646



View Figure

Figure 20.15 Device for applying continuous positive
airway pressure to a nonventilated lung. The adjustable
valve supplies pressures from 1 to 10 cm H
2
O.

A relative contrai ndication to usi ng a DLT is a lesi on (airway
narrowing or endolumi nal tumor) somewhere along the pathway
where the tube wi l l resi de. An aberrant tracheal bronchus may be
a contraindi cati on for using a DLT (172,173).
Trauma
Trauma to the respi rator y tract can occur whenever intubation
wit h a DLT i s performed (187,188). Tears in the trachea and
mainstem bronchus have been reported
(76,187,188,189, 190,191,192,193, 194,195,196,197,198,199,200,
201, 202,203).
Tube si ze is a factor. Large tubes have been i nvolved more often
i n i njur y than smaller ones (188). A tube that i s t oo smal l and
requires excessive cuff i nflati on may cause i schemic i nj ury. In
one reported case, an endobronchial polyp that developed at the
bronchial cuff site ended i n a fatal hemorrhage (204).
Measures to reduce air way trauma i nclude removi ng t he st ylet
after the ti p of t he t ube has passed the vocal cords, avoidi ng cuff
overinf lati on, def lating the tracheal and bronchi al cuffs when
repositioni ng t he pati ent or the tube, and not advanci ng the tube
when resistance is encount ered. Some bronchial cuffs can
provide one-lung i solati on with si gni fi cantly lower pressures than
others (41). It has been recommended that the bronchi al cuff be
kept def lated unti l needed to mi ni mi ze pressure on the bronchi al
mucosa. This may not be prudent i f there i s a bronchi al tumor, as
necroti c t umor may mi grate into the ot her lung (184).
Tube Problems
Reported problems wi th DLTs i nclude mi slabeli ng, tracheal lumen
di storti on that prevented a sucti on catheter from passi ng, a sli t i n
the sept um, a defect that made the bronchi al lumen kink on i tself,
a spli t i n the tubi ng to the bronchial cuff, a ki nk i n the i nflati ng
tube to the tracheal cuff, a protuberance i n the wal l of the tube
wit h resultant tracheal lumen obstructi on, and forei gn bodi es i n
the DLT (205,206, 207,208,209,210,211,212). The carinal hook
may bend backward, obstructing the openi ng of t he tracheal
lumen (213).
Tracheal or bronchi al cuff rupture can occur. Thi s most commonly
results from cont act between the tube and the teeth or
laryngoscope duri ng i nserti on. Proposed methods to avoi d thi s
problem i nclude the use of a retractable protecti ve sheath (214),
a lubricat ed Penrose drain (215), and lubricated teeth guards
(216) and i ncreasi ng t he curve of the bronchi al porti on of the DLT
wit h the st ylet (217). Another possible cause of cuff rupt ure is
movement during reposi tioni ng (218).
Surgical Complications
The bronchi al cuff may be punctured by the surgeon (219,220). A
suture or staple may be placed through the DLT, or the surgical
procedure may result in a ti ght stenosi s, whi ch could entrap t he
bronchial segment (221).
Failure to Seal
One of t he reasons to use a DLT i s to prevent material from
passi ng from one lung to the other during the surgi cal procedure.
Fai lure to prevent fluids from traversi ng the bronchial cuff could
result from malposi ti on or from i mproper cuff i nflati on. Neither an
ai rti ght bronchial seal nor a cuff pressure of 25 cm H
2
O
guarantees protecti on agai nst aspi ration (61). Lubricati ng the cuf f
wit h a gel wi l l reduce the ri sk t hat flui d wi l l leak past t he cuff
(222,223).
Difficult Extubation
Diffi culty in removing a DLT may be due to anatomical
abnormalities, surgical fi xati on, or entanglement by other surgi cal
or anest heti c hardware (220,224).
P.647


Single-lumen Bronchial Tubes
Another option for achi evi ng lung separati on i s to use a single-
lumen tube to intubate a mainstem bronchus. Two bronchial
tubes may be used i n situati ons where dual lung venti lation is
needed but circumstances bode agai nst havi ng one tube in the
trachea (225,226,227).
Single-lumen bronchial tubes are sometimes used i n pedi atric
patients whose air ways are too small for DLTs or in whom a
bronchial blocker cannot be used
(1,165,226,228,229,230,231,232, 233,234, 235,236,237). In the
patient wit h massi ve hemopt ysis, bronchi al i ntubati on wi th a
si ngle- lumen t ube i s often the easi est and qui ckest method of
separati ng t he lungs (5,10).
Equipment
Bronchi al i ntubation is most often carried out wit h a conventional
tracheal t ube. A cuffed tube wi ll prevent re-expansi on of t he
collapsed lung. The di stance from the ti p of the tube t o the
cephalad edge of the cuff must be shorter than the lengt h of the
mainstem bronchus to ensure that the cuff can li e entirely i nside
the bronchus and the upper lobe bronchus i s not obstructed
(238).
Speci al tubes with a single lumen, an angulated distal (bronchial)
ti p, and cuffs at both the tracheal and bronchi al posi ti ons are
avai lable (239,240). They are longer than conventi onal si ngle-
lumen tracheal tubes.
Techniques
Before i nsertion, t he correct length and si ze of the tube should
be esti mated from a chest x-ray or comput ed t omography (CT)
scan (238). If the nasotracheal route is used, most conventi onal
si ngle- lumen t ubes wi ll not be long enough to provi de a reli able
mainstem intubati on. It i s recommended that the tube should be
one half to one si ze smaller than the usual si ze selected for
tracheal i ntubation (237). For bronchi al int ubati on i n chi ldren, a
tracheal t ube 0. 5 to 2. 0 mm smal l er than recommended for the
particular patient should be used (229,231).
Right-si ded int ubati on can usual ly be performed bli ndly, but t he
tube i s more reli ably placed by usi ng a bronchoscope. It may be
possi ble to ali gn the Murphy eye wit h the ri ght upper lobe
bronchus. It may be possi ble to rotate the tube so that the bevel
faces the upper lobe bronchial orifice.
Left mai nstem i ntubati on may be achieved bli ndly by usi ng a
stylet t o curve the di stal end of the tracheal tube to t he left (231)
but often requi res bronchoscopi c guidance. If blood or secreti ons
preclude fi beroptic visuali zati on, fl uoroscopy i s anot her opti on.
The chance of i ntubating the left bronchus wi l l be i ncreased i f the
tube i s rotat ed 180 degrees from i ts usual position before
advanci ng i t beyond the vocal cords and the pati ent' s head i s
turned t o t he right (228,229,241,242,243).
A gum elastic bougi e can be i nserted i nto the chosen bronchus
by usi ng a bronchoscope. The bronchi al tube can then be
rai lroaded over the bougi e int o posi ti on (244).
Correct positioni ng can be confi rmed by auscultation, x-rays,
and/ or f lexible bronchoscopy.
The tube should be wi thdrawn into the trachea when one- lung
venti lati on i s no longer needed.
Evaluation
Advant ages of usi ng a si ngle- lumen tube f or lung separation
i nclude si mpli ci ty and the rapidi ty wit h whi ch lung separati on can
often be achi eved, particularly when the ri ght lung must be
venti lated.
Disadvantages i nclude frequent lack of venti lati on of the ri ght
upper lobe wi th right mai nstem i ntubati on (38,236). Lef t upper
lobe venti lati on may also be excluded when the left mainst em
bronchus i s relatively short (238). Nei ther sucti oni ng nor
application of CPAP to the nonventi lated lung is possi ble.
There may be fai lure t o achi eve an adequate seal, especi ally i f
an uncuffed tracheal tube i s used or i f the cuff i s not i nside the
bronchus (226,236,238,245). Lung col lapse wi l l be incomplete,
and the healthy venti lated lung wi l l not be protected from
contami nati on. Both lungs cannot be venti lat ed at t he begi nni ng
of anest hesia, and the col lapsed lung cannot be re-expanded and
venti lated unti l the tube is wit hdrawn int o the trachea (236).
Bronchial-blocking Devices
Indications and Use
Indications for bronchial blockers are si mi lar to those f or a DLT,
wit h the excepti on of i ndependent lung venti lati on (44,226, 246).
They are often used in pati ents in whom usi ng a DLT is not
possi ble or advi sable (nasal i ntubation, small pati ent, di fficult
i ntubation, patient wi th a tracheostomy, subglotti c stenosi s, thi ck
and excessi ve secreti ons, need for continued postoperati ve
i ntubation)
(240,247,248,249,250,251, 252,253,254,255, 256,257,258, 259,260
,261). A blocker may be especi ally usef ul for providi ng lung
separati on i n a cri ti cally i l l pati ent wit h a si ngle-lumen tracheal
tube already in place. Anot her indi cati on may be the patient on
anticoagulants, since placi ng a bl ocker is usual ly less traumati c
than i nserting a DLT (8). A blocker may al low a larger fiberopti c
endoscope to be used and provi de better suctioni ng than a DLT
(262). A modified bronchial blocker can be used for tracheal gas
i nsuff lation to reduce carbon dioxide wi thin the dead space by
delivering fresh gas near the end of the tracheal t ube (263).
P.648


Another i ndicati on f or a blocker is the need to block a segment of
a lung rather than the entire lung
(9,14,258,259,264,265, 266,267,268,269,270). Thi s cannot be
done wi th a DLT. A blocker may be used t o sequenti ally block
di fferent parts of the lung (270).
A blocker may be used to achieve lung isolation in the pati ent
wit h an improper ly posi ti oned double-lumen or bronchial t ube
(53,122,238,271, 272,273). A blocker may be usef ul i f both lungs
require sequential blockage (274). The blocker can be shifted to
the opposi te lung when needed. If one blocker does not provi de
complete one- lung isolati on, a second blocker may be used
(173,275,276,277).
Fi nally, there i s no need to change the tube at the end of t he
operati on i f postoperati ve mechani cal venti lati on i s needed if a
bronchial blocker is used.
Devices
Univent Bronchial-blocking Tube
Description
The Uni vent tube i s a cuff ed si li cone tracheal tube wi th a smal l
addi ti onal i nternal lumen along i ts concave side
(7,11,226,236,278,279, 280,281,282,283,284) (Fi gs. 20.16,
20.17). The smal l channel cont ains a movable t ubular blocker
that has a blue high-pressure, low-volume cuff. The blocker can
be advanced suffici ently beyond t he tip of the tube to block
ai rways smaller than a mai nstem bronchus (246, 260,264, 265).

View Figure

Figure 20.16 Univent bronchial blocker. The cuffed
tracheal tube has a small lumen along its concave side,
which contains a tubular cuffed bronchial blocker. The
blocker can be advanced into a mainstem bronchus or
smaller airway.

The blocker has external depth marki ngs to help determine the
blocker position i n relati on to the tube. There is a sli ght bend i n
the blocker above the cuff. The blocker ti p i s radiopaque. A gri p
allows the user to rotate t he blocker. A locking clamp fi xes i ts
dept h below the ti p of the tube.
As shown in Table 20.2, the Uni vent tube is avai lable i n several
si zes. It has a sli ghtly larger-than-usual external di ameter for i ts
i nternal diameter because of the space requi red by t he blocker.
Univent tubes that are 5 mm and larger have a lumen that can be
used for sucti oni ng, CPAP, or oxygen i nsufflation (285). Adult
versions of the Univent blocker are hollow.
The Uni vent blocker (Uniblocker) can be purchased separate
from the tracheal tube and used wi th other tracheal tubes
coaxi ally or i n parallel (265,286) (Fi g. 20.18). It i s suppli ed wi th a
swivel adaptor that fi ts onto the tracheal tube connector. This
adaptor allows connection to the breathing syst em and has a port
for a fi beroptic scope in additi on to a port for the blocker.
Use
Before use, t he bronchi al blocker and tube cuffs should be
i nflated and checked for leaks. Both the tube and the blocker
should be well lubri cated. After the cuffs have been deflated, the
blocker should be pushed back and forth i n the tube t o ensure
free movement. The blocker should then be f ull y retracted into
the tube lumen and fixed in place by usi ng the clamp.
If there is an unobstructed view of the larynx, the Uni vent tube i s
i nserted i n the same way as a conventional tracheal tube. If the
patient has a di fficult air way, it can be i nserted over an ai rway
exchange cat heter or other devi ce (287). The blocker can be
extended and used as an i ntroducer (288,289). After the blocker
has passed the vocal cords, t he t ube i s threaded over i t and i nto
place.
Aft er the Uni vent tube i s i nserted, the tracheal tube cuff i s
i nflated, and the pati ent i s venti lated. The blocker i s vi suali zed by
usi ng a flexible fi beropti c endoscope through an airway adaptor
wit h a port for the scope and is maneuvered into the appropri ate
bronchus. The blocker ti p di recti on can be changed by twisti ng
the shaft (290). It may be useful t o def late the tracheal t ube cuff
and rotate the tube so that the blocker i s di rected toward the side
to be occluded.
A gui de wi re can be inserted through t he blocker' s lumen and be
used to direct the blocker i nto place, especi all y when it i s
necessary to block an ai rway smal ler than a mai nst em bronchus
(258).
Another method of placing the blocker i n the right or left main
bronchus i s t o i nsert a fi berscope through the trachea t ube i nto
the bronchus to be blocked and then to advance t he t ube i nto
that bronchus. The blocker i s then advanced i nto the bronchus
and the tube wi thdrawn i nto the trachea, leavi ng the blocker i n
the bronchus. This techni que may result in trauma to the air way
(291).
P.649



View Figure

Figure 20.17 Univent bronchial-blocking tubes.
Top: The bronchial blocker is retracted. Bottom:
The bronchial blocker is advanced, and the cuff is
inflated. (Courtesy of Vitaid.)

TABLE 20.2 Univent Tubes
I nternal Diameter
(millimeters)
Outer Diameter
(millimeters)a
Age (years)
3.5 (uncuffed) 7.5/8.0 6 to 10
4.5 8.5/9.0 10 to 14
6.0 9.7/11.0 14 to 16
6.5 10.2/12.0 16 to 18
7.0 11.6/12.5 Adult
7.5 11.2/13.0 Adult
8.0 11.7/13.5 Adult
8.0 12.2/14.0 Adult
9.0 12.7/14.5 Adult
a
Values are sagittal/transverse.
From Hammer GB, Fitzmaurice BG, Brodsky JB.
Methods for single-lung ventilation in pediatric
patients. Anesth Analg 1999;89:14261429; Frolich
MA. Postoperative atelectasis after one-lung ventilation
with a Univent tube in a child. J Clin Anesth
2003;15:159163; Hammer GB, Brodsky JB, Redpath
JH, et al. The Univent tube for single-lung ventilation
in paediatric patients. Paed Anaesth 1998;8:5557;
Tobias JD. Variations of one-lung ventilation. J Clin
Anesth 2001;13:3539.

The bronchi al blocker can be inserted bli ndly. The whole tube is
turned so t hat its concavity faces t he si de to be blocked. The
blocker is advanced int o the mainstem bronchus and the cuff
i nflated. Thi s method has not proved very successful and may be
associ ated with ai rway trauma (282,292).
The blocker posi ti on should be checked by using a fi berscope.
The cephalad ti p of the bronchial cuff should be below the cari na.
The blocker should t hen be fi xed to the tracheal tube by usi ng
the cap stopper and blocker grip.
When the bronchus needs to be bl ocked, the lung i s deflated wi th
the blocker open to at mosphere. The bronchi al blocker cuff
should be inf lated by usi ng the least amount of air that wi ll
provide a seal. This can be achi eved by attachi ng t he sample line
from a carbon dioxi de analyzer to the proximal end of the blocker
and noti ng when the waveform di sappears (293). Another method
i s the bubble test, i n whi ch t he end of the bronchi al lumen is
placed i nto water in a beaker (294). When the bronchus is
sealed, no bubbles wi ll be observed passi ng through the water.
The typi cal cuff i nflati on volume i s 5 to 6 cc (112).
The blocker from a Uni vent t ube can be removed from the tube
and i nserted alongsi de a tracheal or tracheost omy tube
(265,295,296). The blocker i s then
P.650

gui ded i nto place wi th a fi berscope inserted through the tube.

View Figure

Figure 20.18 The Univent bronchial blocker can be
purchased separately from the tube. The connector has
ports for attachment to the tracheal tube and breathing
system, for introducing the blocker, and for a fiberscope.
Note the cap that fits over the end of the blocker.

When the blocker is no longer needed, the cuff i s deflated and
wit hdrawn i nto the mai n tube. If the Uni vent i s to be used for
postoperative venti lati on, the blocker should be fully retracted
and disabled to avoid inappropri ate use by caregi vers who are
unfami li ar wi th the devi ce (297).
Evaluation
Most studi es show that the Uni vent provi des lung isolati on
equi valent to that of a DLT (11,280,298,299,300,301).
The Uni vent may be easi er to i nsert and posi ti on correct ly than a
DLT and may be especial ly useful for the di fficult-to-int ubate
patient (287,288,289,302,303,304, 305). It can be used i n t he
patient wit h a tracheostomy (254, 253,296) and for nasal
i ntubation (247). It can be used for postoperative venti lati on
wit hout havi ng to rei ntubate the pati ent.
It i s possible to use suction, apply CPAP, or insufflate oxygen
through the blocker lumen (278, 306). The blocker wi th the cuff
def lat ed has been used for j et venti lati on during cari nal resection
(307,308).
Reports of problems wi th the Univent i nclude the cap becomi ng
di slodged from the ti p of the blocker (309,310) and fragmentation
of the tube i nner wal l and connector (311,312).
The Uni vent' s curved shape is fi xed, and t his may be a
di sadvantage when sli di ng it over a bronchoscope. It wi l l not
soften in a warm water bath (38). It may distort the neck anatomy
suffi cient ly to make i nternal j ugular vein cannulati on di fficult
(313). Bronchi al perforation by the blocker duri ng bli nd i nsertion
has been reported (292). A case has been reported of prolonged
postoperative atelectasis after usi ng a Uni vent tube (262). It is
not recommended for use i n chi ldren below t he age of si x years.
When compari ng the Uni vent wi th a left DLT, there was a greater
i ncidence of malposi ti on wi th the Uni vent (119), but compari son
of the Univent and a right DLT fai led to demonstrate a clear
advantage (35). The Uni vent i s more expensi ve than a DLT or
other blockers (79,119,310).
A di sadvant age of the Uni vent tube is the large amount of cross-
sectional area occupied by the blocker channel, especi ally i n the
smaller tubes (236). It i s not avai lable i n a si ze t hat would fi t an
i nfant or small chi ld.
Another problem i s that the small l umen i s relatively easi ly
blocked by blood or pus (285). As a result, blood or pus may
accumulate and cont ami nate the dependent lung when the
blocker is deflated.
The blocker' s low-volume, high pressure cuff may cause i n
mucosal i nj ury (314,315).
The larger external di ameter may make i t di ffi cult to pass t he
Univent between t he vocal cords.
Arndt Bronchial Blocker
Description
The Arndt bronchi al blocker assembly (wire-gui ded bronchi al
blocker, WEB, FWEB) i s designed to be used for a pati ent wi th a
si ngle- lumen tracheal tube already i n place
(44,111,246,253, 316,317,318,319, 320,321,322,323). It consists
of two parts: A blocki ng catheter and a speci al air way adapt or.
Either may be purchased and used separately.
Blocking Catheter
The Arndt blocking cathet er (Fig. 20.19) has a low-pressure,
hi gh-volume balloon that has eit her an el li pti cal or spheri cal
shape. The spheri cal balloon is relati vely compli ant unless
overinf lat ed and takes an elliptical form when i nf lat ed i n a smal l
bronchus. The 9 Fr catheter i s avai lable wit h an elliptical balloon
that provi des a longer seali ng prof i le. It i s recommended that t he
elli pti cal cuff be li mited to left mai nstem i ntubation (236, 246).
P.651



View Figure

Figure 20.19 Arndt bronchial blocker with multiport
adaptor. The wire loop can be cinched around the tip of
the fiberscope, or the fiberscope is passed through the
loop. The adaptor has ports for attachment to the tracheal
tube and breathing system, for introducing the blocker,
and for a fiberscope.

A f lexible nylon wi re passes through the proxi mal end of the
catheter and extends to the distal end, then exi ts as a small loop
(Fi g. 20.19). The si ze of t he loop may be i ncreased or decreased
by advanci ng or retracting the wir e assembly.
There are three si zes: 9, 7, and 5 Fr. Characteri stics of the
blockers are shown i n Table 20. 3. Near the di st al end of the 9 Fr
catheter are si de holes t o f aci li tate lung def lati on.
Airway Adaptor
The multi port adaptor (Fig. 20. 19) allows si mult aneous
i ntroducti on of a bronchoscope and the blocker whi le mai ntai ni ng
mechanical venti lati on. It has four ports:
A 15-mm female connector that attaches to the tracheal
tube;
A si de port wi th a 15-mm male connector that att aches t o
the anesthesi a breathing syst em;
A port angled approxi mately 30 degrees for t he bronchial
blocker; and
A port for the flexi ble endoscope.
The blocker port has a Tuohy-Borst type connector to mai ntai n an
ai rti ght seal and lock the blocker i n place (by ti ghtening the
connector around the blocker) or to allow free movement of the
blocker (by loosening the connector). The bronchoscopy port has
a plastic seali ng cap.
Use
Before use, t he i nsi de of t he tracheal tube and the outsi de of the
blocker and t he bronchoscope should be wel l lubricated wi th a
si li cone spray. The loop should be adj usted so that i t loosely
approxi mates the outside di ameter of the bronchoscope. The
blocker balloon should be i nflated to test for leaks and then ful ly
def lat ed.
For each si ze Web, there is a tracheal t ube si ze for which coaxi al
placement i s li mi ted by t he di ameters of the blocker and
fi berscope used duri ng placement. When these li mi ts are
exceeded, parallel placement may be required. Ei ther the web i s
passed outside the tracheal tube wi th gui de loop i noperable, or a
fi berscope i s also placed in paral lel wi th the tracheal tube before
or after intubati on.
TABLE 20.3 Arndt Endobronchial Blockers
Size
(French)
Smallest Single-lumen
Tube I nternal Diameter
for Coaxial Use
(millimeters)
Length
(centimeters)
Cuff Shape Average Cuff
I nflation Volume
(cubic centimeters)
9 7.5 78 and
65
Elliptical 6 to 12
Spherical 4 to 8
7 6.0 65 Spherical 2 to 6
5 4.5 65 and
50
Spherical 0.5 to 2.0
From Klafta JM. One-lung anesthesia; making it work (ASA Refresher Course
#509). Park Ridge, IL: ASA, 2004.

P.652


The wi re in the blocker lumen i s used in ei ther of two ways: (i)
when ci nched ti ghtly around t he ti p of the fi berscope, the
fi berscope carri es the blocker i nto its desi red location, and (i i)
when the fiberscope is passed through the loop, it provides a
track for blocker to pass t hrough after the fi berscope is placed
i nto the bronchus.
Aft er the pati ent is i ntubated and venti lati on has begun, the
multiport adaptor i s connected between the breathi ng system and
the tracheal tube. The bronchoscope i s advanced through the
gui de loop. This allows t he blocker to fol low the bronchoscope.
Alternately, the wi re loop may be placed over the end of the
blocker pri or to attaching the air way adapt or to t he tracheal tube
(324).
The bronchoscope is advanced into the ai rway to be blocked and
then the gui de loop i s sli d over the end of the bronchoscope. The
bronchoscope i s wi thdrawn slight ly to vi suali ze the blocker. The
blocker is then advanced or wi thdrawn i nto position (324,325). It
may be advisable to advance the blocker approximately 1 cm
beyond the opti mal positi on when the patient i s i n the supi ne
posi ti on to avoi d dislodgi ng the blocker toward the trachea whi le
the patient' s posi ti on i s changed to the lat eral decubit us posi ti on
(246). The balloon i s t hen i nflated under direct vision. The
bal loon should fi l l the enti re bronchi al lumen and not herni ate
i nto the trachea. Followi ng placement, t he bal loon may be
def lat ed unti l one- lung venti lati on i s required.
Removing the wi re loop wi l l result in an open channel, which
allows CPAP appli cati on, oxygen i nsufflati on, sucti oni ng, or
i ntermi ttent inf lation. Leavi ng t he wi re loop duri ng t he operati on
might damage t he ai rway and entai ls the risk that the loop may
acci dental ly be stapled i nto the bronchi al closure (326). However,
leaving the loop in place al lows the blocker to be reposi ti oned
(327). It may be possi ble to reposi ti on t he blocker by usi ng
fi beropti c endoscopy (326). Excessi ve force should not be used
when removing the wi re guide, because this may di splace the
blocker.
Lung collapse can be expedit ed by attachi ng a syri nge or
applyi ng suction to the blocker channel (44,328). However, some
clini ci ans do not recommend usi ng sucti on through this channel
because of the ri sk of developi ng negative pressure pulmonary
edema (326). When no longer needed, the blocker cuff should be
full y def lated and the blocker removed.
Evaluation
The Arndt blocker system can be used i n the patient who is
already intubated (316,317,329), i n the pati ent wi th a
tracheostomy (318, 324,325), or wi th a nasal int ubati on (253,318).
It has been used to provide si ngle-lung venti lation i n chi ldren as
young as 17 months (245). It may be especi al ly useful for the
patient i n whom a DLT would be di fficult to use
(260,316,318,319,320,321, 330). It has been used i n a newborn
(322). It al lows a larger i nternal cross-secti onal area than a DLT
or Univent tube of si mi lar outsi de di ameter (331). It may require
fewer i nsertion attempts t han a DLT (332). If the wi re is removed,
the lumen can be used for sucti oni ng or admi ni stering oxygen or
CPAP.
Problems
A di sadvant age i s that once the wi re loop is removed, i t cannot
be rei nserted t hrough the channel to allow repositi oni ng of the
blocker. Placement requires the availabi lit y of fi beropti c
equi pment and someone able to use it. It takes longer to posi ti on
and to achieve complete lung col l apse compared with the Uni vent
tube or a DLT (328,332). The bal l oon may be sheared when i t is
removed from the blocker port (333).
Cohen Tip-deflecting Bronchial Blocker
The Cohen ti p-def lecti ng bronchial blocker (Fi g. 20.20) has a 9 Fr
external di amet er and a central lumen wi th a 1. 6 mm diameter
(334). The hi gh-volume, low-pressure blue bal loon at the ti p i s
spherical i n shape. The average i nflati on volume i s 5 to 8 mL.
There are side holes bet ween the tip and t he bal loon to evacuate
gas from the dist al lung or to insuf flate oxygen. A proxi mal
control wheel that can be operated with t he thumb and forefi nger
i s used to adjust tip deflection (Fi g. 20.21). The cat heter has
dept h marki ngs and an i ndi cator arrow that shows the di recti on i n
whi ch the ti p deflects.

View Figure

Figure 20.20 Cohen tip-deflecting bronchial blocker. The
proximal control wheel is used to adjust tip deflection. An
arrow on the wheel indicates the direction to which the tip
deflects. (Courtesy of Cook Critical Care.)

P.653



View Figure

Figure 20.21 The tip of the Cohen bronchial blocker can
be manipulated to fit into either bronchus.

In most cases, the blocker and a fi berscope are inserted through
an appropri ately si zed tracheal t ube. The blocker can also be
placed outside the tracheal t ube and guided int o place wi th a
bronchoscope placed through the tracheal t ube.
A multi port air way adaptor li ke t he Arndt is att ached t o t he
breathi ng system end of the tracheal tube. Alt ernatively, a
standard swivel adapt or can be used for inserti on.
An assist ant wi th or wit hout video flexi ble fi beroptic scope may
be necessary because it may requi re t wo hands to mani pulate the
blocker int o posi ti on, one to deflect the ti p and the other to rot ate
and advance the cathet er.
Embolectomy Catheter
Description
An embolectomy (Fogart y) catheter can be used as a bronchi al or
segmental blocker
(1,14,53,62,226,248, 251,256, 257,267, 268,269,275,324,335,336,3
37,338,339,340,341, 342,343,344). Thi s catheter i s readi ly
avai lable i n most operati ng sui tes where vascular surgery i s
performed or can be purchased for this purpose. It comes wit h a
stylet i n place so that it i s possi bl e to place a curvature in the
di stal ti p to faci li tate guidance to the target bronchus. The
occlusi on bal loon has a high-pressure, low-volume cuff (246). It
comes i n a vari ety of si zes. Adult bronchi can be blocked wi th 7
Fr catheters, whereas 2 Fr to 5 Fr catheters are suitable for
segmental or pedi atric blockade.
Use
Pri or to use, the blocker should be lubri cated wit h j elly or si licone
spray to f aci litate passage. The balloon should be t ested for
leaks and then fully def lated. A catheter wit h a faulty or eccentric
bal loon should be discarded.
The embolectomy catheter may be placed before or after
i ntubation wi th a single-lumen tracheal or tracheostomy tube and
can be passed ei ther through or al ongsi de t he t ube. Placi ng t he
catheter alongside the tube allows the t ube to spli nt the blocker
i n posi ti on. An alternati ve method is to i nsert the cat heter
through a hole made i n the si de of the tracheal tube (345).
If the patient i s alr eady i ntubated, the catheter contai ni ng a stylet
may be passed through a fi beropti c endoscope adaptor
(335,341,342). This allows unint errupted venti lation. The Arndt
multiport air way adaptor (previ ously menti oned) or simi lar devi ce
(346) may also be used to prevent an ai r leak. An annular space
around the fi beropti c endoscope and embolectomy cathet er
equi valent to a single-lumen t ube wi th an i nner diameter of 4 to 5
mm wi l l be necessary to al low exhalati on i n a reasonable period
of ti me (347).
A fiberopti c endoscope i s passed down the tracheal tube, and the
embolect omy cat heter i s gui ded i nto the appropriate bronchus
under di rect vi sion. Twi rling the catheter between the fingers at
the proximal end or rotating the tracheal tube wi l l i mpart lateral
di rection to the ti p (98). Additi onal lateral di recti on may be
gai ned by rotati ng t he tracheal tube to one si de or the other.
Aft er the ti p i s advanced i nto the proper posi ti on, the stylet is
removed, t he catheter bal loon is i nflated under direct visi on, and
then the fiberscope wi thdrawn.
A modi fi cati on of this technique is to deli berat ely intubate a
mainstem bronchus wi th a tracheal tube one si ze smaller than
would be appropri ate for the trachea, advance the blocker
through the tracheal tube, then wit hdraw the tracheal tube int o
the trachea (348,349,350,351). It may be helpful to preshape the
tracheal t ube by using a stylet (351). Once the cathet er is in the
targeted bronchus, the stylet is removed. Removing the tracheal
tube followed by inserti on of a larger tracheal tube beside the
Fogarty cathet er wi ll securely fix the catheter in place. The
catheter bal loon is inf lated slowly unti l no air enters the blocked
lung, as detected by using auscultation. The Fogarty cat heter
should be securely taped to the tracheal tube to prevent i t from
bei ng di slodged. A fi beroptic endoscope should be used to check
the posi ti on of the blocker. The catheter ballooon should be
def lat ed and the lung collapsed by usi ng pressure on the chest
and/ or sucti on t hrough the tracheal tube (351). The catheter
bal loon should then be reinflated to the same volume as
previously used.
Evaluation
The use of an embolectomy cathet er has many advantages. It
can be passed through a si ngle- lumen tracheal tube i n an already
i ntubated patient, and t here is no need for reintubati on i f
postoperative mechanical venti lati on is needed. It may be useful
i n
P.654

pedi atric pati ents (62,236,267, 268,324,337,338,340,345,352), the
patient wit h a tracheostomy (252, 336,351,353), or for a nasal
i ntubation. The embolectomy catheter is less expensi ve than a
DLT, Univent t ube, or Arndt blocker (326,339). Fogart y catheters
are relati vely t hinner for a gi ven balloon volume when compared
wit h ot her bronchi al blockers and thus wi ll allow the use of larger
tracheal t ubes, especi ally i n pedi atric pati ents when t hey are
placed si de by si de i n the trachea (351).
Problems
A si gni fi cant di sadvantage is the lack of a hollow cent er.
Suctioni ng, oxygen i nsufflati on, or applyi ng CPAP t o the blocked
lung i s not possible, and lung coll apse takes longer and may not
be as complete as with a DLT or a blocker wit h a hollow lumen
(62). The obstructed lung segment cannot be re-expanded unti l
the blocker is removed. Another di sadvantage i s that it i s made
of latex, so it cannot be used i n the pati ent wi th potenti al latex
allergy (Chapt er 15). Most of these devi ces have low-volume,
hi gh-pressure cuffs and can damage the air way, although t he
pressure may be less than that exerted by the cuf f on a DLT
(109,236).
There are no reported compli cations with the embolectomy
catheter i n adults (246). Bronchi al rupture has been reported wi th
an overi nflated balloon i n a chi ld (337).
Other
Balloon atri oseptostomy, Foley uri nary, and Swan Ganz
pulmonar y arter y catheters have been used as bronchi al
blockers. They have a central lumen for suction or admi ni strati on
of oxygen to the blocked lung.
Problems with Bronchial Blockers
A blocker may not be suitable for the patient wi th a hi gh right
upper lobe bronchus t akeoff or a tracheal bronchus (173,354). It
may be necessar y to ei ther use a second blocker or a DLT under
these condi ti ons. If the di st ance bet ween t he carina and t he
tracheal bronchus i s smal l, i t may be possible to herniate t he
bal loon on the bronchial blocker so that i t blocks t he upper lobe
bronchus (355). It may be possi bl e to use the tracheal cuff of the
Univent tube to block a tracheal bronchus (356).
A blocker may be di slodged into t he trachea (357). The inf lated
bal loon may then block venti lati on to both lungs, prevent collapse
of the operated lung, and/or cause ai r trapping. Other
compli cations reported include fixation by surgi cal staples (358);
perforation of the blocker balloon by a surgical needle (359); and
acci dental i nflati on of the blocker cuff when i t was j ust below the
ti p of the tube, resulti ng i n obstructi on t o gas flow (360).
The narrow blocker lumen may result i n i neff ecti ve removal of
secreti ons and pulmonar y soi li ng after the cuf f is deflat ed (361).
Lung deflati on may not be as sati sfactory or achieved as rapi dly
wit h a bronchi al blocker as wi th a DLT (332).
Development of severe hypoxemi a has been reported after
continuous suctioni ng of the nondependent lung through a
bronchial blocker (362). If suction is used to faci li tate lung
collapse, i t should be appli ed for only a few seconds,
i ntermi ttently and with low pressure (246).
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P.659


Questions
Each question below contains four suggested answers of which
one or more is correct. Choose the answer:
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i f D i s correct
i f A, B, C, and D are correct.
1. Indi cations for a double-l umen tube i nclude
A. Pati ent wi th hemorrhage
B. Pati ent having one-lung surgery
C. Control of i nfecti on from one lung
D. Pati ent wi th a lesi on i n the trachea
View Answer2. When placing a left-sided double-lumen
tube,
A. The outermost accept able posit ion for t he bronchi al cuff i s j ust
below the cari na
B. The average length from the lef t upper bronchus t o the carina
i s 3 cm
C. The tip of the bronchi al lumen should be at the proximal edge
of the left upper lobe bronchus
D. The margi n of safety is less t han for ri ght-sided tubes
View Answer3. Which of the following statements are
correct?
A. A left double-lumen tube can usually be used for ri ght lung
surgery
B. A left double-lumen tube can be used for left pneumonectomy
C. A ri ght double-lumen tube must be used for left lung surgery if
there i s rupture of the left mai nstem bronchus
D. Mani pulati on during surger y i s l ikely to alter the position of a
tube i n t he contralateral bronchus.
View Answer4. Which of the following appl y to i nserting
a double-l umen tube?
A. A st ylet needs to be used f or all i ntubations
B. The tube should be i nserted at a 90-degree angle from where
i t wi ll eventual ly rest
C. If the t ube i s to be placed i n the left mai nstem bronchus, the
head and neck should be rotated to the right before rot ati ng and
advanci ng the tube
D. Removi ng the st ylet after passi ng the cords may prevent
trauma
View Answer5. Techniques useful in confirmi ng the
position of a double-lumen tube incl ude
A. Auscultati on of the chest
B. Fiberopti c exami nati on
C. Chest x-ray
D. Capnography
View Answer6. Possibl e consequences of bronchial tube
malposition incl ude
A. Unsati sfactory lung def lation
B. Air trappi ng
C. Airway obstructi on
D. Trauma
View Answer7. Possibl e double-lumen tube mal positions
incl ude
A. Obstructi on of the upper lobe bronchus
B. Bronchi al ti p above the carina
C. Bronchi al ti p i nadequately advanced i nto the bronchus
D. Inserti on i nto the wrong mai nstem bronchus
View Answer8. Possibl e causes of obstruction to
ventilation when a double-lumen tube is in use i nclude
A. Tube malposition
B. Forei gn body migrati on i nto the dependent lung
C. Overinflati on of t he bronchi al cuff
D. Twi sti ng of the bronchi al lumen
View Answer9. Possibl e consequences of trauma
resulting from doubl e-lumen tubes i nclude
A. Vocal cord paralysi s
B. Rupture of a mai nstem bronchus or the trachea
C. Medi asti nal emphysema
D. Hemorrhage
View Answer10. Uses of bronchi al-blocking devices
incl ude
A. Pati ent on anticoagulants
B. Bronchopleural fist ula
C. Pulmonary hemorrhage
D. Di fferenti al lung venti lation
View Answer11. Problems associ ated with a carinal hook
on a double-lumen tube incl ude
A. Hook fracture
B. Trauma t o the ai rway
C. Int erference wi th bronchial closure duri ng pneumonectomy
D. Malposi ti on of the tube
View Answer12. Whi ch probl ems can be attributed to
using too small a double-lumen tube?
A. Hi gh cuff volume wit h hi gh pressure on the mucosa
B. Displacement may be more li kely
C. The tube may advance t oo f ar into a bronchus
D. Hemorrhage
View Answer13. Indi cations that the bronchial lumen is
not the correct si ze i nclude
A. No ai r leak wi th the bronchial cuff deflated
B. The tube wi ll not fi t i nto the bronchus
C. More t han 3 mL of air i n the bronchi al cuff is needed to make
a seal
D. There is obstructi on of the bronchus
View Answer14. In determing the proper size double-
lumen tube for a patient,
A. The left bronchus i s lar ger than the right
B. The si ze of a mainst em bronchus may be reli ably determi ned
by measuring the widt h from a chest x-ray
C. Wei ght is the best predi ct or of bronchi al diameter i n chi ldren
D. In adult s, the di mensi on of t he cricoi d ring best defi nes those
of the main bronchi
View Answer15. How is the proper depth of insertion for
blind i nsertion of a l eft double-lumen tube determi ned?
A. Pati ent sex
B. Pati ent weight
C. Pati ent age
D. Pati ent height
View AnswerP.660


16. Insertion techniques that can be used to attain the proper
insertion depth incl ude
A. Moni toring the bronchi al cuf f pressure
B. Looki ng for one si de of the chest to i nflate
C. Advancing the tube wit h the br onchi al cuff i nflated unti l it
wedges int o the bronchus and then deflati ng the cuff and
i nserting the tube an addi ti onal 1 t o 1-1/2 cm
D. Inserti ng the bronchial porti on under di rect visi on wi th a
flexi ble endoscope
View Answer17. What are the possible consequences of
overi nflating the bronchial cuff on a DLT?
A. Shi fti ng the carina toward the opposi te side
B. Herni ati on i nto the trachea
C. Narrowi ng t he bronchial segment lumen
D. Obstructi ng t he opposi te mai nstem bronchus
View Answer18. When should the position of a DLT be
checked?
A. Aft er i t is i nitial ly placed
B. At the beginni ng of one- lung venti lati on
C. After the patient i s positioned for surgery
D. Before the chest i s closed
View Answer19. Possible causes of hypoxia associated
with using a double-lumen tube incl ude
A. Bronchi al tube in the wrong bronchus
B. Presence of a tracheal bronchus
C. DLT blockage
D. Shunti ng, even wi th a properly placed tube
View Answer20. Possible measures to combat hypoxemia
duri ng double-lumen tube use i nclude
A. CPAP to the nonventi lat ed lung
B. Occasi onal venti lation of the operative lung
C. PEEP appli ed t o the dependent lung
D. Clamping the pulmonary artery before clamping the bronchus
View Answer21. Problems associ ated with a single-lumen
bronchial tube include
A. Inabi li ty to venti late the ri ght upper lobe bronchus
B. Inabi li ty to admini ster CPAP to the nonventi lated side
C. Inabi li ty to venti late the left upper lobe bronchus
D. Incomplete lung collapse
View Answer