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A 76-year-old, 148-cm woman was scheduled for right upper lobectomy. A 32 Fr left-sided double lumen tube was placed using a conventional technique. Despite several attempts under fiberoptic bronchoscope-guidance, we could not locate the double lumen tube properly. We thus decided to proceed with the bronchial tube in the right mainstem bronchus. D...
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Context 1
... into the right main bronchus. We tried using another method; the stylet was not removed just after the tip of the tube passed the vocal cord and was retained for the entire intubation procedure [4]. However, it could not enter the left main bronchus. In the image of the patient's chest radiography, the trachea was deviated on the right side ( Fig. 1) and in the computed tomography, we noted that the internal diameter of the trachea, at the point of the right main bronchus and the left main bronchus was 11.25 mm, 12.5 mm and 8.6 mm, respectively (Fig. 2). Inevitably, we decided to proceed with the operation while leaving the left bronchial tip of the double-lumen tube inserted in ...Similar publications
Background:
Selective neonatal left mainstem bronchial intubation to treat right lung disease is typically achieved with elaborate maneuvers, instrumentation and devices. This is often attributed to bronchial geometry which favors right mainstem entry of an endotracheal tube deliberately advanced beyond the carina.
Case summary:
A neonate with sev...
Citations
... Risk factors include inexperienced personnel, repetitive attempts, inappropriate use of the stylet, an over-expanded cuff, inappropriate tube size, double-lumen tube use, and abnormal location of the tube (3) . Additionally, factors sourcing from the patient such as short stature, sudden movement, obesity, being more than 50 years old, percutaneous tracheostomy, steroid or radiation therapy, chronic obstructive pulmonary disease, and tracheomalacia increase the risk of perforation and rupture of trachea (4) . Also, tracheal rupture is observed more often in females (4) . ...
... Additionally, factors sourcing from the patient such as short stature, sudden movement, obesity, being more than 50 years old, percutaneous tracheostomy, steroid or radiation therapy, chronic obstructive pulmonary disease, and tracheomalacia increase the risk of perforation and rupture of trachea (4) . Also, tracheal rupture is observed more often in females (4) . In our case, we had many risk factors such as unsuccessful airway management, repetitive attempts, inexperienced clinician, short stature, obesity and gender. ...
... No pneumothorax was observed. After an operation for a tracheal rupture, early extubation is recommended under spontaneous ventilation considering the possibility of damage to the mucous layer of the trachea due to the movement of the endotracheal tube and the pressure of the cuff (4) . Although there is no consensus on the ventilation mode, high-pressure ventilation should be avoided. ...
Endotracheal intubation is a relatively easy procedure, however, complications may occur due to this easy procedure. Practitioners should be ready for unexpected difficult intubation and treat in the lights of guidelines. We herein describe a 48 years old female tracheal rupture case which was diagnosed intraoperatively and treated immediately after diagnosis. Although tracheal rupture after intubation is very rare; respiratory insufficiency, emphysema, even death may happen as a result. Clinical suspicion is the first and the most important step at the diagnosis of the ruptures. An emergency bronchoscopy, chest X-ray and computerized tomography of thorax are necessary for diagnosis of the type and the extention of the laseration. In the literature conservative and surgical therapies are both appropriate for treatment of membranous tracheal rupture. In this case report, the causes of tracheal rupture after unexpected difficult intubation and its treatment approach are explained.
... In our literature review, some reports indicated that use of a stylet could cause tracheal injury. 9,11,[13][14][15][16][17] We considered that such tracheal injury due to use of a stylet may result from over-insertion of the stylet into the tracheal tube before intubation, rapid and powerful advancement of the combined tracheal tube and stylet into the trachea, or unnecessary deep insertion of the combined tracheal tube and stylet into the trachea. The lightwand is a type of stylet often referred to as a lighted stylet. ...
Objective
When performing lightwand intubation, an improper transmitted glow position before tube advancement can cause intubation failure or laryngeal injury. This study was performed to explore the transmitted glow point corresponding to a priori chosen depth for lightwand intubation.
Methods
Before lightwand intubation, we marked the transmitted glow point from a bronchoscope on the neck when it reached 1 cm below the vocal cords. Lightwand intubation was then performed using this marking point. The distances from the mark to the upper border of the thyroid cartilage, upper border of the cricoid cartilage, and suprasternal notch were measured.
Results
In total, 107 patients were enrolled. The success rate of lightwand intubation using the mark was 93.5% (95% confidence interval, 88.7%–99.2%) at the first attempt. The marking point was placed 12.0 mm (95% confidence interval, 10.6–13.4 mm) below the upper border of the cricoid cartilage.
Conclusion
Anaesthesiologists should be aware of the appropriate point of the transmitted glow on the patient’s neck when performing lightwand intubation. We suggest that this point is approximately 1 cm below the upper border of the cricoid cartilage. Trial registration: ClinicalTrials.gov NCT03480035
... [1,13,14] Moreover, the bronchoscopic guidance of the DLT from the right to the left bronchus is technically difficult, and the bronchoscope may be broken during the manipulation. [15] Therefore, it is important to prevent the right bronchial misplacement during blind intubation of left-sided DLTs. ...
Background
During intubation with a blind technique, a left-sided double-lumen tube (DLT) can be misdirected into the right bronchus even though its curved tip of the bronchial lumen turns to the left. This right bronchial misplacement may be associated with the tip angle of DLTs. We thus performed a randomized trial to test the hypothesis that the DLT with an acute tip angle enters the right bronchus less frequently than the tube with an obtuse tip angle.
Methods
We randomized surgical patients (n = 1427) receiving a polyvinyl chloride left-sided DLT. Before intubation, the curved tip was further bent to an angle of 135° and kept with a stylet inside in the curved-tip group, but not in the control group. After the tip was inserted into the glottis under direct or video laryngoscopy, the stylet was removed and the DLT was advanced into the bronchus with its tip turning to the left. We checked which bronchus was intubated, and the time and number of attempts for intubation. After surgery, we assessed airway injury, sore throat, and hoarseness. The primary outcome was the incidence of right bronchial misplacement of the DLT.
Results
DLTs were misdirected into the right bronchus more frequently in the control group than in the curved-tip group: 57/715 (8.0%) vs 17/712 (2.4%), risk ratio (95% CI) 3.3 (2.0–5.7), P < 0.001. The difference was significant in the use of 32 (P = 0.003), 35 (P = 0.007), and 37 (P = 0.012) Fr DLTs. Intubation required longer time (P < 0.001) and more attempts (P = 0.002) in the control group. No differences were found in postoperative airway injury, sore throat and hoarseness.
Conclusions
Before intubation of left-sided DLTs, augmentation of the curved DLT tip reduced the right bronchial misplacement and facilitated intubation without aggravating airway injury.
... However, FOBs may be inapplicable in emergency situations such as massive hemoptysis. Moreover, the smallest-caliber FOBs, which are necessary for small-sized DLTs, may not be always available or may be too fragile to guide DLTs [5]. Therefore, we devised a blind technique for redirecting into the LMB the left-sided DLTs that were misdirected into the RMB. ...
... For 32-or 35-Fr DLTs, which are commonly selected for the Asian females of short stature [10], only smallest-caliber FOBs can be accommodated. Because the FOB may be too fragile to guide the relatively stiff DLT towards the intended direction in an our experience [5], the bronchial tip of the DLT could not be guided into the LMB after several attempts, resulting in completely breaking the FOB. ...
Background:
Double-lumen endobronchial tubes (DLTs) are commonly advanced into the mainstem bronchus either blindly or by fiberoptic bronchoscopic guidance. However, blind advancement may result in misplacement of left-sided DLTs into the right bronchus. Therefore, incidence, risk factors, and blind repositioning techniques for right bronchial misplacement of left-sided DLTs were investigated.
Methods:
This was an observational cohort study performed on the data depository consecutively collected from patients who underwent intubation of left-sided DLTs for 2 years. Patients' clinical and anatomical characteristics were analyzed to investigate risk factors for DLT misplacements with logistic regression analysis. Moreover, when DLTs were misplaced into the right bronchus, the bronchial tube was withdrawn into the trachea and blindly readvanced without rotation, or with 90° or 180° counterclockwise rotation while the patient's head was turned right.
Results:
DLTs were inadvertently advanced into the right bronchus in 48 of 1135 (4.2 %) patients. DLT misplacements occurred more frequently in females, in patients of short stature or with narrow trachea and bronchi, and when small-sized DLTs were used. All of these factors were significantly inter-correlated each other (P < 0.001). In 40 of the 48 (83.3 %) patients, blind repositioning was successful.
Conclusions:
Smaller left-sided DLTs were more frequently misplaced into the right mainstem bronchus than larger DLTs. Moreover, we were usually able to reposition the misplaced DLTs into the left bronchus by using the blind techniques.
Trial registration:
ClinicalTrials.gov Identifier: NCT01371773.
... We believe that nonintubated thoracoscopic surgical procedures are most applicable in small-bodied female patients. These patients are prone to have a small tracheal caliber and are susceptible to intubation-related complications such as hoarseness, subglottic stenosis, and airway injuries, especially when double-lumen endotracheal tubes are used [29]. ...
Intubated general anesthesia with one-lung ventilation is considered mandatory for anatomical pulmonary resections. Nonintubated thoracoscopic segmentectomy for management of lung tumors, which is technically challenging, has not been reported previously. The goal of this study was to evaluate the feasibility and safety of thoracoscopic anatomical segmentectomy without endotracheal intubation.
From August 2009 to December 2012, 21 patients with lung tumors were treated using thoracoscopic anatomical segmentectomy without endotracheal intubation using a combination of thoracic epidural anesthesia, intrathoracic vagal blockade, and target-controlled sedation.
There were 16 patients with primary or metastatic lung cancers and 5 patients with nonmalignant tumors. Left upper lobe apical trisegmentectomy was most commonly performed (n = 6), followed by superior segmentectomy of the right lower lobe (n = 4) and left lower lobe (n = 4). One patient required conversion to intubated single-lung ventilation because of vigorous mediastinal and diaphragmatic movement. No patient required conversion to a thoracotomy or lobectomy. Operative complications developed in 1 patient who had an air leak for more than 3 days postoperatively. The mean duration of postoperative chest tube drainage and mean hospital stay were 2.5 days and 6.0 days, respectively. Anesthetic induction and the operation required a mean 26.5 minutes and 148.0 minutes, respectively.
Nonintubated thoracoscopic segmentectomy is technically feasible and safe. It can be an alternative to intubated single-lung ventilation for management of lung tumors in selected patients.
... softtipped) be utilized for this purpose. Iatrogenic tracheobronchial ruptures due to intubation with an endobronchial doublelumen tubes are rare but can be life threatening [8,9]. Also, tracheal laceration after the use of an airway exchange catheter for DLT placement has been reported previously [10]. ...
During insertion of the double lumen tube in patients with cervical vertebral fixation, the cervical neutral position should be maintained. Although flexible fiberoptic bronchoscopic intubation is the gold standard, novel techniques are needed to facilitate intubation of patients with cervical vertebral fixation in neutral position according to institutional capabilities. In this case report, insertion of the double lumen tube in the neutral position using LMA CTrach and an airway exchanger catheter in a thoracotomy patient with extremely limited head and neck motion due to fixation of the cervical vertebrae is presented.
Background:
Double-lumen tube (DLT) intubation in lateral decubitus position is rarely reported. We designed this study to evaluate the feasibility of VivaSight double-lumen tube (VDLT) intubation assisted by video laryngoscope in lateral decubitus patients.
Methods:
Patients undergoing elective video-assisted thoracoscopic surgery (VATS) for lung lobectomy were assessed for eligibility between January 2022 and December, 2022. Eligible patients were randomly allocated into supine intubation group (group S) and lateral intubation group (group L) by a computer-generated table of random numbers. The prime objective was to observe whether the success rate of VDLT intubation in lateral position with the aid of video laryngoscope was not inferior to that in supine position.
Results:
A total of 116 patients were assessed, and 88 eligible patients were randomly divided into group L (n = 44) and group S (n = 44). The success rate of the first attempt intubation in the L group was 90.5%, lower than that of S group (97.7%), but there was no statistical difference (p > 0.05). Patients in both groups were intubated with VDLT for no more than 2 attempts. The mean intubation time was 91.98 ± 26.70 s in L group, and 81.39 ± 34.35 s in S group (p > 0.05). The incidence of the capsular malposition in the group L was 4.8%, less than 36.4% of group S (p < 0.001). After 24 h of follow-up, it showed a higher incidence of sore throat in group S, compared to that in group L (p = 0.009).
Conclusion:
Our study shows the comprehensive success rate of intubation in lateral decubitus position with VDLT assisted by video laryngoscope is not inferior to that in supine position, with less risk of intraoperative tube malposition and postoperative sore throat.
Trial registration:
Chinese Clinical Trail Register (ChiCTR2200062989).
Objectives
The bronchial diameter measured on computed tomography (CT) can objectively guide double-lumen tube (DLT) sizes. The bronchus is known to be measured most accurately in the so-called bronchial CT window. We investigated whether the bronchial window suggests more appropriately-sized DLTs than the other windows.
Design
CT image analysis and prospective randomized study.
Setting
Tertiary hospital.
Participants
Adults receiving left-sided DLTs.
Interventions
We simulated selection of DLT sizes based on the left bronchial diameters measured in the lung [width 1500 Hounsfield unit (HU) and level -700 HU], bronchial (1000 and -450 HU), and mediastinal (400 and 25 HU) CT windows. Furthermore, patients were randomized depending on whether the bronchial or mediastinal windows were used to guide DLT sizes. Using the underwater seal technique, we assessed whether the DLT was appropriate, undersized, or oversized for the patient.
Main Results
On 130 CT images, the bronchial diameter [9.9 ± 1.2 mm vs. 10.5 ± 1.3 mm vs. 11.7 ± 1.3 mm] and the selected DLT size were different in the lung, bronchial, and mediastinal windows (p < 0.001). In 13 (17%) patients, the bronchial diameter measured in the lung window suggested too small DLTs (28-Fr) for adults. In the prospective study, oversized tubes were chosen less frequently in the bronchial window than in the mediastinal window (6/110 vs. 23/111; risk ratio, 0.38; 95% CI, 0.19–0.79; p = 0.003). No tubes were undersized.
Conclusions
The bronchial measurement in the bronchial window guided more appropriately-sized DLTs compared with the lung or mediastinal windows.
Tracheobronchial rupture is an uncommon but potentially serious complication of endotracheal intubation. The most likely cause of tracheal injury is massive overinflation of the endotracheal tube cuff and pre-existing tracheal wall weakness. We review the relevant literature and predisposing factors contributing to this complication. Only articles that reported at least the demographic data (age and sex), the treatment performed and the outcome were included. Papers that did not detail these variables were excluded. We also focus on a case of tracheal laceration after tracheal intubation in a patient with severe thyroid carcinoma. This patient received surgical repair and recovered uneventfully. Two hundred and eight studies that reported cases or case series were selected for analysis. Most of the reported cases (57·2%) showed an uneventful recovery after surgical therapy. The overall mortality was 19·2% (40 patients). Our patient too recovered without any serious complication. Careful prevention, early detection and proper treatment of the problem are necessary when tracheal rupture occurs. The morbidity and mortality associated with tracheal injury mandate a high level of suspicion and expedient management.
