An audit of Robertshaw double lumen tube placement using the fibreoptic bronchoscope

A. H. Seymour1, L. Lynch1, S. H. Pennefather2 and G. N. Russell2

1 Birmingham, UK 2 Liverpool, UK

Editor—An editorial by Pennefather and Russell1 added to the continuing debate about confirming the location of double lumen tubes with a fibreoptic instrument. Papers were quoted which found a primary malplacement rate varying between 39%2 and 83%,3 with one4 reporting critical malposition in at least 13%. The need for further checks throughout surgery was also suggested.1 Most of the evidence used to support these conclusions was based on the use of plastic tubes and only one paper, that by Hurford and colleagues,5 involved any of the genuine Robertshaw pattern tubes (then made by Leyland Medical, now by Phoenix Medical Ltd. of Preston, Lancashire), which continue to be widely used in many parts of the world. However, only 21% of their 70 Robertshaw intubations were confirmed with fibreoptic bronchoscopy, whilst 7% (no doubt with some overlap) were checked in the course of surgery. This department uses Robertshaw tubes extensively but with varying methods of placement, and in the current climate it was felt necessary to audit the location of a series of conventionally placed tubes by inspection with a fibreoptic bronchoscope.

Consecutive conventional Robertshaw double lumen intubations carried out by one of us (AS) were checked by a second consultant thoracic anaesthetist using a fibreoptic bronchoscope. Cases where it was difficult to obtain a satisfactory clinical location were excluded, as were those where a suitable fibreoptic bronchoscope or bronchoscopist were not available. The findings from surgical bronchoscopy were available in most instances. The induction sequence included an anti-sialogogue (atropine 600 µg). Invariably, intubation of the dependent lung was attempted with the largest Robertshaw tube that would negotiate the larynx. The location sequence relied mainly upon visual inspection, estimating relative compliance and listening for leaks. In a few troublesome cases, final checks were made with the aid of a pressure/volume loop trace.2 Bronchial cuffs were primed and inflated with saline, the precise amount required being accurately adjusted. Fixation employed sleek over a Guedel airway. When the patient was turned into the lateral position, the degree of head flexion used during intubation was maintained since it is known that flexion and extension may advance or withdraw the tip respectively.6

Fifty adults were included in the audit—36 males and 14 females. There were 35 major thoracotomies, seven video-assisted thoracoscopies, five open lung biopsies and three other procedures. The Robertshaw tubes used were as follows: left, 17 large, five medium and three small; and right, 16 large, eight medium and one small (a 50/50 split). In the 14 females 10 medium and four small tubes were used. Thirty-three males accepted large tubes and three required medium—all right sided. In one of these the large tube stuck at the larynx and the other two failed to advance sufficiently into the bronchial tree.

The single fibreoptic bronchoscope check was made as soon as practicable after commencement of surgery. The tracheal and bronchial sides were checked primarily to ensure that both main and upper lobe bronchi were free of obstruction. The extent to which the tube departed from the best possible (that is, optimal) position having regard to the anatomy was also noted. We grouped the observations into four categories.

(i) Optimal or near-optimal. In the case of a left-sided tube ‘near optimal’ is defined as up to 1 cm from the perfect position, consistent with unobstructed airways and a clear view of the main carina and sub-carina. With the right-sided tube, there is little scope for variation and the two terms become synonymous.

(ii) Sub-optimal. This can only apply to a left-sided tube and indicates a situation where it is more than 1 cm from the best possible position but with both the main and sub-carina still visible and no obstruction to the right main or left upper lobe bronchi.

(iii) Misplaced (but satisfactory). Here the tube is out of position but the lungs are safely isolated and there is a reasonable passage into the appropriate main and upper lobe bronchi.

(iv) Unsatisfactory. Potentially dangerous, bad enough to require re-positioning.

The tube positions noted on fibreoptic bronchoscope checking were as follows.

(i) 42 (84%) were optimal or near-optimal.

(ii) 6 (12%) were sub-optimal but satisfactory.

(iii) 2 (4%) were malplaced but satisfactory.

(iv) No tube was designated unsatisfactory or required re-positioning.

None of the 50 investigations gave rise to any clinical problem that could be attributed to the position of the tube. Of the two instances of malplacement one was a medium left tube in a female scheduled for right video-assisted thoracoscopy. It proved impossible to detect the position of the left upper lobe orifice on clinical grounds because, as it turned out, it was completely stenosed. The tube had deliberately been pulled back as far as possible, consistent with satisfactory lung isolation and the main carina was partly obscured, although there was a good passage into the right main bronchus. The second was a large right tube in a 56 kg, 173 cm male which behaved normally in all respects but was, in fact, wedged in the right main bronchus above, and clear of, the right upper lobe orifice. The left main bronchus was not obstructed and there was no clinical indication to replace the tube.

Fifty-two patients were omitted from the audit. This was mainly because of the absence of a suitable fibreoptic bronchoscope or bronchoscopist, but positioning problems were a factor in nine cases. One wholly and two partially tracheal, right upper lobe orifice locations were noted by an experienced surgeon at bronchoscopy in patients destined for right-sided tubes. These apart, the failure to obtain completely satisfactory clinical location in 102 consecutive patients was 6%—in line with other comparable series.7 8 The nature of the location problems made it unlikely that this figure could have been improved upon by direct visualization. Our main findings were as follows.

(i) Where placement of a Robertshaw tube, without the aid of a fibreoptic bronchoscope, was satisfactory on clinical grounds, this was confirmed in at least 96% of cases upon direct visual inspection—indeed, there was no instance of critical malposition.

(ii) Where a Robertshaw tube had been carefully placed and firmly fixed, its position was unlikely to alter. Our single fibreoptic bronchoscope check was made after positioning the patient. The timing was random and eventually it would have detected that tubes were being displaced during surgery, even if that was not clinically apparent.

There can be no doubt that the fibreoptic bronchoscope is a useful tool. However, for an experienced anaesthetist, this audit has not shown it to be essential; indeed the instrument provides objective support for the contention by Conacher and colleagues8 that the design and materials of the Robertshaw tube contribute to safe deployment by conventional means. The ability to place a Robertshaw tube blind may be vital where, for example, a suitable flexible bronchoscope is not available or there is heavy bleeding into the bronchial tree.

A. H. Seymour

L. Lynch

Birmingham, UK

Acknowledgement: We gratefully acknowledge the help of Dr Brendan O’Connor, consultant anaesthetist, in conducting this audit.

Editor—Thank you for the opportunity to reply to Seymour and Lynch who conclude from an audit of patients receiving red rubber Robertshaw (Phoenix) double lumen endobronchial tubes (DLEBT) that the use of a fibreoptic bronchoscope is not essential for these patients. In our opinion, neither this audit nor the literature they quote support this conclusion.

Seymour and Lynch audited the blind placement of red rubber tubes in 102 consecutive patients. They bronchoscoped 50 patients; in one patient undergoing left lung anaesthesia, an occluded left upper lobe bronchus was detected. Nine of 52 patients omitted from this study were excluded because of difficulty placing the DLEBT blindly. In three of these nine patients there was a tracheal origin to a right upper lobe or right upper lobe segmental bronchus. No details of the location problems experienced in the remaining six patients are given but a fibreoptic bronchoscope would have facilitated the accurate placement of an alternative DLEBT/ bronchial blocker if optimal placement of the DLEBT in use could not be achieved. As discussed in our editorial, the variability in tracheobronchial anatomy is central to any discussion on placement of DLEBT and cannot be dismissed.1 It is difficult to comment on the incidence of significant DLEBT malplacement during this audit because of the large number of patients excluded. It can be concluded that using a fibreoptic bronchoscope in all audited patients would have provided clinically useful information and/or aided the accurate placement of an appropriate tube to provide one lung ventilation (OLV) in at least 10% of these patients.

Seymour and Lynch quote a paper by Hurford and colleagues5 auditing the blind placement of DLEBT by residents working in their department. Seventy of their patients received a red rubber Robertshaw DLEBT (Leyland). Fibreoptic bronchoscopy was never performed on 55 of these 70 patients. The DLEBT was repositioned in 13 of the 15 patients in whom fibreoptic bronchoscopy was performed after initial blind placement of the DLEBT. Thus although 19% of all Robertshaw tubes were repositioned as a result of bronchoscopy following initial blind placement, the tube was repositioned in 87% of those patients in whom the initial blind placement was checked with a fibreoptic bronchoscope.

Seymour and Lynch quote Conacher and colleagues,8 who prospectively analysed the blind placement of 100 red rubber Robertshaw DLEBTs (Leyland) without the use of a fibreoptic bronchoscope. Reasonable surgical conditions and oxygenation were achieved in 90% of patients. In 11% of patients, difficulty was experienced in ventilating the contralateral lung; this was presumed to be due to bronchial cuff herniation. Upper lobe bronchus blocking by the tube was detected in 8% of patients.

We agree with Seymour and Lynch that the ability to place a DLEBT blindly is a useful skill and that red rubber tubes of the original Robertshaw design are best suited for blind placement. We teach our registrars to place a variety of DLEBTs blindly. However, we require our registrars to then check and recheck the position of all blindly placed DLEBTs with a fibreoptic bronchoscope. Most registrars need no further convincing that a fibreoptic bronchoscope should be used in all patients.

As discussed in our editorial, the routine use of fibreoptic bronchoscope facilitates the detection of anatomical and pathological variation in the structure of the major airways, thus enabling the choice and placement of an appropriate tube to provide OLV.1

We are of the opinion that the audit by Seymour and Lynch and the literature they quote adds further support to the arguments for the routine use of fibreoptic bronchoscope in all patients undergoing OLV.

S. H. Pennefather

G. N. Russell

Liverpool, UK

References

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