Letters to the Editor: Letters & Announcements
To the Editor:
We read with interest the letter by Rajan in which he reported a tracheal laceration from a 37F double-lumen tube (DLT) (1). Because most, if not all, of the injuries to the trachea associated with DLTs are to the membranous portion of the trachea (2), we agree that if the tip of the tube is advanced anteriorly facing the tracheal cartilages, the incidence of this devastating complication should be reduced. However, there is no evidence to support his suggestion that doing so will not compromise accuracy of DLT placement.
Using the conventional 90°-120° counterclockwise turn before advancing the tube down the trachea, we have not had a single tracheal laceration with more than 2500 left DLTs. Lieberman et al.(3), in a small clinical study kept the bronchial stylet in place, rotated the DLT 110° counter-clockwise, and advanced all tubes into the appropriate left bronchus without any complications.
We believe a potential cause of tracheal injury is from selection of a DLT that is relatively small for the patient’s airway. In this situation, after removal of the bronchial stylet, the angle of the distal end of the bronchial lumen will be maximized because of the memory of the plastic, and the tube’s tip will impinge on the tracheal wall during the entire advancement sequence (Figure 1A). If a DLT is selected that fits more snugly in the trachea, there is less tip impingement on the airway mucosal and, perhaps, less chance of damage (Figure 1B). Serious injury resulting from a DLT remains a relatively uncommon occurrence. Probably the most important preventive steps are avoidance of forceful insertion of the tube and overinflation of the cuffs.
Jens Lohser, MD
Jay B. Brodsky, MD
Department of Anesthesia
Stanford University Medical Center
1. Rajan GR. Tracheal perforation with modified Broncho-Cath: is it the tube or the technique? Anesth Analg 2005;100:291.
2. Fitzmaurice BG, Brodsky JB. Airway rupture from double-lumen tubes. J Cardiothorac Vasc Anesth 1999;13:322–9.
3. Lieberman D, Littleford J, Horan T, Unruh H. Placement of left double-lumen endobronchial tubes with or without a stylet. Can J Anaesth. 1996;43:238–42.