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Insertion of Double-lumen Tube to Adequate Depth: Anaesthesiologist’s Dilemma!

2023; Medknow; Volume: 6; Issue: 3 Linguagem: Inglês

10.4103/arwy.arwy_32_23

2665-9433

Manbir Kaur, Darshana Rathod, Ankur Sharma, Monisha Ashwin Kulkarni,

Tracheal and airway disorders

Sir, Double-lumen tube (DLT) is commonly used in thoracic surgeries for isolating one lung from another. Selecting the appropriate size of DLT tube is challenging for anaesthesiologists.[1,2] The height-based recommendations which have been mentioned in the literature cannot be generalised to all patients.[3,4] We, with this, describe our experience where we had to place the DLT in a position much deeper than expected height-based recommendations. A 47-year-old male patient (weight 102 kg and height 193 cm) with a follow-up case of emphysematous bullae on the right lung was planned for right lung decortication. He had shortness of breath and tightness in his chest for 1 day. On chest auscultation, bilateral vesicular breath sounds with decreased intensity on the right side were present, with oxygen saturation of 81% on room air. Contrast-enhanced computerised tomography of the thorax showed a giant emphysematous bulla (22 cm × 17 cm × 25 cm) on the right side, causing significant atelectasis of the right lung and contralateral mediastinal shift towards the left side of the chest. After taking written informed consent, the surgery was planned with a left-sided DLT (Shiley™ endobronchial tube [Covidien]) for one-lung ventilation. After induction of anaesthesia, a DLT size 41 (based on expected height-based recommendations) was inserted under video-laryngoscopy guidance. The tube was inserted to a depth of approximately 32 cm (as per Brodsky et al.'s[2] formula, i.e. 0.11 × body height + 10.53 cm, according to which depth came 31.76 cm). On auscultation, lung isolation was not achieved. We could not visualise the carina on fibreoptic bronchoscopy through the tracheal lumen. We thought the tube might be too deep; hence, we withdrew the DLT. Even after doing so, the carina was not visualised. On pushing the tube further, we could isolate one lung from another. As shown in Figure 1, the DLT was inserted till the bite block of the tube came at the level of incisors; the calculated depth of the tube came to be 35.5 cm (higher than the Brodsky formula).Figure 1: Patient with double-lumen tube (DLT) in situ where DLT is inserted too deepIn this case, we used the appropriate-size DLT as per recommendations; however, we had to insert it deeper than the anticipated height-based formulas. The patient's height should not be the ideal criterion for measuring the depth of DLT insertion. There must be a standard method or guidelines for inserting the DLT to adequate depth. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.