Double lumen tube placement/cofirmation

[XRanger]

Just wanna see how ya’ll place a double lumen tube. Insert it blind then go through the tracheal lumen to check for carina? Do you insert it just past the vocal cords and then go through the bronchial lumen and guide the DLT to the left bronchus? Other??

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[drmwvr]

... insert it just past the vocal cords and then go through the bronchial lumen and guide the DLT to the left bronchus? Other??

This way. Unless it's a right sided tube.

 

[deleted162650]

Tube through cords. FOB through tracheal lumen. Advance tube watching the bronchial side slide into the L-Main. Stop right when the close edge of the cuff is at the carina. Done.

 

[zzsleepytinizz]

I DL and place the tube through the vocal cords while turning counterclockwise 90 degrees, and then I confirm placement with fiberoptic.

 

[2Fast2Des]

Our CTA attendings don't allow us to do it that way. We have to intubate, push DLT all the way in, listen to BS, Fiberoptic in, move tube back and forth to place correctly. I think fellows who tried to push the FO immediately after cords got push back that its not the way its done here.

 

[dhb]

Our CTA attendings don't allow us to do it that way. We have to intubate, push DLT all the way in, listen to BS, Fiberoptic in, move tube back and forth to place correctly. I think fellows who tried to push the FO immediately after cords got push back that its not the way its done here.

Ridiculous.

 

[drmwvr]

Our CTA attendings don't allow us to do it that way. We have to intubate, push DLT all the way in, listen to BS, Fiberoptic in, move tube back and forth to place correctly. I think fellows who tried to push the FO immediately after cords got push back that its not the way its done here.

That's a good way to learn placement and especially trouble shoot placement. When there is no pathology, you'll bullseye the correct bronchus and depth nearly every time. When there is pathology like an empyema or pneumothoraces, things can get confusing. Distorted anatomy, swelling and inflammation, blood/puss in the airway all conspire to delay correct placement. Having directly observed the distal balloon enter the intended bronchus is valuable when trying to tease out a confusing problem (like an un- diagnosed pneumothorax on the non-operative side.) At the end of the day, when you just don't know where you are, you back the tube out to "normal" depth, identify the mainstem bronchi and either advance under direct vision or Seldinger the tube over the scope into the correct airway.

For my money, I'd rather do that the first time rather than add steps.

 

[pgg]

90% of the time, I put the DLT in, advance it all the way, then put the scope through the tracheal lumen, ID the carina and RUL, then adjust depth to put the bronchial cuff where it belongs.

With secretions or blood I do the same, but it’s harder and I have to connect the suction to the scope. Every once in a while I have to pull the tube back, scope through the bronchial lumen, find the left side, and advance the tube over the scope.

Always simple, not always easy.

 

[Maverikk]

I had an attending in residency who made us do it the old fashioned way: listen to breath sounds. Put tube in. Inflate both cuffs, ventilate tracheal lumen. If you hear it on the right, not on the left you're good. If you hear it on the left advance until you don't. I thought it was silly because we scoped anyway afterward but now I appreciate it, it's faster than scoping and I never had it fail. If your scope doesn't work it's good to be able to do know the motions to do it quickly

 

[drmwvr]

I had an attending in residency who made us do it the old fashioned way: listen to breath sounds. Put tube in. Inflate both cuffs, ventilate tracheal lumen. If you hear it on the right, not on the left you're good. If you hear it on the left advance until you don't. I thought it was silly because we scoped anyway afterward but now I appreciate it, it's faster than scoping and I never had it fail. If your scope doesn't work it's good to be able to do know the motions to do it quickly

It's as good as any other way, but moving the tube with the cuffs inflated increases the risk of airway trauma. When I teach this technique, I advise leaving the cuffs down and turning up the FGF.

 

[Radar26]

A rep was at our hospital and had a DLT with a camera just past the tracheal cuff. I was able to DL and then immediately turn to the screen and watch as I advanced the bronchial cuff into the left bronchus. I also watched as the bronchial cuff herniated into the trachea during the case and corrected it even before the peak pressures changed- although these tubes cost double a normal DLT and the camera is shot after it gets covered in tracheal secretions (which also happened during my case)

 

[Ronin786]

A rep was at our hospital and had a DLT with a camera just past the tracheal cuff. I was able to DL and then immediately turn to the screen and watch as I advanced the bronchial cuff into the left bronchus. I also watched as the bronchial cuff herniated into the trachea during the case and corrected it even before the peak pressures changed- although these tubes cost double a normal DLT and the camera is shot after it gets covered in tracheal secretions (which also happened during my case)

Sounds like a colossal waste of money. You can keep the scope lodged in the tube to watch positioning during the case.

 

[nimbus]

Sounds like a colossal waste of money. You can keep the scope lodged in the tube to watch positioning during the case.

Not necessarily. Dlt(175)+single use bronchoscope(250) might be more than that tube. We are transitioning to single use bronchoscopes because we spend so much repairing our reusable ones.

 

[partydoc]

Not necessarily. Dlt(175)+single use bronchoscope(250) might be more than that tube. We are transitioning to single use bronchoscopes because we spend so much repairing our reusable ones.

A DLT IS 175?

 

[nimbus]

A DLT IS 175?

Yeah. At least that’s how much we pay. EZ blocker is $150 which seemed like a lot to me. So I asked our supply guy how much the DLT is. We are in the wrong business....

Edit:

Maybe I was given incorrect information...this site lists it for $113.


https://www.tri-anim.com/portex-end...tylet-group-24937-3775.aspx?search=70-198-37L

 

[pgg]

We are transitioning to single use bronchoscopes because we spend so much repairing our reusable ones.

We made that switch also.

If a DLT with a camera costs less than the disposable bronchoscopes ... sounds like a win. Until a gob of snot gets on the tube's camera and you need to get out a disposable bronchoscope anyway.

 

[partydoc]

We made that switch also.

If a DLT with a camera costs less than the disposable bronchoscopes ... sounds like a win. Until a gob of snot gets on the tube's camera and you need to get out a disposable bronchoscope anyway.

DLT + disposable sounds like the way to go. Forget that tube with the camera

 

[fakin' the funk]

Tube through VC, scope through bronchial, drive to just short of LMSB bifurcation. Tape. Turn. Check tracheal. OLV.

 

[drmwvr]

We've gone to the disposable scopes and are generally not unhappy with the change. The biggest issue is that the entire thing is white which reflects the light and washes out the image. You can adjust the contrast and brightness to a certain degree, but in difficult cases, you have to turn the room lights down. We're looking for black scopes if these folks can't deliver, but oddly, no one makes them.

 

[Psai]

We've gone to the disposable scopes and are generally not unhappy with the change. The biggest issue is that the entire thing is white which reflects the light and washes out the image. You can adjust the contrast and brightness to a certain degree, but in difficult cases, you have to turn the room lights down. We're looking for black scopes if these folks can't deliver, but oddly, no one makes them.

Just dip them in black paint

 

[Noyac]

I haven’t read all the posts so forgive me if this is redundant. I place the DLT all the way down, starting with the bronchial lumen at 12 o’clock. Once past the cords I turn it to 9 o’clock. Advance to gentle resistance, inflate the cuffs and check placement with ventilation and lung isolation. If all is good then I allow surgery team to position the pt. After the pt is positioned is when I will pull out the FOB. I watch people futz around with the FOB before positioning and then have to do it all over again after. I don’t like to waste my time much less anyone else’s time.

 

[fakin' the funk]

I haven’t read all the posts so forgive me if this is redundant. I place the DLT all the way down, starting with the bronchial lumen at 12 o’clock. Once past the cords I turn it to 9 o’clock. Advance to gentle resistance, inflate the cuffs and check placement with ventilation and lung isolation. If all is good then I allow surgery team to position the pt. After the pt is positioned is when I will pull out the FOB. I watch people futz around with the FOB before positioning and then have to do it all over again after. I don’t like to waste my time much less anyone else’s time.

Anecdotal: inflating both cuffs right away and doing so in a spot where it seems like the DLT is not trying to move out (observe tube at lip as you inflate bronchial) really helps prevent dislodging during turning.

 

[deleted162650]

these tubes cost double a normal DLT and the camera is shot after it gets covered in tracheal secretions (which also happened during my case)

Until a gob of snot gets on the tube's camera and you need to get out a disposable bronchoscope anyway.

The Ambu rep was at our place this am. He said there are 5 tiny ports around the camera at the distal end which you can flush with saline (like a little shower) to wash off the goobers. I have no idea how well it works.

The biggest issue is that the entire thing is white which reflects the light and washes out the image.

I mentioned this to the rep who said the problem isn't the white scope, but rather the image processing software on the first generation. Of course this is now fixed/improved in generation 2 although the scope remains white. Maybe it's true, or maybe he's just trying to sell the new version.