Right-Sided Double-Lumen Endobronchial Tubes for Left-Sided Thoracic Surgery

To the Editor:

How refreshing it was to read the article by Campos et al. (¹) on the safety and appropriateness of using the right-sided double-lumen endobronchial tube (DLT) for left thoracotomies. I have been practicing thoracic anesthesia for more than 30 years and have routinely placed a right-sided DLT for left thoracotomies. Many of the advantages of this practice are well documented by Campos et al., but there must also be included in this list the development of an expertise in placement of the right-sided DLT, when there is no alternative. It does take experience with the fiberoptic bronchoscope to place the right upper lobe ventilation slot in precisely the correct position and to be able to adjust the position, if necessary, during the surgery. This is not the tube to use for the first time in an adverse situation, but by its frequent use, we can gain the necessary skills to competently secure its position in any circumstance.

The trend in many centers and residency programs is to teach and use only the left-sided DLT. This appears to be the result of peer pressure generated by the publication of studies from Benumof et al. (²) and McKenna et al. (³) that raised the question of the safety of the right-sided DLT. The outcome of this change in practice is that the skills in placement of the right-sided DLT are often lacking when the need arises. Clinical situations that often occur, that are not mentioned by Campos et al. include compression of the dependent airway by the weight of the mediastinum in the obese patient, resulting in obstruction of the down-side lung. Occasionally, the left mainstem bronchus may be slightly smaller than the right side and may be deployed at such an acute angle that placement of the left-sided DLT is difficult or the cuff herniates out over the carina during the surgery. These problems may cause an interruption in the operation and are easily corrected by exchanging the left DLT for a right-sided one.

I hope that the study by Campos, will allow this valuable tool to return to routine use for left thoracotomies. The right-sided DLT is an important device in our armamentarium and should be more universally accepted and used.

Michael A. E. Ramsay MD