comparison of two diff erent right-sided double-lumen tubes with diff erent designs

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urk J Med Sci2012; 42 (6): 1063-1069 BAKE-mail: [email protected]:10.3906/sag-1201-46

Comparison of two different right-sided double-lumen tubeswith different designs

Hilal SAZAK1, Uur GKA2, Ali ALAGZ1, ilsem SEVGEN DEMRBA1, zlem GVEN1,

Eser AVKILIOLU1

Aim: o compare usage o 2 right-sided double-lumen tubes (RDLs) with different designs in thoracic anesthesia.Although the lef-sided double-lumen tube (DL) is preerred, the RDL is necessary in some circumstances.

Materials and methods: A total o 40 patients undergoing lef thoracotomy were divided into 2 groups receiving aRsch or Sheridan RDL. Te position o the RDL was verified by clinical evaluation. It was also checked by fiberopticbronchoscope (FOB). When malposition was detected, it was corrected using the FOB. Te correct installation time othe RDL, requency o bronchoscopy, and lef lung collapse time were recorded.

Results:According to the bronchoscopic assessment, the rates o patients with a misplaced RDL in the supine (40% vs.50%) and lateral decubitis position (35% vs. 30%) were similar between the groups (P > 0.05). Ratios o total malpositionsto total bronchoscopies were similar. Te most requent malposition types were displacement o RDLs proximally ordistally. Correct RDL installation time (262 vs. 291 s) and collapse time o the lef lung (215 vs. 234 s) were comparablebetween the groups (P > 0.05).

Conclusion:With the aid o bronchoscopic evaluation, our data suggest that Rsch and Sheridan RDLs are not superior

to each other in one-lung ventilation. Tey were similar in terms o malpositions.

Key words:One-lung ventilation, right-sided double-lumen tube, fiberoptic bronchoscopy

Original Article

Received: 17.01.2012 Accepted: 15.06.20121Department o Anesthesiology and Reanimation, Atatrk Chest Disease and Toracic Surgery Education and Research Hospital, Ankara - URKEY2

Department o Anesthesiology and Reanimation, Faculty o Medicine, Yznc Yl University, Van - URKEYCorrespondence: Hilal SAZAK, Department of Anesthesiology and Reanimation, Atatrk Chest Disease and Toracic Surgery Education and Research Hospital, Ankara - URKEY

E-mail: [email protected]

Introduction

Endobronchial intubation and one-lung ventilation(OLV) are the most important practices in thoracicanesthesia (1). oday, Robertshaw type double-lumen tubes (DLs) are requently used in patients

undergoing thoracic surgery (2-4). Te margin osaety is the margin in which the location is stillcorrect despite the displacement o the DL (2).Both in right and lef thoracotomies, the lef-sidedDLs are usually preerred to the right-sided DLs(RDLs), which have a lower margin o saety (5,6)and higher risk o right upper lobe collapse andobstruction (2).

In particular, anatomical eatures o the rightupper lobe division render the use o the RDL morediffi cult compared to the lef-sided DL. It is statedthat the use o RDLs only with clinical assessment,without confirming the location via fiberoptic

bronchoscope (FOB), is unacceptable (7,8). All RDLshave an additional opening, allowing ventilationo the right upper lobe, in their endobronchiallumen. Failure to fit this opening onto the bronchiallumen o the right upper lobe can lead to somecomplications such as atelectasis and hypoxia (9).Although the design o the RDL has been modifiedmany times in order to acilitate correct installation


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and to allow ventilation o the right upper lobe, theoptimal DL design has not yet been ound. Variousbrands o RDLs with different bronchial balloonconfigurations and locations are currently available.Both the size and the place o the right upper lobeventilation openings are also different rom eachother in these RDLs (8). It has been reported thatthe incidence o malposition detected by FOB variesbetween 73% and 89%, when a right-sided RDLis placed without the use o a FOB (10-12). In thisstudy, we aimed to compare the effectiveness othe Rsch and Sheridan brands o RDLs havingdifferent configurations o endobronchial balloonand upper lobe ventilation openings. We compared

their clinical usage evaluating installation into theright main bronchus, intraoperative misplacements,and collapse o the operated lung.

Materials and methods

Tis prospective, randomized and single-blindedstudy was perormed with approval o the institutionalhuman investigation ethics committee and writteninormed consent obtained rom all patients.Te study was perormed in accordance with theprinciples o the Declaration o Helsinki. Forty adultpatients (28 males, 12 emales) undergoing electivelef-sided thoracotomy were allocated into 2 groups.Patients with destroyed lung, emphysematous lungdisease, or endobronchial lesions in the right mainbronchus or intermediary bronchus were excludedrom the study.

In the operating room, ollowing pre-oxygenation,anesthesia was induced with propool (2.5 mg/kgI.V.), entanyl citrate (2 g/kg I.V.), and vecuronium

bromide (0.1 mg/kg I.V.). Anesthesia was maintainedwith isourane (1%-1.5%), entanyl citrate, andvecuronium bromide. Oxygen 100% was used duringOLV and a routine OLV procedure was perormedthroughout this study. Electrocardiography,peripheral oxygen saturation (SpO

2), invasive arterial

pressure, and end-tidal carbon dioxide (ECO2) were

monitored. Te arterial blood gases were analyzedhourly during the operation.

All patients were intubated with a Robertshaw

type, disposable RDL using the conventionalmethod by the same thoracic anesthesia specialist.

Rsch (Rschelit, Bronchopart, Willy Rsch AG,Kernen, Germany) and Sheridan (Sher-i-bronch,Hudson Respiratory Care Inc., emecula, CA, USA)brand o RDLs were placed in Group R (n = 20)and Group S (n = 20), respectively. Te size o theDL was 35-37 French (Fr) in emales, while it was39-41 Fr in males. In the conventional intubationmethod, the endobronchial cuff passed the vocalcords with direct laryngoscopy, as the distal concaveangle o DL aced the anterior. Te RDL wasinstalled by pushing the tube with a 90 rotationtowards the right side. Te stylet was pulled as soonas the endobronchial cuff passed the vocal cords.Te tracheal and endobronchial cuffs were inated

consecutively until no leak was observed. Teplacement o the DL was assessed clinically withmanual ventilation, inspection, and auscultationo the chest by clamping the lumens o the DLindividually. Te position o the DL was recorded asappropriate or inappropriate based on a clinicalevaluation. In the supine position, correct placemento the DL was verified using a FOB (OlympusLFDP, Olympus Medical System Corp., okyo, Japan)by another anesthetist. Inappropriately located DLswere positioned in the expected place via the FOB.Afer bronchoscopic evaluation, i the DL had to bemoved more than 0.5 cm to correct its position, thiscondition was defined as malposition.

Te bronchoscopic criteria o correct RDLinstallation were described as ollows: observationo the carina and direction o the endobronchiallumen towards the right when examining rom thetracheal lumen, and observation o the right upperlobe bronchus orifice at the level o right upperlobe ventilation opening when checking rom the

bronchial lumen o the DL. When the right upperlobe ventilation opening o the DL was not placedat the level o right upper lobe bronchus orifice, theposition o the DL was corrected by turning andpushing or pulling it along by FOB. Te correctinstallation time was regarded as the time beginningrom the passage o the endobronchial cuff betweenthe vocal cords to the moment that the DLs positionwas decided to be appropriate using a FOB.

Te position o the DL was also assessed via

FOB in the lateral decubitis position and throughoutthe operation every 30 min. In the event o DL


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malposition it was corrected immediately. Additionalbronchoscopies were perormed whenever a diffi cultyexisted in the operated lung collapse or dependentlung ventilation. otal number o bronchoscopies,and the number and types o malpositions wererecorded. Te malposition types are defined in able1. Te surgeon was asked to evaluate the lef lungcollapse as good surgical view, partial collapse, orno collapse. Te time beginning rom the initiationo OLV to complete collapse o the operated lung wasrecorded as lung collapse time.

Te descriptive statistics were defined as meanand standard deviation or continuous variables.Categorical variables were defined as numbers

and percentages. Te Pearson chi-square test andFishers exact test were used or determination o therelationships between categorical variables.

Results

Te groups were similar with respect to patientcharacteristics (P > 0.05) (able 2). In clinical

assessment, DL malpositions were significantlylower in Group R compared to Group S (P = 0.05) inthe patients in the supine position. However, there wasno significant difference between the groups in theassessment of DL placement via FOB (able 3). Nosignificant difference was found between the groupsin terms of malposition types determined using FOBin the patients in the supine and lateral decubitispositions (able 4). During the operation, includingadditional bronchoscopies, DLs were found to bedisplaced proximally in 8 and 7 patients in Group R

and Group S, respectively. DLs were observed to bedisplaced distally in 3 patients in each group. Tisdifference was not statistically significant (P > 0.05).

able 1. Description o malposition types.

Malposition types

ype 1Protrusion o the bronchial balloon into the carina and inadequate visualization o the right upper lobe orifice rom theupper lobe ventilation opening in the bronchial lumen (proximal displacement o DL)

ype 2

Nonvisualization o the upper margin o the bronchial balloon at the entrance o the main bronchus and inadequate

visualization o the right upper lobe orifice rom the upper lobe ventilation opening in the bronchial lumen (distaldisplacement o DL)

ype 3 Both lumens o DL are in the trachea

ype 4 Intubation o the lef main bronchus

DL: double-lumen tube.

able 2. Patient characteristics.

Group R (n= 20) Group S (n= 20) P

Age (year) 50.5 12.8 48.8 17.9 0.74Weight (kg) 68.40 9.70 66.80 12.80 0.65

Height (cm) 166.9 5.4 168.4 7.6 0.30

Female/Male 6/14 6/14 1.00

Operation time (min) 177.15 56.62 177.15 34.40 1.00

Surgical procedures 0.251

Pneumonectomy 7 3

Lobectomy 6 12

Wedge resection 5 3

Cystotomy 2 2


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Te data or DL placement by bronchoscopicevaluation are given in able 5. Tere was nosignificant difference between the groups in termso correct installation time or lef lung collapse time(P > 0.05). Te ratios o total malpositions to totalbronchoscopies were 26/152 (17.1%) and 26/146(17.8%) in Group R and Group S, respectively(P > 0.05). Te number o patients without DLmalpositions was 8 (40%) and 9 (45%) in Group

R and Group S, respectively, in all bronchoscopicchecks (able 5).

Te surgeon evaluated the lef lung collapseas good in 18 and 17 patients in Group R andGroup S, respectively, whereas it was defined aspartial in 2 and 3 patients in Group R and GroupS, respectively. Tere was no statistically significantdifference between the groups with regard to surgicalassessment o the lef lung collapse (P > 0.05). Teinstallation o the DL and FOB handling weremanaged uneventully in the present study. Arterialblood gases and ECO

2 values were within the

normal physiological ranges. Hypoxemia (SaO2

comparison of two diff erent right-sided double-lumen tubes with diff erent designs

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