DLT size choice, tips for placement, etc...

[VentdependenT]

Do you all choose DLT's based on pt height and gender or do you use different criteria (tracheal lumen size on a CT scan for example)?

Seems like for women we go 35 mainly then 37 (haven't placed a 37 in a female yet). For the fellas its a 37 (ususally) or a 39.

We go Mainly Left DLT. Today we placed a Right for the hell of it. It was a little tricky after the turn but we finagled it in there.


Today we had a 6'0 100kg 82 y/o guy who had a crap MP for esophageal resection. Could only see epiglottis with a MAC. A miller left absolutely NO room to place the DLT. We then went to pedi fiberscope, cut the DLT down so as to allow manupulation of scope, once down at cords the damn thing WOULDN'T pass. It just kept bouncing off the glottis with a 39. Same with a 37.

Eventually we had to use a blocker.

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[coccygodynia]

I base my DLT on both height and sex - being a 6'0 female, I'd probably need a 37. Haven't been given the option to choose the size from a CT scan. Like you, I always have one size up and down readily available. Seems like my success rate with bronchial blockers lately (and by success, I mean optimal surgical exposure) has been on the decline. And I use a left DLT about 90% of the time.

 

[urgewrx]

6'0 female, I'd probably need a 37.

I'm sure you can get a 41 there.

 

[coccygodynia]

I'm sure you can get a 41 there.

Not if you're putting it in ... more like a 28Fr.

 

[UTSouthwestern]

I select my DLT's by height and weight and would prefer to downsize it if there is any question as too large of a DLT, in addition to causing significant trauma during placement also tends to not sit properly in the bronchus and frequently will slide out.

Aside from the basics of bending and lubricating the tip, removing the stylet upon the tip passing the cords, etc., I have found that rotating clockwise instead of counter clockwise as we are taught allows the tip to more easily past the cords and proximal portion of the trachea.

Always reconfirm placement by FOB after you secure the tube and secure it with tape above and below the tube to make sure that it stays firmly seated.

I use DLT's at least five times a week for a variety of cases (thoracotomies, thoracoscopies, closed chest MAZE procedures, Ivor Lewis esophagectomies, transplants, etc.) and since erring on the side of undersizing, have had very little problems with them.

If you use a bronchial blocker or Univent, just be sure that you take the patient off the ventilator for a few seconds before you inflate the bronchial cuff. If not, your lung will be incompletely collapsed and the central channel of the blocker may require attachment of suction to more completely collapse the lung, and that may not happen if even a little debris gets stuck to the tip of the blocker.

 

[VentdependenT]

I select my DLT's by height and weight and would prefer to downsize it if there is any question as too large of a DLT, in addition to causing significant trauma during placement also tends to not sit properly in the bronchus and frequently will slide out.

Aside from the basics of bending and lubricating the tip, removing the stylet upon the tip passing the cords, etc., I have found that rotating clockwise instead of counter clockwise as we are taught allows the tip to more easily past the cords and proximal portion of the trachea.

Always reconfirm placement by FOB after you secure the tube and secure it with tape above and below the tube to make sure that it stays firmly seated.

I use DLT's at least five times a week for a variety of cases (thoracotomies, thoracoscopies, closed chest MAZE procedures, Ivor Lewis esophagectomies, transplants, etc.) and since erring on the side of undersizing, have had very little problems with them.

If you use a bronchial blocker or Univent, just be sure that you take the patient off the ventilator for a few seconds before you inflate the bronchial cuff. If not, your lung will be incompletely collapsed and the central channel of the blocker may require attachment of suction to more completely collapse the lung, and that may not happen if even a little debris gets stuck to the tip of the blocker.

Do you mainly shoot for the Left DLT unless contraindicated (R mainstem dz. Complete R lung isolation from pus/blood, etc..)?

 

[UTSouthwestern]

Do you mainly shoot for the Left DLT unless contraindicated (R mainstem dz. Complete R lung isolation from pus/blood, etc..)?

I do primarily because the takeoff of the right upper lobe is very short and very variable. If I can't place a L DLT for whatever reason, but can ventilate the left side and just need to isolate the right, I will use a blocker or Univent.

If I have a pussed out lung left lung that needs to be isolated, I will still try to make the L DLT work usually by undersizing it, to minimize trauma to inflamed tissues.

Lastly, I manage my DLT in the ICU no matter who is the attending. Last month, a CRNA in house on call at a smaller hospital put a DLT at the request of an ER doc into a patient emergently with a right bronchial bleed to isolate the left lung from the right (the patient was not exsanguinating) and left the patient in the ICU. Problem was that he forgot to inflate the bronchial cuff or did not inflate it sufficiently so by the time I received the patient in the OR three hours later, both lungs were full of blood and debris. I know that in the academic centers, leaving DLT's in place and taking patients to the ICU isn't uncommon, but check it frequently and make sure someone hasn't accidentally deflated the bronchial cuff, withdrawn the tube accidentally, or clamped the wrong lumen and defeated the entire purpose of this endeavor.

 

[VentdependenT]

Thanks UT.

I almost forgot to drop the bronchial cuff after the down lung was allowed to come up at end of surgery...coulda been bad if I forgot to deflate prior to extubation.

One more question...

Any quick and simple/basic tips for trouble shooting the DLT for when the surgeon is remarking about poor isolation/down lung commen up in his field?

 

[UTSouthwestern]

Thanks UT.

I almost forgot to drop the bronchial cuff after the down lung was allowed to come up at end of surgery...coulda been bad if I forgot to deflate prior to extubation.

One more question...

Any quick and simple/basic tips for trouble shooting the DLT for when the surgeon is remarking about poor isolation/down lung commen up in his field?

First, always clamp the surgical side before you turn the patient onto his/her side and listen for absence of breath sounds on the surgical side of the patient. After positioning the patient, listen to ascertain that the tube is still properly position and that the surgical side has no breath sounds in addition to rescoping the patient to confirm placement.

Assuming you have checked the bronchial cuff integrity, look at the field to see if a single lobe is staying up or if the entire lung is ventilating. If it is the former, you may have to aggressively suction the lung to remove any obstructing debris, or you may have to use the FOB to see if there is any obstructive lesions at the take off to that lobe that is acting as a one way valve and keeping the lobe inflated. In that case, gently push on the obstruction to see if you can move it to allow the lung to deflate. If the entire lung is ventilating and the cuff is up, first check to see if you have adequately clamped the tube leading to the non-dependent lung. Frequently, there is a leak past the clamp point and you can address that by simply adding another clamp downstream to your first one. You can also directly connect the ventilator to only the dependent lung's tube.

Always check with your FOB that you are indeed at the carina and not down the right or left main bronchus and have the tube lodged at the takeoff of a secondary bronchus. That happens frequently and you may have to tell the surgeon to stop, withdraw the tube with the FOB in place until you see the real carina or you know you have travelled so far back that it cannot possibly be in the wrong position.

In that case, reseat the DLT and advance the bronchial tip to a position that allows only a slight amount of the bronchial cuff to be visible at the carina. What can happen, especially if you are having to use high pressures to ventilate the down lung (i.e., super obese patients - like my 550 pound man for right lung decortication) is that even with the cuff up, a small amount of air is leaking around the blue cuff and being forced into the surgical lung. With each breath, the leaks will become cumulative. If its too late to replace the tube with a larger one or a blocker, you may have to open both lungs to the atmosphere periodically to allow for better collapse of the lung.

 

[VentdependenT]

Thats why you the man UT.

Muchas gracias.

 

[huktonfonix]

you can also use the suction cath down the lumen of the down lung and keep it on to suction. This may give you a little better collapse