Wrong end? Double lumen tube exchange catheter

[DrN2O]

The discussion on whether to use the straight end of the wire for placing central lines reminded me an argument about what's the proper way of using the DLT exchange catheter from Cook. Someone showed me that you should stick the green, stiffer end down a SLT before exchange it for a DLT. I was always taught to put the blue, floppier end down to avoid tracheal injury. But I stopped using it precisely because the floppy end is never that helpful for reinserting the DLT. Am I wrong?

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[abolt18]

The discussion on whether to use the straight end of the wire for placing central lines reminded me an argument about what's the proper way of using the DLT exchange catheter from Cook. Someone showed me that you should stick the green, stiffer end down a SLT before exchange it for a DLT. I was always taught to put the blue, floppier end down to avoid tracheal injury. But I stopped using it precisely because the floppy end is never that helpful for reinserting the DLT. Am I wrong?

Soft floppy end EVERY time. It's made that way for a reason, so you don't injure the lungs. Just stick it in far enough that you don't have the floppy part in the oropharynx and the exchange should be easy.

 

[PpfSuxTube]

The discussion on whether to use the straight end of the wire for placing central lines reminded me an argument about what's the proper way of using the DLT exchange catheter from Cook. Someone showed me that you should stick the green, stiffer end down a SLT before exchange it for a DLT. I was always taught to put the blue, floppier end down to avoid tracheal injury. But I stopped using it precisely because the floppy end is never that helpful for reinserting the DLT. Am I wrong?

Whatever the answer is, some flute will tell you your position is indefensible anyways...

Good luck

 

[Hoya11]

The discussion on whether to use the straight end of the wire for placing central lines reminded me an argument about what's the proper way of using the DLT exchange catheter from Cook. Someone showed me that you should stick the green, stiffer end down a SLT before exchange it for a DLT. I was always taught to put the blue, floppier end down to avoid tracheal injury. But I stopped using it precisely because the floppy end is never that helpful for reinserting the DLT. Am I wrong?

why not a bougie with a glidescope?

 

[Leinie]

why not a bougie with a glidescope?

I've not tried this. Does it fit through the tracheal lumen? I can't imagine it is either small enough or long enough for the bronchial lumen.

 

[ucsfgaspain]

Don't overcomplicate things. Either end will work. Soft, hard don't matter. If you manage to perf the trachea, you clearly don't have very good propiceptive feel and I think you've managed to f+ck things up on other procedures as well IMHO. I use the blue bougie all the time for DLT exchanges although it is shorter and so you have to finesse it more since you don't have as much length to work with.

The hangups that I think people have with the "seldinger" method is not creating space in the oropharynx to pass the DLT. I often will use a mac blade. Tearing the tracheal cuff on the incisors as they go through is the common F=ck up. Best protection is just to be cognizant of the risk of this. the other is to use that plastic bite guard or even tape the alcohol wipe molded to the the "top" teeth.

 

[caligas]

Get glidescope view, pass lubed exchanger of choice (green 14 F double lumen exchanger is ideal but won’t pass some 37 tubes), pull single lumen tube, place DL under view of glide scope.

 

[abolt18]

Get glidescope view, pass lubed exchanger of choice (green 14 F double lumen exchanger is ideal but won’t pass some 37 tubes), pull single lumen tube, place DL under view of glide scope.

I think this is ideal, because then you can visualize as the DLT is passing the cords and if it's getting caught you can adjust and manipulate it gently. No jamming through.

 

[JOHNBROCHILL]

I have never had luck tube exchanging a DLT with the glidescope. The tip of DLT will go through cords and then the whole tube will just bend as I push. Despite spinning, thyroid pressure, whatever tricks I can I often end up with a flexible tube bending in the hypopharynx and not advancing forward into the trachea.

 

[abolt18]

I have never had luck tube exchanging a DLT with the glidescope. The tip of DLT will go through cords and then the whole tube will just bend as I push. Despite spinning, thyroid pressure, whatever tricks I can I often end up with a flexible tube bending in the hypopharynx and not advancing forward into the trachea.

Smaller double lumen tube I guess.

The one thing I'll say is never force it! Had a lady in residency who got transferred in from St. Elsewhere after difficulty with DLT placement caused a huge tear in the junction between the muscular and cartilaginous portions of the trachea. It was like 4-6cm long if I remember correctly. They had aborted placing a DLT, placed a SLT, and woke her up and took her to PACU. She decompensated and was reintubated in PACU. Came to us with massive subQ emphysema and respiratory failure.

Kept the lady on VV ECMO after surgical repair with no secured airway for 7-10 days just so it would heal and to avoid positive pressure.

 

[urge]

The discussion on whether to use the straight end of the wire for placing central lines reminded me an argument about what's the proper way of using the DLT exchange catheter from Cook. Someone showed me that you should stick the green, stiffer end down a SLT before exchange it for a DLT. I was always taught to put the blue, floppier end down to avoid tracheal injury. But I stopped using it precisely because the floppy end is never that helpful for reinserting the DLT. Am I wrong?

Blue end of course.

And you pass it through the bronchial lumen on the DLT.

I’m thinking the person who told you to use the stiff end must be trying to pass it through the tracheal lumen of the DLT and struggling all along.