Left double lumen tube malposition

Editor—We read with interest the paper by Inoue and colleagues1 describing the importance of left double lumen tube (L-DLT) malpositioning during one-lung ventilation (OLV) and the prevalence of hypoxaemia.

The authors defined their correct DLT position according to Slinger2 as ‘an unobstructed view into the left upper and lower lobe bronchus through the endobronchial lumen with the bronchial cuff immediately below the carina and just visible in the main left bronchus through the tracheal lumen’. They defined malposition ‘if the tube had to be moved (in or out) by more than 1.0 cm to correct its position’.

We disagree with their definition of DLT malpositioning. Clinically, a malpositioned L-DLT occurs when the tube obstructs the left upper lobe bronchus or when the top of the endobronchial cuff is above the carina. This type of malpositioning may explain desaturation or insufficient lung separation. A position between these two extremes has no clinical significance and should be considered inside the margin of safety. The authors did not report the type of malpositioning they encountered (proximal or distal), and it seems to us that a 1 cm displacement is difficult to evaluate by fibreoptic bronchoscopy.

Finally, the authors discussed ‘how can we stop DLTs becoming misplaced? We have no solution so far, ....’ We would like to highlight the fact that the L-DLT was redesigned in 1994 to increase its margin of safety.3 These modifications cause problems when the tube is positioned using the classic approach,2 and the patient is therefore placed in lateral decubitus before checking the L-DLT position.4 We conducted a study to address the problem of L-DLT malpositioning and described a new method of positioning by visualizing the carina through the transparent wall of the L-DLT.5 This new method necessitated less re-positioning of the L-DLT than the classic technique (23% compared with 53%), and should be use routinely in thoracic surgery.

G. Fortier, D. Coté, J. Soucy, R. Lelièvre and J. Bussières

Québec, Canada


 
Editor—Thank you for giving us the opportunity to reply to this interesting letter. We agree with the comment that we used the classic definition by Slinger2 for DLT positioning and we would have had different results if we had used the new definition described by Fortier and colleagues.5 However, the main point that we would emphasize is that patients who have DLT malposition after being placed patient in the lateral position had more DLT malposition and hypoxaemia during OLV.1 Using either definition of DLT positioning, classic or new, malposition will occur in some cases. It has been reported that even with the new positioning method, 23% of patients developed DLT malposition, although this technique substantially reduced its incidence.5 We think that some patients are more susceptible to intraoperative factors inducing DLT malposition and more easily develop hypoxaemia during OLV. In our report, we discussed how we can stop DLTs becoming misplaced, but missed the opportunity to comment on the new approach to DLT positioning. We really appreciate the new positioning method.

Regarding our definition of DLT malposition, we think that it is correct when using ‘classic approach’ for DLT placement. In fact, Klein and colleagues used the same classic approach but a more strict definition for DLT malpositioning, which was evaluated by fibreoptic bronchoscopy.4 As mentioned in our report, patients with DLT malposition met the bronchoscopic criteria for DLT malposition of Campos and colleagues,6 which is very similar to the clinical malposition that Fortier and colleagues5 define in their article and letter. In addition, we should note that most of our patients developed proximal malposition. Lastly, we accept that as just over 1.0 cm of movement can cause clinical malposition, we should use the new approach instead of the classic one in future.

S. Inoue, N. Nishimine, K. Kitaguchi, H. Furuya and S. Taniguchi

Kashihara, Japan

References

1 Inoue S, Nishimine N, Kitaguchi K, Furuya H, Taniguchi S. Double lumen tube location predicts tube malposition and hypoxemia during one lung ventilation. Br J Anaesth 2004; 92: 195–201[Abstract/Free Full Text]

2 Slinger PD. Fiberoptic bronchoscopic positioning of double-lumen tubes. J Cardiothorac Anesth 1989; 3: 486–96[Medline]

3 Yahagi N, Furuya H, Matsui, et al. Improvement of the left Broncho-Cath double-lumen tube. Anesthesiology 1994; 81: 781–2

4 Klein U, Karzai W, Bloos F, et al. Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia. Anesthesiology 1998; 88: 346–50[ISI][Medline]

5 Fortier G, Coté D, Bergeron C, Bussieres JS. New landmarks improve the positioning of the left Broncho-Cath double-lumen tube-comparison with the classic technique. Can J Anaesth 2001; 48: 790–4[Abstract/Free Full Text]

6 Campos JH, Kernstine KH. A comparison of a left-sided Broncho-Cath with the torque control blocker univent and the wire-guided blocker. Anesth Analg 2003; 96: 283–9[Abstract/Free Full Text]





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