Full text of DOI:10.1007/BF03016696

7
90
CARDIOTHORACIC ANESTHESIA, RESPIRATION AND AIRWAY
New landmarks improve the positioning of the
TM
left Broncho-Cath double-lumen tube-compari-
son with the classic technique
[De nouveaux repères facilitent la mise en place du tube double-lumière
Broncho-CathTM gauche - comparaison avec la technique classique]
G. Fortier MD,* D. Coté MD,† C. Bergeron MD,† J.S. Bussières MD†
Purpose: To compare a new technique (NT) for positioning the left
modified Broncho-Cath double-lumen tube (LM- DLT) by fibre-
groupes NT ou TC. Suivant la NT, l’endoscopiste confirme l’intubation
TM
de la bronche souche gauche et le sommet du ballonnet ne doit pas
être visualisé juste sous la carène. Par la lumière bronchique, par
transparence au travers de la paroi du tube, on ajuste celui-ci pour
que la carène se situe à mi-chemin entre la ligne noire radio-opaque
et le sommet du ballonnet bronchique. On s’assure également que la
bronche lobaire supérieure gauche (LSG) est libre. Suivant la TC, l’en-
doscopiste utilise la technique décrite par Benumof et Slinger. Après le
positionnement en décubitus latéral, le TDL-GM est repositionné
lorsque le sommet du ballonnet fait hernie au dessus de la carène ou
si la bronche LSG est obstruée.
optic bronchoscopy (FOB) to the classic technique (CT).
Methods: Sixty-one adult patients undergoing elective thoracic
surgery with LM-DLT were randomly assigned to the NT or to the
CT group. For the NT, the endoscopist confirms the left mainstem
endobronchial intubation. The proximal edge of the blue bronchial
cuff should not be visualized at the carina. Then, through the left
bronchial lumen, by transparency across the wall of the tube, the
position of the tube is adjusted so that the carina lies midway
between the black radiopaque line and the top of the bronchial cuff.
After this, the orifice of the left upper lobe (LUL) bronchus should
be clearly seen. For the CT, the endoscopist uses the technique
described by Benumof and Slinger. After lateral positioning of the
patient, the LM-DLT was repositioned if the top of the endo-
bronchial cuff was above the carina or when the LUL bronchus was
obstructed.
Résultats: Les repositionnements proximaux sont significativement
moins fréquents en utilisant la NT comparativement à la TC (16 % vs
43 %, P=0,007).
Conclusion: Lorsqu’on utilise la NT, la partie endobronchique du
TDL-GM est insérée plus profondément dans la bronche souche
gauche avec de nouveaux points de repère et augmente par con-
séquent la marge de mouvement qui peut être tolérée sans nécessiter
un repositionnement du TDL-GM. Cette NT de positionnement et de
vérification, par transparence au travers de la paroi du tube, est mieux
adaptée aux modifications récentes du TDL-GM.
Results: The incidence of proximal repositioning was significantly
less in the NT compared to the CT (16% vs 43%, P=0.007).
Conclusion: Using this new technique, the LM-DLT is inserted
deeper in the left mainstem bronchus. This new landmark aug-
ments the range of movement that can be tolerated without requir-
ing repositioning of the LM-DLT. This NT to position and to assess
LM-DLT, by transparency across the wall of the tube with FOB, is
better adapted to the LM-DLT and its recent modifications.
HE left Broncho-CathTM (Mallinckrodt
Anesthesiology, St-Louis MO, USA) dou-
ble lumen tube (DLT) was redesigned in
T
1
994. It was the first major modification in
Objectif: Comparer une nouvelle technique (NT) de positionnement
du tube double-lumière Broncho-Cath gauche modifié (TDL-GM), à
l’aide de la fibroscopie, à la technique classique (TC).
15 yr. The left modified-DLT (LM-DLT) incorpo-
rates several new design changes that facilitate its use
(Figure 1). First, the endobronchial portion was
shortened from 58 to 45 mm. Second, the endo-
bronchial cuff length was reduced from 19, including
TM
Méthodes: Soixante et un patients adultes devant subir une chirurgie
thoracique programmée avec un TDL-GM ont été randomisés aux
From the Department of Anesthesiology, Laval University* and from the University Heart and Lung Institute,† Laval Hospital, Québec,
Québec, Canada.
Address correspondence to: Dr. Jean Bussières, Hôpital Laval, 2725 chemin Ste-Foy, Ville de Québec, Québec G1V 4G5, Canada.
Phone: 418-656-8711; Fax: 418-656-4637; E-mail: jean.bussieres@anr.ulaval.ca
Accepted for publication September 19, 2000.
Revision accepted May 23, 2001.
CAN J ANESTH 2001 / 48: 8 / pp 790–794

Fortier et al.: IMPROVED DLT POSITIONING
791
confirmed this result with the use of LM Broncho-
TM
Cath
DLT. After using classic recommendations,
proximal malpositioning was seen in 43% of patients,
10
following lateral positioning of the patient.
We describe a new technique for placing the LM-
DLT and propose an innovative method to assess posi-
tioning. The aim of this study was to investigate the
potential usefulness of this new technique for better
positioning and verifying of the LM-DLT. The new
technique was compared with the actual standard rec-
ommendations for positioning the LM-DLT using
4,5
FOB.
Materials and methods
With the approval of the Research Ethics Committee
of our institution, we obtained informed consent from
6
1 adult patients. These patients underwent elective
thoracic surgery requiring endotracheal intubation
with a LM-DLT and were randomly assigned to the
CT (30 patients) or the NT (31 patients). Exclusion
criteria included any anatomical abnormality in a
major airway such as a proximal tumour, significant
tracheal deviation, previous pulmonary resection or
FIGURE 1 Left broncho-cath DLT modifications.
11
the outside proximal seal of the cuff (Figure 1A), to
thoracic radiotherapy. We used the LM Broncho-
Cath DLT. The study started when the LM-DLT
TM
1
5 mm as the proximal seal of the cuff had been repo-
sitioned inside the cuff (Figure 1B), and the cuff was
moved 3 mm caudally. Third, the angle between the
tracheal tube axis and the bronchial tube axis was
increased from 30 to 45, and finally, the bevelled
bronchial tip was eliminated. These modifications
increase its margin of safety and diminish the risk of
obstruction in the expiratory phase.
However, in our experience, the modification of
the tip and the cuff of the LM-DLT caused problems
when it was positioned using the classic approach
for insertion by fibreoptic bronchoscopy (FOB). It
was observed frequently that, after moving the patient
from the supine to the lateral position, the cuff moved
to bulge in the trachea and the bronchial tip tended to
herniate or dislodge from the left mainstem bronchus.
Proper placement of a DLT is imperative for its prop-
er functioning. Malpositioning can impair gas
exchange and the capacity to isolate and deflate the
operated lung.
It is well demonstrated that the position of the
DLT during anesthesia may be altered by surgical
manipulation, patient coughing, or by moving the
head, the neck or the entire patient. Desiderio et al.
demonstrated that the Sher-I-Bronch
was inserted after induction of anesthesia and ended
when the lateral positioning was completed and after
verification and repositioning of the LM-DLT when
necessary.
Monitoring consisted of electrocardiography, inva-
sive arterial blood pressure, pulse oximetry, end-tidal
CO2 and pressure-volume loop displayed by side
stream spirometry (Capnomac Ultima, Datex-
Engstrom, Helsinki, Finland). Glycopyrrolate, 0.2 mg
iv was injected just after the installation of the iv line
as an antisialogue to permit optimal visualization with
the FOB.
1,2
3
4,5
Under general anesthesia, the LM-DLT was insert-
ed into the trachea. The size was selected according to
12,13
Brodsky’s chart.
The patient’s head was placed on
a pillow in a neutral position. With the LM-DLT in
place, the cuffs were inflated with the minimum
amount of air necessary to ensure absence of air leaks,
confirmed by the pressure-volume loop displayed by
6
7
14
side stream spirometry.
One investigator (G.F.) performed all the fibreoptic
examinations using a 4-mm FOB (Olympus LF-1,
Olympus Optical Co Ltd, Tokyo, Japan) and assessed
adequacy of tube placement according to the following
criteria : 1- CT: In the supine position, via the right tra-
cheal lumen, the endoscopist should see a clear,
straight-ahead view of the tracheal carina. It is impor-
tant to see the upper surface of the left endobronchial
8
TM
(Sheridan,
Argyle NY, USA) DLT moved in 72% of cases during
lateral positioning and this regardless of endo-
bronchial cuff inflation. This movement is predomi-
9
nantly in the upward direction. Recently, Klein

792
CANADIAN JOURNAL OF ANESTHESIA
FIGURE 3 Visualization of the carina by transparency.
FIGURE 2 Left double lumen tube positions.
blue cuff just below the carina (Figure 2C). Then,
looking down the left endobronchial lumen, the orifice
of the LUL bronchus and the bronchial carina should
be seen clearly to assure a properly positioned LM-
DLT. 2- NT: The endoscopist confirms the left main-
stem endobronchial intubation and the position of
tracheal carina. The proximal shoulder edge (Figure 1)
of the blue bronchial cuff should not be visualized at
the carina. However, through the left bronchial lumen,
and by transparency across the wall of the tube, the
position of the tube is adjusted so that the carina is
midway between the black radiopaque line and the top
of the bronchial cuff (Figures 2D and 3). Finally, the
orifice of the LUL bronchus and the bronchial carina
should be clearly seen.
categorical variables. Mean values of quantitative vari-
ables were compared using a Student’s t test.
Categorical variables were analyzed using the Fisher’s
exact test. The results were considered significant if P
values were 0.05. The data were analyzed using the
statistical package program SAS (SAS Institute Inc.,
Cary NC, USA).
Results
The demographic data including age, sex, weight and
ASA status were similar in each group (Table I). There
was a difference in the two groups concerning height.
Among the 61 patients, 72% were operated for
lung cancer surgery, 7% for emphysema reduction
surgery and the residual 21% for other conditions or
procedures (e.g., tuberculosis, lung biopsy, etc.). The
distribution of the type of surgery was similar in the
two techniques.
The LM-DLT was fixed firmly in position with a tie
at the level of the lips and a bow tie at the bifurcation
15,16
of the lumens of the DLT.
After lateral positioning
of the patient, FOB was used to evaluate the position
of the LM-DLT. The most proximal acceptable posi-
tion was when the top of the blue endobronchial cuff
The displacement of the LM-DLT after lateral posi-
tioning was similar in each group and in each direction
(cephalad, caudal or none) as described in Table II. The
incidence of proximal repositioning was significantly less
for the NT compared to the CT (16% vs 43%, P=0.007).
The incidence of distal repositioning for a clear view of
the LUL bronchus was similar in each group.
4
was just below the carina. The most distal acceptable
position was when the LUL was clearly seen. If dis-
placement exceeded the described limits, the LM-
DLT was repositioned.
Means and standard error of the mean (SEM) were
determined for continuous variables and percent for
In both groups, the following variables were exam-
ined and did not significantly influence repositioning:

Fortier et al.: IMPROVED DLT POSITIONING
793
TABLE I Demographic data
left mainstem bronchus. For these reasons, a new
technique is proposed to position and to assess the
LM-DLT. This new technique (Figure 2D) probably
represents the equivalent of the “clinical position”
Variables
Classic group
SEM#
New group
SEM#
Age (yr)
Gender
F
63.67
2.06
58.00
2.72
(
Figure 2B) used for the left conventional-DLT. The
13 (43%)
17 (57%)
09 (29%)
22 (71%)
170.27*
68.75
endobronchial part of LM-DLT is inserted deeply.
This position necessitates less repositioning than the
classic position (Figure 2C) because the proximal mar-
gin of movement is increased to about 5 mm. In this
study, when the NT is compared to the CT, the inci-
dence of proximal repositioning was significantly
reduced (16% vs 43%). Since distal repositioning was
similar in each group, the NT represent an improve-
ment over the CT.
M
Height (cm) 163.47*
1.54
2.09
1.76
2.53
Weight (kg)
67.46
ASA
II
III
19 (63%)
11 (37%)
21 (67%)
10 (32%)
*
P <0.005
#
Standard error of the mean.
However, after positioning of the patient, the LM-
DLT still tends to herniate and dislodge from the left
TABLE II Results
Technique
patients
Classical
New
#31
P
10
mainstem bronchus. The LM-DLT is vulnerable to
malpositioning when changing the patient from the
#
#30
Displacement
Proximal
Distal
Combined
Repositioning
Proximal
Distal
19
supine to the lateral decubitus position. Desiderio et
13 (43%)
12 (40%)
25 (83%)
10 (32%)
14 (45%)
24 (77%)
0.434
0.797
0.749
al. stated that it is actually advantageous to have the
endobronchial cuff at least 1 cm inside the left main-
stem bronchus, considering the tendency for carinal
shift downward and perhaps LM-DLT movement
upward with positioning. However, they did not
determine the precise positioning and the modalities
used to assess it, nor did they discuss the margin of
13 (43%)
03 (10%)
16 (53%)
5 (16%)
2 (07%)
7 (23%)
0.007*
0.635
0.018*
Combined
*
significant
9
safety. The merit of our study is to specify the land-
marks of a NT. To our knowledge, this study repre-
sents one of the very few prospective studies
comparing and challenging standard FOB recommen-
performance of the epidural before or after induction,
the presence or absence of superior or inferior denti-
tion, the side of surgery and the size of the LM-DLT.
Height did not influence displacement or repositioning.
Endotracheal visualization of the landmarks with
FOB, across the wall of the LM-DLT, was evaluated
and was easy in all of the patients in this study.
4,5
dations for positioning DLT.
Our FOB definition of tube displacement may be
responsible for the high rate of displacement observed
(53%), compared to the rate reported (43%) by
10
Klein for whom the definition of acceptable proxi-
mal displacement was when the cuff herniated by
about 0.5 cm. Such borderline tube placement carries
the potential risk of subsequent displacement,
obstruction or insufficient lung separation.
Discussion
The LM-DLT was redesigned to achieve the primary
objectives described previously: ease of use, elimina-
tion of potential for obstruction during the expiratory
Conclusion
2
,15,17
phase and an acceptable margin of safety.
When the NT is compared to the recommended CT,
the incidence of proximal repositioning is lessened by
63% (16% vs 43%). This NT inserts the endobronchial
part of the LM-DLT more deeply in the left mainstem
bronchus with the use of new landmarks visualized by
transparency across the wall of the DLT. The new posi-
tion increases the margin of movement and is better
adapted to the LM-DLT and its recent modifications.
However, the LM- DLT has the seal of the cuff inside
the endobronchial cuff. This finding can explain par-
tially why the LM-DLT tends to be malpositioned
proximally.18 Furthermore, the endobronchial part of
the LM-DLT is shorter (45 mm vs 58 mm) than the
left conventional-DLT. This diminishes the relative
stability of the LM-DLT while in the left mainstem
bronchus. The increase in the angulation between the
tracheal and endobronchial sections, while adapting to
the anatomy, facilitates endobronchial intubation but
equally augments the facility of dislodgement from the
Acknowledgement
To Mr. Serge Simard, Professional Statistical
Consultant.

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CANADIAN JOURNAL OF ANESTHESIA
References
17 Brodsky JB. Modified bronchocath double-lumen tube
(Letter). J Cardiothorac Vasc Anesth 1995; 9: 784–5.
18 Campos JH, Reasoner DK, Moyers JR. Comparaison of
a modified double-lumen endotracheal tube with a sin-
gle-lumen tube with enclosed bronchial blocker.
Anesth Analg 1996; 83: 1268–72.
19 Cheng KS, Wu RSC, Tan PP. Displacement of double-
lumen tubes after patient positioning (Letter).
Anesthesiology 1998; 89: 1282–3.
1
Benumof JL. Improving the design and function of
double-lumen tubes. J Cardiothorac Anesth 1988; 2:
29–33.
7
2
Yahagi N, Furuya H, Matsui J, et al. Improvement of
the left Broncho-Cath double-lumen tube.
Anesthesiology 1994; 81: 781–2.
3
4
Desai FM, Rocke DA. Double-lumen tube design fault
(Letter). Anesthesiology 1990; 73: 575–6.
Slinger PD. Fiberoptic bronchoscopic positioning of
double-lumen tubes. J Cardiothorac Anesth 1989; 3:
486–96.
5
6
Benumof JL. Anesthesia for Thoracic Surgery, 2nd ed.,
San Diego, CA: W.B. Saunders Company, 1995:
354–60.
Boucek CD, Landreneau R, Freeman JA, Strollo D,
Bircher NG. A comparaison of techniques for place-
ment of double-lumen endobronchial tubes. J Clin
Anesth 1998; 10: 557–60.
7
8
9
Brodsky JB, Shulman MS, Mark JBD. Malposition of
left-sided double-lumen endobronchial tubes.
Anesthesiology 1985; 62: 667–9.
Riley RH, Marples IL. Relocation of a double-lumen
tube during patient positioning (Letter). Anesth Analg
1992; 75: 1071–5.
Desiderio DP, Burt M, Kolker AC, Fischer ME, Reinsel
R, Wilson RS. The effects of endobronchial cuff infla-
tion on double-lumen endobronchial tube movement
after lateral decubitus positioning. J Cardiothorac Vasc
Anesth 1997; 11: 595–8.
1
1
1
0 Klein U, Karzai W, Bloos F, et al. Role of fiberoptic
bronchoscopy in conjonction with the use of double-
lumen tubes for thoracic anesthesia. Anesthesiology
1998; 88: 346–50.
1 Slinger PD, Chripko D. A clinical comparaison of
bronchial cuff pressures in three different designs of
left double-lumen tubes. Anesth Analg 1993; 77:
305–8.
2 Brodsky JB, Macario A, Mark JBD. Tracheal diameter
predicts double-lumen tube size: a method for select-
ing left double-lumen tubes. Anesth Analg 1996; 82:
861–4.
13 Brodsky JB, Mackey S, Cannon WB. Selecting the cor-
rect size left double-lumen tube (Letter). J
Cardiothorac Vasc Anesth 1997; 12: 924–5.
14 Bardoczky GI, Engelman E, D’Hollander A.
Continuous spirometry: an aid to monitoring ventila-
tion during operation. Br J Anaesth 1993; 71: 747–51.
5 Benumof JL. Anesthesia for Thoracic Surgery, 2nd ed.,
San Diego, CA: W.B. Saunders Company, 1995: 366.
6 Cohen E, Koorn R. An easy way to safely tie a double-
lumen tube (Letter). J Cardiothorac Vasc Anesth 1991;
1
1
5: 194–5.