Double Lumen Endotracheal Tube

OVERVIEW

A double lumen endotracheal tube (DLT) is an endotracheal tube designed to isolate the lungs from one another anatomically and/or physiologically

USES

Anatomical lung separation (this isolates a diseased lung from contaminating the non-diseased lung)

• Massive hemoptysis (protect normal lung from blood)
• Whole lung lavage for pulmonary alveolar proteinosis (lavage worst lung first)
• Copious secretions (e.g. bronchiectasis, lung abscess) (protect normal lung from pus)

Physiological lung separation (ventilates each lung as an independent unit)

• Unilateral parenchymal injury:
  — Aspiration
  — Pulmonary contusion
  — Pneumonia
  — Unilateral pulmonary edema
• Single lung transplant (post operative complications)
  — e.g. COPD patient with lung transplant requiring different ventilation strategies for each lung
• Bronchopleural fistula
  — allow ventilation of normal lung without worsening leak through fistula
• Unilateral bronchospasm
• Thoracic surgery e.g. pneumonectomy
  — right-sided DLT only used if left pneumonectomy or surgery on left main bronchus (e.g. to avoid dispruption of anastomosis on on left lung transplant)

DESCRIPTION

DLTs may be “left” or “right” depending on bronchus they are designed to intubate

• right sided tubes have a slit to be positioned to facilitate ventilation of RUL but are more difficult to position, so left DLTs are more commonly used
• size = external diameter of tube (French Gauge – 26-41 Fr)
• males; 39-41 Fr
• females; 37-39 Fr
• children use bronchial blocker technique
• remember in an emergency (ie. pulmonary haemorrhage) a standard ETT can be advanced into non-diseased lung (a bougie may help facilitate this)

Table below give diameter of bronchus (usually left) measured on PA CXR (magnifies air bronchogram by 10%). Measurement can also be made on CT.

Manufacturer	XR size (mm) 110% actual
	28Fr	32Fr	35Fr	37Fr	39Fr	41Fr
Sheridan	9.6	–	11.4	12.2	12.5	12.8
Mallinkcrodt	8.2	9.3	11.3	12.2	12.5	13.0
Portex	–	–	10.8	11.8	12.1	12.8
Rusch	–	–	11.2	12.4	12.5	13.0

• bronchoscope must be a narrow scope (<4 mm diameter) to pass down the lumens of a DLT
• Features of a Mallinckrodt DLT
  • high volume, low pressure cuff, bronchial tube and pilot balloon blue
  • radioopaque marker stripe running to tip of bronchial lumen
  • broncho cuff tubes have a radio-opaque line circling the tube proximal to the bronchial cuff, 4 cm from the tip of the bronchial lumen (should be positioned above the carina)

METHOD OF INSERTION

Blind technique for a left DLT:

• ensure lumen are patent and individual cuffs are working
• anaesthetise and paralyse patient
• perform direct laryngoscopy
• insertion of endotracheal tube with bronchial concave curve facing anteriorly
• as tip passes through larynx rotate the ETT anti-clockwise 90 degrees until resistance met (usually about 29 cm at the teeth in an average height adult)
• once trachea cannulated and tracheal cuff just below the vocal cords, inflate tracheal cuff and ensure ventilation of both lungs via inspection and auscultation
• check ventilation through bronchial lumen (clamp off gas flow to tracheal lumen at Y connector and open the tracheal sealing cap to air) – inflate bronchial cuff 1mL at a time until leak stops
• check whether can isolate other lung via tracheal lumen – close the sealing cap, remove Y connector and ventilate
• confirm position with bronchoscopy (auscultation alone is unreliable)
  • via tracheal lumen to confirm that:
    • endobronchial portion is in the left main bronchus
    • the bronchial cuff is just visible ~5mm below the carina, without cuff herniation above the carina
    • the RUL bronchus is identifiable via the right main bronchus, with 3 lobar branches (apical, anterior and posterior)
    • identify the radio-opaque line encircling the bronchial lumen (if present) above the carina
  • via endobronchial lumen:
    • identify origins of the left upper and lower lobe bronchi

Insertion of a right DLT:

• overview
  • must take into account the location of the right-upper lobe bronchus and the potential for obstructing its orifice
  •  the right mainstem bronchus is shorter than the left bronchus
  • the right-upper lobe bronchus originates at a distance of 1.5 to 2 cm from the carina so the right-sided DLT incorporates a modified cuff, or slot, on the endobronchial side that allows ventilation for the right-upper lobe
  • absolute contraindication for right-sided DLT use is the presence of an anomalous right upper lobe take off from the trachea (present in 1/250)
• similar overall approach to insertion of left-sided DLT, however use of bronchoscope is more important
• after the right-sided DLT enters the trachea, the fiberoptic bronchoscope is advanced through the endobronchial lumen
• Before advancing the DLT identify:
  • the tracheal carina
  • the right mainstem bronchus
  • the takeoff of the right-upper lobe bronchus
• rotate clockwise/ 90º to the right (opposite to a left-sided DLT) and advance with the aid of the bronchoscope
  • patient can be moved from supine to lateral decubitus position to facilitate this
• confirm position with bronchoscopy (auscultation alone is unreliable)
  • ensure good alignment between the opening slot of the endobronchial lumen relative to the take off of the right-upper lobe bronchus and distally (endobronchial lumen) a free view of
  • via the tracheal lumen:
    • identify the edge of the blue cuff (the endobronchial balloon) when inflated just below tracheal carina
    • identify the entrance of the right main bronchus
  • via endobronchial lumen:
    • identify good alignment between the opening slot of the endobronchial lumen relative to the take off of the right-upper lobe bronchus
    • identify the bronchus intermedius and the right-lower lobe bronchus distally

Trouble-shooting techniques for DLT insertion include

• using fiberoptic bronchoscope to cannulate bronchus and then rail road tube over the scope (perhaps the gold standard approach)
• use stylet to help place
• using a bougie as an introducer
• clinically check ventilation once changes have been made between normal ventilation and isolated lung ventilation
• once tracheal cuff below cords, rotate tube towards bronchus that is to be cannulated, turn patient’s head to opposite side, gently slide tube down until resistance felt

OTHER INFORMATION

Problems with DLT /SLV

• airway trauma
  • risk of tracheal/ bronchial rupture
  • pneumothorax and air leaks creates shunt (blood flow to
• creates shunt (blood flow to non-ventilated / collapsed lung -> hypoxaemia
• mucosal ischemia or trauma and tracheo-bronchial stenosis from cuff inflation and repositioning
• sizing and placement of DLT can be difficult
• malposition or dislodgment of the endobronchial cuff because of:
  • over inflation
  • surgical manipulation of the bronchus
  • extension of the head and neck during or after patient positioning and movement
• damage to DLT by accidentally clamping the endotracheal tube rather than its connectors
• high risk of failure to ventilate RUL with right-sided DLTs
• lack of lung collapse due to malposition may increase risk of direct lung injury during cardiothoracic surgery
• resource requirements
  • expertise required for insertion and subsequent selective lung ventilation
  • need for skilled and intensive nursing and specialised monitoring
  •  availability and expertise in bronchoscopy

Size of DLT

• A left-sided DLT that is too small requires a large endobronchial cuff volume which might increase the incidence of malposition. In addition, a small DLT does not readily allow fiberoptic bronchoscope placement and can make suction difficult.
• Ideally, a properly sized DLT passes without resistance through the glottis and advances easily within the trachea, and has a bronchial component that also passes into the intended bronchus without difficulty
• DLTs that are too small have problems including:
  • difficult to suction
  • difficult to pass bronchoscope
  • prone to malposition due to need for large endobronchial cuff volume

VIDEO

References and Links

LITFL

• CCC — Selective lung ventilation

Journal articles

• Anantham D, Jagadesan R, Tiew PE. Clinical review: Independent lung ventilation in critical care. Crit Care. 2005;9(6):594-600. PMC1414047.
• Brodsky JB. Lung separation and the difficult airway. Br J Anaesth. 2009 Dec;103 Suppl 1:i66-75. PMID: 20007992.
• Campos JH, Ueda K. Lung separation in the morbidly obese patient. Anesthesiol Res Pract. 2012;2012:207598. PMC3287015.
• Campos JH. An update on bronchial blockers during lung separation techniques in adults. Anesth Analg. 2003 Nov;97(5):1266-74. PMID: 14570636.
• Karzai W, Schwarzkopf K. Hypoxemia during one-lung ventilation: prediction, prevention, and treatment. Anesthesiology. 2009 Jun;110(6):1402-11. PMID: 19417615. [
• Russell WJ. A blind guided technique for placing double-lumen endobronchial tubes. Anaesthesia and intensive care. 20(1):71-4. 1992. [pubmed]
• Russell WJ, Strong TS. Dimensions of double-lumen tracheobronchial tubes. Anaesthesia and intensive care. 31(1):50-3. 2003. [pubmed]

FOAM and other web resources

• W. John Russel — Insertion of a double lumen tube