|Year : 2015 | Volume
| Issue : 4 | Page : 516-520
Double-lumen tube insertion using flexible fiberoptic bronchoscope compared with conventional blind technique in esophageal cancer patients: a randomized controlled study
Waleed M.R. Elsarraf MD
Department of Anesthesia and Surgical Intensive Care, Surgical Gastroenterology Center, Mansoura Faculty of Medicine, Mansoura, Egypt
|Date of Submission||21-May-2014|
|Date of Acceptance||12-Jan-2014|
|Date of Web Publication||29-Dec-2015|
Waleed M.R. Elsarraf
Department of Anesthesia and Surgical Intensive Care, Surgical Gastroenterology Center, Mansoura Faculty of Medicine, Gehan Street, 14799 Mansoura
Source of Support: None, Conflict of Interest: None
Double-lumen tube (DLT) is usually performed using blind placement followed by bronchoscopic position confirmation, which is time consuming and complications may occur. We assume that bronchoscopic-guided DLT placement and position confirmation will save time and complications may be less.
Patients and methods
A total of 31 patients included in this study were randomly allocated into either the conventional group (n = 15) or the bronchoscopic group (n = 16) on the basis of DLT placement; in the conventional group the DLT was inserted blindly, whereas in the bronchoscopic group the DLT was inserted under guidance of the flexible bronchoscopy passed into the bronchial lumen. Thereafter, clinical assessment was performed followed by bronchoscopic assessment in both groups. Clinical findings and bronchoscopic assessment as well as time needed for each were recorded. Hemodynamic response, oxygen saturation, and arrhythmias were also recorded.
Both groups were comparable with respect to demographic data. There was significant difference when comparing time needed for placement and confirmation of DLT in both groups. The clinical assessment was satisfactory in 12 as against 16 patients, whereas the bronchoscopic assessment revealed proper positioning in seven as against 13 patients and misplacement in eight as against three patients in the conventional and bronchoscopic groups, respectively. Hemodynamic response, oxygen saturation, and arrhythmias did not show any differences.
Flexible fiberoptic bronchoscopy could be used safely as an initial guide for placement and position confirmation; time needed for placement and confirmation as well as complications were reduced.
Keywords: double-lumen tube, fiberoptic bronchoscope, malposition, one-lung ventilation
|How to cite this article:|
Elsarraf WM. Double-lumen tube insertion using flexible fiberoptic bronchoscope compared with conventional blind technique in esophageal cancer patients: a randomized controlled study. Ain-Shams J Anaesthesiol 2015;8:516-20
|How to cite this URL:|
Elsarraf WM. Double-lumen tube insertion using flexible fiberoptic bronchoscope compared with conventional blind technique in esophageal cancer patients: a randomized controlled study. Ain-Shams J Anaesthesiol [serial online] 2015 [cited 2020 Mar 29];8:516-20. Available from: http://www.asja.eg.net/text.asp?2015/8/4/516/172673
| Introduction|| |
Double-lumen tubes (DLTs) were used successfully over years during anesthesia for lung isolation using a well-established technique. This depends on passage of the tube through the larynx then rotation of the tube 90° under direct conventional laryngoscopy. Thereafter, the anesthesiologists used to push the tube blindly into the targeted bronchus (e.g. left bronchus) followed by confirmation of proper positioning of the DLT by flexible fiberoptic bronchoscopy. However, the blind insertion of the DLT may cause damage to the trachea from overinflation of cuffs  . In addition, malposition may occur in about 34%  . Because of the controversies concerning the routine application of fiberoptic bronchoscopy in placement and position confirmation of DLT, this study was designed to test the hypothesis that the use of fiberoptic bronchoscopy as an initial guide to placement of DLT will limit the potential complications of malpositioning.
| Patients and methods|| |
This prospective randomized controlled study was conducted at Gastroenterology Surgery Center, Mansoura School of Medicine, Mansoura, Egypt over a period of 18 months. Informed patients' consents were obtained from all patients after approval from the local research and ethics committee in Mansoura Faculty of Medicine. Thirty-one patients (ASA I-II) suffering from esophageal cancer and undergoing elective total or partial esophagectomy were enrolled in this study. All patients were assessed in the preoperative visit for criteria of suspected difficult intubation using Mallampati score. Patients were excluded from the study if they had Mallampati II. Other exclusion criteria included bleeding disorders (international normalized ratio>2), clinically detected neck swellings, or cervical spine deformities. In the operating room, patients were attached to ECG and pulse oximetry. Noninvasive blood pressure and capnography were also monitored. After 3 min preoxygenation, anesthesia was induced in all patients with propofol (1-2 mg/kg) (1% Fresenius Kabi Deutchland GmbH, Homburg, Germany) and fentanyl (1-2 mg/kg) (Janssen-Cilag, Beerse, Belgium); muscle relaxation with atracurium (0.5 mg/kg) (Hameln pharmaceuticals, Langes Feld, Germany) was used to facilitate intubation and laryngoscopy. The lungs were ventilated with one to two minimum alveolar concentration sevoflurane (Abbott Laboratories, Illinois, USA) and 100% oxygen until initiation of laryngoscopy and intubation.
After 2 min of muscle relaxant injection, patients were intubated with a left-sided DLT (Rusch Bronchopart, Betschdorf, France). The size of DLT was chosen on the basis of both patient's sex and height; 35-39-Fr left-sided DLTs were used in the majority of the cases. Anesthesia was maintained with sevoflurane one minimum alveolar concentration in air/oxygen mixture (0.4%).
Patients were randomly allocated using closed envelope method into two groups: the conventional group (n = 15) and the bronchoscopic group (n = 16). In the conventional group, the DLTs were inserted in the conventional manner; the DLT was introduced by normal laryngoscopy into the glottic opening with distal curvature concave anterior and rotating it counterclockwise 90°. The stylet was removed once the tracheal cuff passed the vocal cords, then the tube was advanced until there was a feeling of slight resistance. The bronchial and tracheal cuffs were inflated with air (2 and 10 ml, respectively) and clinical verification of correct DLT position was performed with the patient in the supine position, including observation of chest wall movements, auscultation of both lungs before and after selective clamping of bronchial and tracheal lumen, and checking lung compliance by manual ventilation. Thereafter, the evaluation as well as the time for clinical placement were recorded. Immediately after this procedure and when the patient was still in the supine position, flexible fiberoptic bronchoscope (Olympus 3.7 mm diameter video bronchoscope (Mercury Dr Champaign, Illinois, USA)) was introduced into the tracheal lumen then into the bronchial lumen to assess its position, to determine whether the bronchoscopic findings confirmed the clinical impression of successful placement of the tube, and to correct any tube malposition. After obtaining a proper position, the DLT was secured in position.
In the bronchoscopic group, DLT was introduced as in the conventional group until the tracheal cuff passed the vocal cords, and, after stylet removal, the fiberoptic bronchoscope was introduced into the bronchial lumen and was pushed toward the left main bronchus until visualization of all three secondary divisions of the left main bronchus, and then it was pulled proximally about 2.5 cm. After fixation of the bronchoscope, the DLT was threaded over it and positioned about 2.5 cm before the carina of the second generation [Figure 1].
|Figure 1: Proper position of double-lumen tube, 2.5 cm before the carina of second generation of the left main bronchus|
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The bronchial and tracheal cuffs were inflated with air (2 and 10 ml, respectively) and clinical verification of correct DLT position was performed as in the conventional group. Time for placement of DLT was recorded, then bronchoscope was passed through the tracheal lumen for confirmation of position by viewing the right bronchial opening and herniation of the blue bronchial cuff just below the carina. After obtaining a proper position, the DLT was secured in position.
In both groups, the clinical and bronchoscopic assessments as well as adjustment and time taken for DLT placement and position confirmation were recorded.
Bronchoscopic assessment of correct position of the left DLT was defined as follows: unobstructed view of the left upper and lower lobe bronchus through the endobronchial lumen with the bronchial cuff immediately below the carina and just visible in the left main bronchus with unobstructed main right bronchus through the tracheal lumen. Misplacement was diagnosed when the tube had to be moved (in or out) by more than 0.5 cm to correct its position. Critical malpositions were defined as follows: left endobronchial limb compromising the left upper or left lower lobe bronchus and right endobronchial and tracheal dislocation. These malpositions were considered critical because they might have affected patient safety or influenced surgery  .
After positioning the patient on the lateral side, DLT was clinically checked for correct position and time needed for check was not included in time analyzed for placement and confirmation of position.
A previous study by Cheong and Koh  who compared conventional placement technique similar to our study and a modified bronchoscopic placement reported an effect size of 69.3% between both groups in the total time for tube insertion and confirmation. We adopted the same effect size and conducted a two-tailed t-test for independent groups. It was estimated that 15 patients in each group will be sufficient to detect a 70% effect difference between the studied groups assuming a type I error of 0.05 with a power of 80%. For dropout compensation, 18 patients were recruited in each group.
Continuous numerical data were presented as mean ± SD, whereas categorical data were presented as number of patients [n (%)] or median (range) as appropriate. Data analysis was performed using the c2 -test and t-test of independent groups (two-tailed) as appropriate. Analysis was performed using SPSS ver. 17 (IBM corporation, Endicott, New York, USA).
| Results|| |
Thirty-one patients undergoing elective total or partial esophagectomy were prospectively enrolled in this study. During laryngoscopy, three patients were found to be grade II and one patient grade III, according to the Cormack and Lehane classification, and hence they were excluded; another patient developed tooth bleeding and bronchoscopy was not proceeded. Patients in both groups were comparable regarding demographic data and Mallampati score [Table 1].
There was statistically significant difference with respect to times needed for placement (242-140 s) and confirmation (88-32 s) as well as total time (330-172 s) of DLT insertion in the conventional and bronchoscopic groups, respectively [Table 2].
|Table 1 Demographic data of the studied groups, the conventional group and the bronchoscopic group|
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|Table 2 Tube placement and confirmation times of the studied groups, the conventional group and the bronchoscopic group|
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[Table 3] shows the clinical and bronchoscopic assessment in the studied groups; the clinical assessment was satisfactory in 12 (80%) versus 16 (100%) patients in the conventional group compared with the bronchoscopic group, respectively, whereas it was unsatisfactory in three patients in the conventional group. The fiberoptic bronchoscopic assessment revealed achievement of proper position in seven (46.7%) versus 13 (81.25%) patients, which was the only statistically significant difference; misplacement (distal left bronchial positioning) occurred in five (33.3%) versus three (20%) patients, whereas critical malposition (right bronchial intubation) occurred only in three patients in the conventional group.
|Table 3 Clinical and bronchoscopic assessment parameters in the studied groups, the conventional group and the bronchoscopic group|
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The hemodynamic response, peripheral oxygen saturation, and arrhythmias in response to intubation in both groups revealed increased blood pressure and heart rate and decreased oxygen saturation during the first 2 min after initiating intubation; these changes were not significant neither between groups nor to the basal values, whereas there were no arrhythmias in both groups [Table 4].
|Table 4 Hemodynamic parameters in the studied groups, the conventional group and the bronchoscopic group|
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| Discussion|| |
One-lung ventilation (OLV) is usually needed in thoracic surgeries, lung surgery, and other emergencies requiring lung separation; the DLT is the cornerstone in OLV  . Proper position of DLT is mandatory to produce collapse of the separated lung and help in surgery  . Malposition may lead to either intraoperative or postoperative complications, and this may affect the surgery results  . The malpositioned endobronchial DLT may result in serious complications; the dependent lung (nonoperated lung) can be difficult to ventilate, the operative lung may not collapse on initiation of OLV, and gas exchange could be significantly impaired  .
Several techniques have been used to place and confirm the position of DLT. Before introduction of fiberoptic bronchoscope, the assessment of tube position depended only on clinical examination (inspection, auscultation, and assessment of ventilation pressure)  .
Even in the positive clinical assessment performed by anesthesiologist, a DLT can be misplaced or critically malpositioned, requiring slight adjustment of its position or even complete repositioning under bronchoscopic guidance , . In agreement with this, eight (66%) patients compared with three (18%) patients in the conventional and bronchoscopic groups, respectively, needed bronchoscopic repositioning of DLT in this current study.
Our data are consistent with the study by De Bellis et al.  who found that complete repositioning of DLT using fiberoptic bronchoscope was needed in 48% of the patients after blind intubation. Similar data were reported by Alliaume et al.  in which flexible bronchoscopy revealed misplacement of the left-sided DLT in 78% of patients undergoing thoracic surgery.
Other authors reported a lower incidence of DLT misplacement (32-44%) detected by flexible bronchoscopy after blind intubation , .
The lower incidence of misplacement of DLT under bronchoscopic guidance (18%) compared with (66%) the conventional method may be explained by the fact that it is performed under direct vision allowing easy and accurate intubation, and this could be of great importance especially when breath sounds auscultation is difficult.
The most outstanding feature of our results is the significant decrease in total time (172 s) needed for bronchoscopic-guided insertion and position confirmation of DLT compared with the conventional group (330 s) (P < 0.05). This finding is compatible with those of Cheong and Koh  who used the fiberoptic bronchoscope as a guide through the tracheal lumen for DLT placement followed by position confirmation; they reported a more rapid intubation (106.2 vs. 347 s) for blind insertion followed by bronchoscopic confirmation.
However, our result is inconsistent with that of Boucek et al.  who found that the conventional technique was twice as fast as the bronchoscopic-guided approach, and this may be attributed to personal experience of the operator. Hence, some authors advised that an anesthesiologist specialized in thoracic surgery should be adequately trained and experienced in bronchoscopy  .
| Conclusion|| |
Our data support the use of flexible fiberoptic bronchoscopy as an initial guide for placement of DLT in differential lung ventilation. This technique could be considered as a safe alternative to the conventional method of insertion, as it may reduce both time needed for proper placement as well as complications of malposition.
| Acknowledgements|| |
Conflicts of interest
| References|| |
Sakurag T, Kumano K, Yasumoto M, Dan K. Rupture of the left main stem bronchus by the tracheal portion of a double lumen endobronchial tube. Acta Anaesthesiol Scand 1997; 41:1218-1220.
Smith G, Hirsch N, Ehrenwerth J. Placement of double-lumen endobronchial tubes. Correlation between clinical impressions and bronchoscopic findings. Br J Anaesth 1986; 58:1317-1320.
Cohen E. Double-lumen tube position should be confirmed by fiberoptic bronchoscopy. Curr Opin Anesthesiol 2004; 17:1-6.
Cheong K, Koh K. Placement of left-sided double- lumen endobronchial tubes: comparison of clinical and fiberoptic guided placement. Br J Anaesth 1999; 82:920-921.
Merli G, Guarino A, Della Rocca G, Frova G, Petrini F, Sorbello M, et al.
in cooperation with SIAARTI Studying Group on Difficult Airway. Recommendations for airway control and difficult airway management in thoracic anesthesia and lung separation procedures. Minerva Anestesiol 2009; 75:59-96.
Cohen E. Methods of lung separation. Minerva Anestesiol 2004; 70:313-318.
Pennefather S, Russell G. Placement of double lumen tubes - time to shed light on an old problem. Br J Anaesth 2000; 84:308-310.
Benumof JL. The position of a double-lumen tube should be routinely determined by fiberoptic bronchoscopy (editorial). J Cardiothorac Vasc Anesth 1993; 7:513-514.
Inoue S, Nishimine N, Kitaguchi K, Furuya H, Taniguchi S. Double lumen location predicts tube malposition and hypoxaemia during one lung ventilation. Br J Anaesth 2004; 92:195-201.
De Bellis M, Accardo R, Di Maio M, Lamanna C, Rossi G, Pace M, et al
. Is flexible bronchoscopy necessary to confirm the position of double-lumen tubes before thoracic surgery? Eur J Cardiothorac Surg 2011; 40:912-918.
Alliaume B, Coddens J, Deloof T. Reliability of auscultation in positioning of double-lumen endobronchial tubes. Can J Anaesth 1992; 39:687-690.
Hurford W, Alfille P. A quality improvement study of the placement and complications of double-lumen endobronchial tubes. J Cardiothorac Vasc Anesth 1993; 7:517-520.
Boucek C, Landreneau R, Freeman J, Strollo D, Bircher N. A comparison of techniques for placement of double-lumen endobronchial tubes. J Clin Anesth 1998; 10:557-560.
[Table 1], [Table 2], [Table 3], [Table 4]