Another Potential Factor That May Cause Bronchial Rupture by a Double-Lumen Endobronchial Tube

Dr. Gilbert et al. (¹) report a bronchial rupture during an anesthetic employing a double-lumen endobronchial tube (EBT). In their discussion, they listed multiple factors that seem to increase the risk of injury from an EBT. One potential factor was omitted.

Dr. Gilbert et al. did not state whether the endobronchial cuff was inflated during patient positioning. It has been suggested that the bronchial cuff should be deflated when a patient’s position is changed from prone to lateral and vice versa (²). It is possible that during movement, the relative movement of the endobronchial cuff into the bronchus may be equivalent to forceful insertion of the EBT. If there is relative movement in the opposite direction, there could still be significant shear force applied to the bronchial mucosa. It would seem that, with the bronchial cuff deflated, there would be significantly less shear force applied to the bronchus as the EBT moves relative to the bronchus, as long as the outer diameter of the EBT is less than the diameter of the bronchial lumen.

To minimize the chance of bronchial trauma, the bronchial cuff should be deflated after verifying lung isolation, reinflated only immediately before one-lung ventilation is needed, and deflated as soon as two-lung ventilation resumes. Exception should be made for the rare situation where there is an immediate, absolute indication for lung isolation. Keeping the endobronchial cuff inflated to stabilize the position of the EBT during positioning is, in my view, unnecessary and potentially dangerous. In my experience, the EBT usually migrates proximally 1–2 cm after the patient’s changing from the supine to the lateral decubitus position. Inserting the EBT 1–2 cm deeper than ideal when the patient is supine typically results in the EBT’s being appropriately positioned when lateral.

Jonathan V. Roth MD