double lumen tube survey

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jennyboo

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I'm curious as to how you practice at your different institutions.

How do you decide what size DLT to use?

What do you use to confirm placement? (Auscultation? Bronchoscopy?)

Does your practice stock and/or use right-sided DLTs?

What do you use to clamp off one lumen? (Kelly clamp? Other?)

How do you secure it, i.e. prevent the thing from malpositioning or falling out?
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height
both
no
whatever i can find (usually kocher)
tape
 
jennyboo said:
I'm curious as to how you practice at your different institutions.

How do you decide what size DLT to use?
Click to expand...

Height mostly + appearance (never measured it out on XRAY)

What do you use to confirm placement? (Auscultation? Bronchoscopy?)
Click to expand...

Use both, but mostly FOB

Does your practice stock and/or use right-sided DLTs?
Click to expand...

Yes, rarely used

What do you use to clamp off one lumen? (Kelly clamp? Other?)
Click to expand...

Kelly

How do you secure it, i.e. prevent the thing from malpositioning or falling out?
Click to expand...

Tape
 
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jennyboo said:
I'm curious as to how you practice at your different institutions.

How do you decide what size DLT to use?

What do you use to confirm placement? (Auscultation? Bronchoscopy?)

Does your practice stock and/or use right-sided DLTs?

What do you use to clamp off one lumen? (Kelly clamp? Other?)

How do you secure it, i.e. prevent the thing from malpositioning or falling out?
Click to expand...

Based off general appearance, height for DLT size, have never, and never intend to look at the ct to figgure this out.

Placement is always confirmed by a quick bronch. If its questionable, auscultation to confirm my suspicion. If still not sure, I swallow my pride and have the ct surgeon look at the bronch for me.

We have a whole slew of Rights, prolly sitting around since the 1970's since theyre never used

I use whatever clamp is close by
 
jennyboo said:
I'm curious as to how you practice at your different institutions.

How do you decide what size DLT to use?

What do you use to confirm placement? (Auscultation? Bronchoscopy?)

Does your practice stock and/or use right-sided DLTs?

What do you use to clamp off one lumen? (Kelly clamp? Other?)

How do you secure it, i.e. prevent the thing from malpositioning or falling out?
Click to expand...

height, although that isnt the board answer

we confirm with bronchoscopy both after auscultation and after repositioning of patient

ive seen one right DLT in my training

we have kelly clamps in our thoracic room for lung isolation

taping a DLT tube properly is an art and ive had more than one tube migrate enough to lose lung isolation at inopportune times. id love to hear if anyone has a trick for this.
 
Specifically, what size DLT do you use for what height? For guys, I've been using 5'11" as cutoff between using a 39 and a 41, for girls in our institution we usually use 35 or 37. However, there seems to be a lot of variability among different people.

I ask about what you use to clamp the thing and what you do to tape it because I've found they do tend to migrate out over time mainly because 1) tape is fairly flexible and still allows in-and-out movement, and 2) the clamp adds to the weight of the apparatus and I think often contributes to the tube being pulled down/out.
 
http://www.anesthesia-analgesia.org/content/106/2/379.full

Remember to take any ONE article with a grain of salt. Besides 35F I often use 37F and 39F in patients. These days I use 39F for men larger than 5'11"-6'0" who weigh more than 190 pounds. I restrict the use of 41F double lumen utubes to the really big men over 6'2" and 250++ pounds. I find the 41 French just isn't necessary most of the time.

In Conclusion, this is one example of where smaller may be better.:laugh:

I can testify to the fact that 35F and 37F double lumen tubes can at times be INADEQUATE for large men (6'2" over 250 pounds).

http://www.anesthesia-analgesia.org/content/107/6/2092.3.full.pdf
 
I should have posted that I also feel their thyroid cartilage. If it feels large, then I might go with a bigger tube than height alone would dictate. Same is true for the opposite.

I follow the "think of the size that is appropriate for the height, then use one size smaller". It hasn't failed me yet.
 
jennyboo said:
I'm curious as to how you practice at your different institutions.

How do you decide what size DLT to use?
Like everyone else, height and weight

What do you use to confirm placement? (Auscultation? Bronchoscopy?)-it's mandatory for us to use bronch.

Does your practice stock and/or use right-sided DLTs? Very few and mostly in the ICU. Most will place an endobronchial blocker before using a right-sided tube.

What do you use to clamp off one lumen? (Kelly clamp? Other?)- does it matter?

How do you secure it, i.e. prevent the thing from malpositioning or falling out?- we use cloth straps with velcro for every CT cases regardless of tube type.
EndotrachealTubeHolders1.jpg
Click to expand...
 
Last edited:
jennyboo said:
Specifically, what size DLT do you use for what height? For guys, I've been using 5'11" as cutoff between using a 39 and a 41, for girls in our institution we usually use 35 or 37. However, there seems to be a lot of variability among different people.

I ask about what you use to clamp the thing and what you do to tape it because I've found they do tend to migrate out over time mainly because 1) tape is fairly flexible and still allows in-and-out movement, and 2) the clamp adds to the weight of the apparatus and I think often contributes to the tube being pulled down/out.
Click to expand...

We use Kellys. I orient the clamp such that it rests nicely on the pillow supporting their head, thus does not add weight to the tube. Once or twice when I had a problem with a tube perpetually migrating out, I positioned the tube holder/christmas tree bracket to maintain enough pressure on the elbow to keep the tube in.
 
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with the folks I have worked with....

all right side resections get a left tube.
all left pneumonectomy patients will get a right side tube.
all minimally invassive left chest procedures or left lung resections get a right side tube.
all tube placement is confirmed with FFB after placement and after patient lateral positioning.
 
JackADeli said:
with the folks I have worked with....

all right side resections get a left tube.
all left pneumonectomy patients will get a right side tube.
all minimally invassive left chest procedures or left lung resections get a right side tube.
all tube placement is confirmed with FFB after placement and after patient lateral positioning.
Click to expand...

This isn't the best practice, but if a resident needs practice with a RDLT, this is a good enough reason.
 
An endobronchial blocker is a nice technique to have in your pocket, and can be used on the right or left side.

I put one in a couple weeks ago on a thoraco-lumbar fusion in an RLD position where the orthopedic surgeon originally didn't think he would need to drop a lung, but of course after a couple hours, he changed his mind. Instead of stopping the procedure, turning the patient flat, replacing the tube, turning him again, reprepping and redraping, we just slid in the blocker while the patient was still on his side and dropped the left lung. The surgeon had never seen one before and was quite impressed.
 
The gen'l rule as a resident was 39 for men and 37 for women. Now the gen'l rule is one step down: 37 for men and 35 for women. Rarely will I have to get a longer tube to enable it to work (1 time in two years?).
I take a quick look down the R side for the trifurcating R upper lobe to confirm position. We place it a little further than text books/residency, i.e., a slightly herniating cuff is not deep enough. Push it down and only pull back if after venting the left lung you think the upper lobe is blocked (lower than expected SaO2). Actually, I often don't even look. My first step is to look at peak pressures. Clamp one side, look for expected rise in pressure, then lower the flows to about .3L and wait to see if there is a leak. The surgeon often looks, because then I think he can bill for a bronch. He'll confirm the location for me. If I have time, I'll take a cursory glance just so I know what it looks like if I have to look again later after repositioning.
We don't have any R sided tubes. Have done many L sided pneumonectomies. Simply pull the DL tube back at the appropriate time (just before taking the L lung).
I clamp with whatever the tech leaves me.
haven't done a bronchial blocker since residency. We used those for minimally invasive valve replacements. They are nice, just haven't had the need here.
Tuck
 
Look at the patient + height and weight in chart. This will determine DLT size.
Once placed, I don't listen. I go straight to bronch. Look down the Tracheal side first to see blue cuff down the left mainstem. If the patient has serious pathology I'll take a look around the right and left sides and in each lobe.
Tape in place.
Flip, take a look again. Confirm, clamp desired side and place suction to nondependant lung.
I don't ever look at CT's to determine size of DLT, I look at CT's to investigate pathology like a big 'ol mass hanging out the left mainstem.
I'm not a big fan of bronchial blockers, but I will use them if necessary. I will use a BB before a right sided DLT.

If I have problems with oxygenation, a jackson reese circuit to nondependant lung and add CPAP. CPAP always before PEEP (actually, I use 3cm h20 of peep to dependent lung) because PEEP may theoretically divert blood to non-ventilated lung.

If the patient is on bleomycin or mitomycin (or other toxic drugs) I try to restrict high O2 concentrations if the patient can tolerate it. Post-op atelectasis is always higher with 100% O2. I aim for 65-75% when possible.
 
sevoflurane said:
If I have problems with oxygenation, a jackson reese circuit to nondependant lung and add CPAP. CPAP always before PEEP (actually, I use 3cm h20 of peep to dependent lung) because PEEP may theoretically divert blood to non-ventilated lung.
Click to expand...

I know that's the board answer but it really depends where you are on the pulmonary compliance. We use Mapleson D circuits for CPAP.

If hypoxemia is caused by shunting, then CPAP to nonventilated before PEEP.
If hypoxemia is caused by atelectasis, then PEEP before CPAP.
 
proman said:
I know that's the board answer but it really depends where you are on the pulmonary compliance. We use Mapleson D circuits for CPAP.

If hypoxemia is caused by shunting, then CPAP to nonventilated before PEEP.
If hypoxemia is caused by atelectasis, then PEEP before CPAP.
Click to expand...
:thumbup:



How do you know if it's atelectasis vs. shunting? By definition you have a large shunt during OLV. By definition you also have atelectasis via GA/paralysis/highO2/etc...
This is why I always add a little PEEP to the dependant lung. I think 3 cmH2O won't cause much harm. I'm more cautious about PEEP when you are hitting 10-15cmH2O. Sometimes I feel I can find "best peep", but I'll still hook up CPAP before I start using higher Peep values. I have found CPAP to the nondependant lung works very well, so long as you can keep the lung down and your surgeon doesn't complain.

I hear you on the complience curve. Hard to determine where you are. But trial and error usually guide you in the right direction IMO.
 
For those who use a bronchial blocker before they would resort to a right-sided DLT, is this a "comfort level" decision or a clinical decision? In other words, what is your reasoning?

Just curious because I've been using LDLTs for right sided surgery and RDLTs for left sided surgery pretty much all the time (institutional practice) and nobody has offered me much reason not to do so. Yes, it's a little more tricky to position and therefore there's slightly more risk for RUL atelectasis/collapse but I don't find it that difficult and haven't encountered any significant problems unique to RDLTs.
 
jennyboo said:
For those who use a bronchial blocker before they would resort to a right-sided DLT, is this a "comfort level" decision or a clinical decision? In other words, what is your reasoning?

Just curious because I've been using LDLTs for right sided surgery and RDLTs for left sided surgery pretty much all the time (institutional practice) and nobody has offered me much reason not to do so. Yes, it's a little more tricky to position and therefore there's slightly more risk for RUL atelectasis/collapse but I don't find it that difficult and haven't encountered any significant problems unique to RDLTs.
Click to expand...


In our case is attending dependent. I've used Left DLT for right and left sided surgery except pneumonectomies without any problems. I think it's good to get practice with both.
 
jennyboo said:
...I don't find it that difficult and haven't encountered any significant problems unique to RDLTs...
Click to expand...
Hello,

If this is true, you are significantly better than most of us. I respect you and admire you. Congratulations!

I imagine that, as in everything else, practice makes perfect. If you have patient attendings, patient surgeons, and enough cases, you may get good at it. The rest of us dread placing a right sided DLT.

Greetings
 
Sergio99 said:
Hello,

If this is true, you are significantly better than most of us. I respect you and admire you. Congratulations!

I imagine that, as in everything else, practice makes perfect. If you have patient attendings, patient surgeons, and enough cases, you may get good at it. The rest of us dread placing a right sided DLT.

Greetings
Click to expand...

I find that if you place the RDLT, confirm correct sided placement, then bronch the tracheal side and adjust the tube to the right depth, when you bronch the bronchial side the murphy eye is usually sitting right at the RUL takeoff. If it's not, a little side-to-side rotation usually fixes it.

As long as the tube is inserted to the right depth (easy enough to check on the tracheal side), this doesn't take any longer than placing a LDLT.
 
Sergio99 said:
...The rest of us dread placing a right sided DLT...
Click to expand...
That is unfortunately sad. At the institutions I have been at, the attendings looked for a reason to place a right side tube so the residents could become very proficient and comfortable.

On the flip side, I have found those that dreaded the right-side tube were the same individuals that regularly had more difficulty placing a left side tube. They generally had less bronch skill and less understanding of the anatomy they were seeing through the bronch.

I am not in anesthesia. But as a surgery resident, the anesthesia attendings allowed me to place a few right side tubes. It took me a little more time then the left side tubes but was not particularly a complex ordeal.... otherwise, I am not sure why the attending allowed me to do it. Also, I do not believe they would allow the nurse anesthesia do it if it was such an issue.
 
proman said:
This isn't the best practice, but if a resident needs practice with a RDLT, this is a good enough reason.
Click to expand...
sevoflurane said:
...I will use a BB before a right sided DLT...
Click to expand...
jennyboo said:
For those who use a bronchial blocker before they would resort to a right-sided DLT, is this a "comfort level" decision or a clinical decision? In other words, what is your reasoning?...
Click to expand...
Click to expand...
I am really curious about this as well. The minimally invasive chest cases and open pneumonectomies I have seen, the patients were not particularly healthy specimens (COPD/age/etc...). They would use a right side tube to assure nothing in the left airway and good isolation. It is a strong statement to say "not best practice".... but ~Ok if you want to do it for teaching reasons. If it isn't best practice.....??? Again, is this just a comfort level issue, i.e. not best practice because the anesthesiologist isn't very good at the practice or something else?
 
JackADeli said:
I am really curious about this as well. The minimally invasive chest cases and open pneumonectomies I have seen, the patients were not particularly healthy specimens (COPD/age/etc...). They would use a right side tube to assure nothing in the left airway and good isolation. It is a strong statement to say "not best practice".... but ~Ok if you want to do it for teaching reasons. If it isn't best practice.....??? Again, is this just a comfort level issue, i.e. not best practice because the anesthesiologist isn't very good at the practice or something else?
Click to expand...

It's not the best practice because you are at a higher risk of misplacement (these move a lot, both left and right-I'm sure you've seen that). If these people are such pulmonary cripples, I wouldn't accept that risk, especially since I disagree that a right tube provides better left isolation. Ultimately, in the absence of an absolute indication for right DLT, the correct tube is the one the anesthesiologist is most comfortable placing and managing.

There's this article:

The Incidence of Right Upper-Lobe Collapse When Comparing a Right-Sided Double-Lumen Tube Versus a Modified Left Double-Lumen Tube for Left-Sided Thoracic Surgery
Anesth Analg. 2000 Mar;90(3):535-40.

The incidence of malpositions, (five versus two), need for fiberoptic bronchoscopy, time for adequacy of left lung collapse, and incidence of intraoperative right upper-lobe collapse (0) did not significantly differ between R-DLT and L-DLT groups. We conclude that R-DLTs can be used for left-sided thoracic surgery without an increased risk of right upper-lobe collapse. Our data suggest that R-DLTs may be more prone to intraoperative dislodgment/malposition than L-DLTs; however, in all cases, correction of malposition was easily achieved.

But then, there's this article:

Right- and Left-Sided Mallinckrodt Double-Lumen Tubes Have Identical Clinical Performance. Ehrenfeld, Jesse M. MD; Walsh, John L. MD; Sandberg, Warren S. MD, PhD. Anesth Analg 2008; 106: 1847-52

CONCLUSIONS: The supposition that left-sided double-lumen tubes are safer than right-sided tubes when intraoperative hypoxemia, hypercapnea, and high airway pressures are used as criteria for safety is not supported by our data comparing the two types of tubes from one manufacturer.
 
First, Thank you Proman for your reply.
proman said:
It's not the best practice because you are at a higher risk of misplacement (these move a lot, both left and right-I'm sure you've seen that)...
Click to expand...
So, you are saying double lumen in general is not best practice? Again, not an anesthesiologist but have not seen difference in the two sliding propensity. I have only seen a difference in individuals' ability to address a dislodgement/malposition during the case.
proman said:
...Ultimately, in the absence of an absolute indication for right DLT, the correct tube is the one the anesthesiologist is most comfortable placing and managing...
Click to expand...
This again goes back to the issue that this is an anesthesiologist comfort issue and not really a data driven position then.
proman said:
...There's this article:

The Incidence of Right Upper-Lobe Collapse When Comparing a Right-Sided Double-Lumen Tube Versus a Modified Left Double-Lumen Tube for Left-Sided Thoracic Surgery
Anesth Analg. 2000 Mar;90(3):535-40.

....We conclude that R-DLTs can be used for left-sided thoracic surgery without an increased risk of right upper-lobe collapse. Our data suggest that R-DLTs may be more prone to intraoperative dislodgment/malposition than L-DLTs; however, in all cases, correction of malposition was easily achieved.

But then, there's this article:

Right- and Left-Sided Mallinckrodt Double-Lumen Tubes Have Identical Clinical Performance. Ehrenfeld, Jesse M. MD; Walsh, John L. MD; Sandberg, Warren S. MD, PhD. Anesth Analg 2008; 106: 1847-52

CONCLUSIONS: The supposition that left-sided double-lumen tubes are safer than right-sided tubes when intraoperative hypoxemia, hypercapnea, and high airway pressures are used as criteria for safety is not supported by our data comparing the two types of tubes from one manufacturer.
Click to expand...
I appreciate you taking the time to provide these references. Not being in anesthesia, i would not readily view this literature. Again, thank you.
 
Here is the answer to all your questions:
The only reason to place a right sided DLT is scientific masturbation.
There is nothing wrong with masturbating when you have time or when you are some guy who placed 3 DLTS and suddenly think that you are an expert but in the real world we usually try to keep the masturbation to a minimum.
Thank you for your input though.




JackADeli said:
First, Thank you Proman for your reply.So, you are saying double lumen in general is not best practice? Again, not an anesthesiologist but have not seen difference in the two sliding propensity. I have only seen a difference in individuals' ability to address a dislodgement/malposition during the case.This again goes back to the issue that this is an anesthesiologist comfort issue and not really a data driven position then.I appreciate you taking the time to provide these references. Not being in anesthesia, i would not readily view this literature. Again, thank you.
Click to expand...
 
Planktonmd said:
Here is the answer to all your questions:
The only reason to place a right sided DLT is scientific masturbation.
There is nothing wrong with masturbating when you have time or when you are some guy who placed 3 DLTS and suddenly think that you are an expert but in the real world we usually try to keep the masturbation to a minimum.
Thank you for your input though.
Click to expand...
I'm not sure if that is directed at me. Further not sure, if it is, what your hostility is about. I am the first to say I am not an anesthesiologist and am not an expert at intubation single, double, BB, LMA, etc... I am an expert at bronchoscopy. I have asked questions similar to questions asked by others to simply ascertain the rationale. It would appear others, presumably within the field of anesthesiology have not been provided these answers either based on similar questions in this thread. I was unaware asking such a question was not allowed at all. A comment was made as to what was "not best practice". The reasoning provided was that best practice is based on 1. the anesthesiologists ~comfort/skill with different techniques and/or 2. risk of slippage. That seems fair enough as I think the original questions were fair enough. I do appreciate Proman's honest reply and providing some articles.
 
Planktonmd said:
Here is the answer to all your questions:
The only reason to place a right sided DLT is scientific masturbation.
There is nothing wrong with masturbating when you have time or when you are some guy who placed 3 DLTS and suddenly think that you are an expert but in the real world we usually try to keep the masturbation to a minimum.
Thank you for your input though.
Click to expand...

Dude... you had me rolling. Bravo Plank, Bravo. :rofl: :corny:
 
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