Dlt

[PpfSuxTube]

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What's the fastest way of placing these things?

My most reliable is DL or VL to get the thing in, then park it mid trachea. Then turn it 90 degrees left and FOB down the bronchial lumen to make sure you're in left main. Then FOB down the trachea lumen to test and see the bronchial balloon go up and down in good position.

Thats most reliable but not very quick and takes 2 FOB passes. Any thing better?

I could just go down the trachea lumen with FOB and assume the bronchial lumen will navigate to the left main?

The only times I've been caught with these or unsure is when the bronchial lumen went into right main stem inadvertently and I got all confused with the anatomy

 

[CopaceticOne]

I go down trachea side first.

 

[amyl]

I also go down the tracheal side first. Past the cords rotate left. Go down the tracheal side, get the view of the carina with the blue cuff in the left side… adjust until I get this view if not already there… watch inflation of blue cuff in real time. This has been the fastest simplest way for me.

 

[CopaceticOne]

I also go down the tracheal side first. Past the cords rotate left. Go down the tracheal side, get the view of the carina with the blue cuff in the left side… adjust until I get this view if not already there… watch inflation of blue cuff in real time. This has been the fastest simplest way for me.

Plus, if unsure where the tube is, you can easily look for the triple takeoff of the RUL

 

[cittykat]

We had these for a while and they worked very well for most patients and were very quick to place and confirm placement. Didn’t need to open an FOB in most cases. Another advantage was that we could continuously monitor the DLT position throughout the case. Downside was that if the patient had a lot of secretions and the lens got fouled, you’d have to open a FOB too which made for a very expensive case.

On average these were fastest and slickest.

Ambu® VivaSight™ 2 DLT

www.ambu.com

 

[Arch Guillotti]

I don’t do a whole lot but always look down the tracheal lumen first.

 

[Drwine]

If I have good assistance, my preferred method is to place the tip of the tube past the vocal cords with a laryngoscope, then have the taller person pass the fiberoptic scope through the bronchial lumen. I place the scope through the L mainstem bronchus, which is easy to discern because the longitudinal striations are always posterior. I use the bronchoscope as a stylet to slide the tube over. I am on the lookout for lesions or tracheal compression on the way down that might make me shift gears. I then pull out the scope and go down the other lumen to fine-tune the depth. I tend to err on the side of the tube being in a little too deep before flipping the patient and fine-tuning once in position. With practice and communication with whoever is helping me, I can do this in seconds. In the clinical realm, my goal is to achieve 100% success and avoid wasting time fixing instances where other methods fail. Blood and secretions are the enemy of any video endoscopic technique, so I prioritize seeing virgin anatomy and avoid any land mines.

 

[PpfSuxTube]

Ok thanks. So some mentioned tracheal 1st.

So I assume if the look down the tracheal confirms good placement then thats the only look required? And the "first look" becomes the only look?

Does going down the bronchial add anything if you have seen the carina via the tracheal view and then also seen the bronchial Lumen enter the left main via that same tracheal view?

 

[ucladoc2b]

Ok thanks. So some mentioned tracheal 1st.

So I assume if the look down the tracheal confirms good placement then thats the only look required? And the "first look" becomes the only look?

Does going down the bronchial add anything if you have seen the carina via the tracheal view and then also seen the bronchial Lumen enter the left main via that same tracheal view?

The only time I go down the bronchial lumen is if I had poor visualization down the tracheal lumen or had a question about exact placement.

 

[pgg]

Tube past vocal cords, rotate 90, advance generously, connect ventilator, look down tracheal lumen. Most of the time (80%?) the bronchial balloon has gone the right way and I'm done.

If I can't confirm it's where I want it, I'll put the scope down the bronchial lumen, and pull everything back until I see carina, then go down the left main with the scope, then seldinger the tube into the right place, then look in the tracheal lumen once more to confirm proper depth.

The biggest challenge is the ****ty disposable scopes we use are harder to steer and have terrible suction capacity, so if there are any secretions or blood it can be very frustrating to get a view and get oriented.

 

[pgg]

Ok thanks. So some mentioned tracheal 1st.

So I assume if the look down the tracheal confirms good placement then thats the only look required? And the "first look" becomes the only look?

I always look again after the patient is lateral and the bed broken, to ensure the tube hasn't moved with all the positioning shenanigans. I often find myself advancing another cm or two to keep the bronchial cuff fully into the left main.

Does going down the bronchial add anything if you have seen the carina via the tracheal view and then also seen the bronchial Lumen enter the left main via that same tracheal view?

I don't think so. I don't routinely look.

Rarely, if I want to do some actual bronch work to clear secretions. Sometimes the surgeons will want to do a quick bronch exam and I'll watch them do it.

 

[coolforschool]

Tube past vocal cords, rotate 90, advance generously, connect ventilator, look down tracheal lumen. Most of the time (80%?) the bronchial balloon has gone the right way and I'm done.

If I can't confirm it's where I want it, I'll put the scope down the bronchial lumen, and pull everything back until I see carina, then go down the left main with the scope, then seldinger the tube into the right place, then look in the tracheal lumen once more to confirm proper depth.

The biggest challenge is the ****ty disposable scopes we use are harder to steer and have terrible suction capacity, so if there are any secretions or blood it can be very frustrating to get a view and get oriented.

I’ve done a ton of thoracic for the past 5 years including high volume lung transplants. This is my exact flow. I always confirm RUL as well as bronchial cuff inflation at the carina under scope visualization.

We have the Olympus P190 scopes and the tower for most cases. I refuse to use the Glidescope disposable ones unless it’s an emergency for those very reasons.

One trick I’ve done to be more expeditious when getting “lost” in the airway: keep the scope in the tracheal lumen, withdraw the DLT, go past the bronchial lumen (which is now in the main trachea) with the scope to visualize the carina, confirm RUL, then re-advance the DLT/rotate it left to guide the bronchial side down the left mainstem. 99% of the time, it goes to the proper place with slight rotation +/- external rightward tracheal displacement without having to remove the scope to put it down the bronchial side.

Usually the only times I have to go down the bronchial side is to suction out secretions or confirm that I’m not too deep and missing the LUL takeoff.

 

[sethco]

I almost never go down the Bronchial side. I DL, insert past the cords, then rotate and advance until I hit resistance. Then FOB through the Tracheal side. 95% of the time I'm in the correct location, so I inflate the balloon while looking in the Tracheal side to make sure the balloon didn't herniate into the right side. Very rarely do I have to use a Bronchial Blocker, tube exchange, or VL

(Sorry had to edit for my own stupidity)

 

[abolt18]

What's the fastest way of placing these things?

My most reliable is DL or VL to get the thing in, then park it mid trachea. Then turn it 90 degrees left and FOB down the bronchial lumen to make sure you're in left main. Then FOB down the trachea lumen to test and see the bronchial balloon go up and down in good position.

Thats most reliable but not very quick and takes 2 FOB passes. Any thing better?

I could just go down the trachea lumen with FOB and assume the bronchial lumen will navigate to the left main?

The only times I've been caught with these or unsure is when the bronchial lumen went into right main stem inadvertently and I got all confused with the anatomy

I do the same as you. Bronchial lumen right after the tube passes cords, then seldinger over scope into left mainstem. Glance down tracheal to confirm depth and check RUL. Tape, turn lateral, go down tracheal to adjust and inflate cuff, immediately start OLV. Could probably do like I used to (and others do too) and just advance blind then check via tracheal. But then you have to take longer adjusting it. I don't know the right answer. I suspect having to pull it back and fix it when it goes down the wrong side likely takes longer than the way I currently do it.

 

[PpfSuxTube]

So it seems theres at least moderate (maybe more) agreement that a single look down the tracheal is sufficient in the majority of cases. And bronchial look rarely required .

Thanks all!

 

[DrN2O]

What's the fastest way of placing these things?

The fastest way is the way you do it after you have done hundreds of these. For left DLT, it seems most of us prefer the tracheal look first because the RUL/BI is the most definitive anatomy in 95% of patients. I would still look down the bronchial side to ensure the tip is not too deep and up against a wall/obstructing one of the lobes, especially since I like to place the DLT deep because the lateral positioning will cause it to migrate out. The surgeon will be more concerned about your lung isolation than the extra 30 seconds of FOB.

I have to disagree with the one that uses an assistant to drive the scope during routine intubation. Unless it's an OHNS, pulm or CT surgeon, I don't have the luxury/trust for an assistant. For routine cases, CT should be available to avoid any tracheal surprise.

 

[GassYous]

so I prioritize seeing virgin anatomy and avoid any land mines.

I also prioritize seeing virgin anatomy

 

[2buckchuck]

Once it’s in (past cords and advanced to a reasonable depth), look down tracheal side. If everything looks normal I leave it a little deep and tape the bejesus out of it. I inflate the bronchial cuff looking at it with the scope after we have turned lateral and done all the bed flexing and positioning adjustments we are gonna do. IME the DLT pulls out a little after all the positioning; as a resident I did many a case where everything looked good supine but the isolation was bad and the bronchial cuff kept popping back from the carina a little during the case. Also worked with a thoracic surgeon who wanted to have the final say on tube depth; looked perfect supine but always pulled back lateral. Got in the habit of inconspicuously pushing it in while taping it.

 

[cittykat]

Unless there is an anatomic variant like a pig bronchus, there are only 4 possible scenarios (correct side, wrong side, too deep, too shallow). Should be an easy one for AI. Much easier than chess or IMO problems. Watch out guys n gals!! 😉

 

[Katheudontas parateroumen]

I agree that the fastest way is the way you are used to. I also intubate VL or DL doesn’t matter too much (usually DL because we only have hyper angled VL so angle is off with DLT). One past cords, hopefully in mid trachea, I FOB through the tracheal lumen, confirm L and R main, and then I advance the DLT into the L, and the inflate seeing the balloon not herniating out too much. I only go through the bronchial cuff if I’m having trouble getting to the L or need to adjust the depth.

I on a side note, I think sizing DLT is a little arbitrary. I think 39 fits basically everyone. Unless <5ft or over 6ft. I have looked into CT tracheal size to determine DLT size though.

 

[abolt18]

Realistically I use an EZ blocker 75%+ of the time. Right-side case I'll glance at the CT and make sure I have a large enough area to land the balloon before RUL takeoff. If it's questionable, I'll do a DLT.

 

[pgg]

I use the smallest DLT that I think I can get away with. Even the smaller ones are still huge and I feel sad for the vocal cords every time I jam one in.

37s mostly

Can't remember the last time I put a 41 in someone.

 

[DG51]

I agree that the fastest way is the way you are used to. I also intubate VL or DL doesn’t matter too much (usually DL because we only have hyper angled VL so angle is off with DLT). One past cords, hopefully in mid trachea, I FOB through the tracheal lumen, confirm L and R main, and then I advance the DLT into the L, and the inflate seeing the balloon not herniating out too much. I only go through the bronchial cuff if I’m having trouble getting to the L or need to adjust the depth.

I on a side note, I think sizing DLT is a little arbitrary. I think 39 fits basically everyone. Unless <5ft or over 6ft. I have looked into CT tracheal size to determine DLT size though.

Agree with you about arbitrary sizing, but I'll put a 35 in just about every adult

 

[Katheudontas parateroumen]

Agree with you about arbitrary sizing, but I'll put a 35 in just about every adult

I never used 35 much. 37 is like my “size 7” tube and 41 is like my “8”. You’ve never run into issues where you can’t get a good seal with a 35?

 

[Katheudontas parateroumen]

I use the smallest DLT that I think I can get away with. Even the smaller ones are still huge and I feel sad for the vocal cords every time I jam one in.

37s mostly

Can't remember the last time I put a 41 in someone.

That’s true. I’d agree to use smallest one that works. For elective cases I usually use a 6 or 6.5 tube. Idk just makes sense.

 

[sethco]

Only mildly derailing the thread, what does everyone do for difficult Intubations needing Lung isolation? I've never really been very successful in using VL with double lumen tubes. Tube exchanging from a single to a double can also be very difficult with a flimsy Cook airway exchange catheter. In the rare case I have trouble with the double lumen Insertion, I just use a Bronchial Blocker with the single lumen. Wonder if anyone does anything different or has any tricks for the difficult Intubations

 

[coolforschool]

Only mildly derailing the thread, what does everyone do for difficult Intubations needing Lung isolation? I've never really been very successful in using VL with double lumen tubes. Tube exchanging from a single to a double can also be very difficult with a flimsy Cook airway exchange catheter. In the rare case I have trouble with the double lumen Insertion, I just use a Bronchial Blocker with the single lumen. Wonder if anyone does anything different or has any tricks for the difficult Intubations

I do Glidescope + fiberoptic with the Olympus P190 scope for known anterior/difficult airways. Usually obtaining the view is easy, but getting the tube in through the anterior vocal cords is the challenge as the DLTs tend to bend down into the posterior oropharynx as you’re advancing the tube. Glidescope’s disposable fiberoptic scopes and the Cook exchange catheters are too flimsy to provide the structure necessary to advance through the cords. I’ll usually get the view and have a tech/RN hold the Glidescope blade still, so I can manipulate the scope and DLT. Knock on wood, I’ve never not been able to intubate someone using Glide + P190.

One old trick I’ve done if the scope isn’t available is to use VL, park the bronchial cuff at the posterior arytenoids, remove the stylet slightly, and then stick a finger into the mouth to hook/lift the DLT up and provide some posterior support as I’m advancing the tube, especially if the tube has bent down instead of advancing through the cords on prior attempts.

 

[2buckchuck]

Only mildly derailing the thread, what does everyone do for difficult Intubations needing Lung isolation? I've never really been very successful in using VL with double lumen tubes. Tube exchanging from a single to a double can also be very difficult with a flimsy Cook airway exchange catheter. In the rare case I have trouble with the double lumen Insertion, I just use a Bronchial Blocker with the single lumen. Wonder if anyone does anything different or has any tricks for the difficult Intubations

One thing I started doing when using VL was putting the DLT in the mouth first (before the glidescope or McGrath). This sounds stupid, BUT the problem I have sometimes is that the DLT with VL needs kind of a hyperangulated bend to get the tip pointed at the vocal cords. It can be a tight fit to pass a DLT when the blade is already in the mouth, and trying to snake the DLT past the teeth and around the bend in the back of the throat I would lose the bend and couldn’t get the tube in. When I put the DLT in the mouth first, there’s ample space and I can preserve the bend in the tube. Then I slide the video scope in beside the tube and usually it works well.

 

[DG51]

I never used 35 much. 37 is like my “size 7” tube and 41 is like my “8”. You’ve never run into issues where you can’t get a good seal with a 35?

Hasnt been an issue for me, although I will put an extra cc or two in the bronchial cuff if needed, which might be frowned upon by some. We aren't doing all day esophagectomies, transplants, etc. at my hospital so I feel like the risk of mucosal ischemia is fairly low and this is a nice trade off for reducing the risk or hoarseness and/or VC injury.

 

[ucsfgaspain]

Only mildly derailing the thread, what does everyone do for difficult Intubations needing Lung isolation? I've never really been very successful in using VL with double lumen tubes. Tube exchanging from a single to a double can also be very difficult with a flimsy Cook airway exchange catheter. In the rare case I have trouble with the double lumen Insertion, I just use a Bronchial Blocker with the single lumen. Wonder if anyone does anything different or has any tricks for the difficult Intubations

I use the blue plastic bougie and bend the tip straight and use that as a tube exchanger. If I don't have a blue bougies, I'll use a bigger and longer yellow tube exchanger . Also use a mac blade to create space when railroading dlt and also use a tooth guard so you don't rip your tracheal tube on the way in. Haven't had difficulty with that.

 

[ucsfgaspain]

In my old age, I've lost a lot of the ego. So if I ever get lost, I'm friends with my thoracic surgeons so I just say I don't know where the f*ck I am. I'm sure they don't want to watch a monkey humping a soccer ball. So why don't you cut to the chase, and and let them drive the fiber? Makes for much quicker placements..

Couple other old school tricks I use. I secure my tube higher on the shaft of the dlt and pull it down towards the mouth, so there's tension keeping the tube in. Also I mark my DLT with a sharpie at the the lips so I reference marker, when I'm f*cking around with positioning under the drapes. It allows me to not lose track of my depth. Also just drive the systemic blood pressure higher when you have sketchy oxygenation on one lung. Don't know why it works, but it just does.

 

[Guillemot]

I don't do a lot of thoracic, but I generally size my tubes on the smaller side. 37F for men and 35F for women. The tubes are the same length, so upsizing for height/depth is not needed. One may need to add in more air to a cuff, but AFAIK this doesn’t translate to increased pressure exerted against the bronchial and/or tracheal walls unless the extra air is added in excess of what is needed to get a seal. The pilot balloon being only mildly turgid should be enough to get an adequate seal.

Regarding, more difficult/anterior airways, the smaller tube size definitely makes it easier to place.

If it’s really truly difficult then SLT with BB would be necessary, but that doesn’t seem to happen often.

 

[cchoukal]

. I'm sure they don't want to watch a monkey humping a soccer ball.

If you think I'm not stealing that, you're dead wrong.

 

[ucsfgaspain]

If you think I'm not stealing that, you're dead wrong.

Yeah, it's a whole lot of futile movement and effort... but no satisfaction for anyone🙂

 

[Iso4ane]

Little late to the party agree with tracheal first, then bronchial to confirm if not too deep. I also will leave it a little deep prior to repositioning, as it easier to pull a tube out than push it in when the patient is lateral.

For things that haven’t been discussed yet. I like taping the tube to the operative side, as it gives you easier access for repositioning and retapjng.

Also if you get lost, pull back into the tube and look for the flat part as that’ll should be midline. Like (db), for left DLT flat bit should be on the right when in the bronchial lumen.

 

[DrN2O]

Also I mark my DLT with a sharpie at the the lips so I reference marker, when I'm f*cking around with positioning under the drapes. It allows me to not lose track of my depth.

Consider it also stolen.

Also just drive the systemic blood pressure higher when you have sketchy oxygenation on one lung. Don't know why it works, but it just does.

I just tell them higher BP means more perfusion, to the vented lung, OR more vasoconstriction to enhance HPV. Never say both to the same person though.

 

[gunnershow]

Consider it also stolen.


I just tell them higher BP means more perfusion, to the vented lung, OR more vasoconstriction to enhance HPV. Never say both to the same person though.

I think it's due to the 6th cause of hypoxemia - low SVO2. Usually doesn't matter, but when combined with a 50-80% shunt, you're gonna see the clinical relevance.

 

[Iso4ane]

was

Also just drive the systemic blood pressure higher when you have sketchy oxygenation on one lung. Don't know why it works, but it just does.

i have noted this too. I’ve also assured it was a dead space sort of issue, as you increase blood pressure you drive more blood in the the well-ventilated areas (which have slightly higher intra pulmonary pressure and caused the blood flow to decrease through those areas when the pressure dropped.)