A 72-yr-old female (height 162 cm, weight 55 kg) was admitted to our Intensive Care Unit (ICU) because of acute respiratory failure (PaO2/inspired O2 fraction (FiO2) 10.3 kPa). On admission, her trachea was intubated with a 7.5 mm inner diameter endotracheal tube (Portex, Kent, UK) and lungs mechanically ventilated in a pressure-regulated volume-controlled mode (Siemens 300C®, Berlin, Germany). Tidal volume was set at 380-400 mL, respiratory rate 20 breaths min−1, externally applied positive end-expiratory pressure (PEEP) 0 cmH2O. The achieved PaO2/FiO2 was 12 kPa. The patient was sedated with propofol (4 mg kg−1 h−1). The admission chest radiograph revealed diffuse, bilateral pulmonary infiltrates. She had no prior history of chronic inhalation of dusts causing inflammation and pulmonary fibrosis. Microbiological, serological and imaging investigations for patients with suspected interstitial lung disease  failed to establish a definitive, causal diagnosis. Thus, surgical lung biopsy [1-4] under selective lobar collapse  was decided.
For selective left upper lobar collapse, the following technique was employed.
(a) Determination of left mainstem bronchus length. A 3.4 mm fibreoptic bronchoscope was inserted through the original endotracheal tube; the upper incisor-to-carina distance (23.5 cm) was determined by subtracting the endotracheal tube connector-to-upper incisor length (part of endotracheal tube protruding from the patient's mouth) from the fibreoptic bronchoscope insertion length at the level of carina (endotracheal tube connector-to-carina); in a similar way, the upper incisor-to-left upper bronchus orifice distance (26.0 cm) was determined by subtracting the endotracheal tube connector-to-upper incisor length from the fibreoptic bronchoscope insertion length at the level of the left upper bronchus orifice; lastly, the difference of the aforementioned distances yielded the left mainstem bronchus length (2.5 cm).
(b) LUL isolation. Additional propofol (1 mg kg−1), fentanyl (3 μg kg−1) and cisatracurium (0.2 mg kg−1) were given. Then the original endotracheal tube was replaced by a 37-FG, left-sided, double-lumen tube (BronchoCath®; Mallinckrodt Medical Inc., St. Louis, MO, USA); the double-lumen tube was inserted to the 28.0 cm mark at upper incisor level, and the inflation of both tracheal and bronchial cuffs resulted in the desired selective LUL isolation (Fig. 1).
(c) Confirmation of LUL isolation. A fibreoptic bronchoscope inspection via the tracheal lumen of the double-lumen tube revealed the carina and both mainstem bronchial orifices; on inspection through the bronchial lumen only the segmental left lower bronchial orifices were visualized; on chest auscultation, with both double-lumen tube cuffs inflated, breath sounds were diminished solely over the left upper lobe.
In the right lateral decubitus position, the desired double-lumen tube positioning was reconfirmed as above. Following left upper lobe collapse , an uneventful videothoracoscopic biopsy of the left upper lung was performed within 40 min. Intraprocedural ventilator settings were: FiO2, 1.0; tidal volume, 350-360 mL; respiratory rate, 23 breaths min−1; inspiratory time-to-total respiratory cycle time ratio 0.5; externally applied PEEP 0 cmH2O. Peak, plateau and mean airway pressures were 45-46, 28-30 and 8-9 cmH2O, respectively; intrinsic PEEP was 2 cmH2O. PaO2 was maintained ≥8 kPa throughout the procedure.
In patients in respiratory failure with a short (≈2.5 cm) left mainstem bronchus , we recommend our selective left upper lung isolation technique for open lung biopsy. The left lower lobe can still be ventilated through the left endobronchial lumen of the double-lumen tube and the right lung is ventilated through the tracheal lumen. This is likely to minimize the risk of intraoperative hypoxaemia.
S. D. Mentzelopoulos
M. J. Tzoufi
A. S. Michalopoulos
Department of Intensive Care Medicine; Henry Dunant General Hospital; Athens, Greece
E. P. Papageorgiou
Department of Anaesthesiology; Henry Dunant General Hospital; Athens, Greece
1. Toews GB. Interstitial lung disease. In: Goldman L, Bennett JC, eds. Cecil Textbook of Medicine,
21st edn. Philadelphia, USA: WB Saunders Company, 2000: 409-419.
2. Popper HH. Which biopsies in diffuse infiltrative lung diseases and when are these necessary? Monaldi Arch Chest Dis
3. Zegdi R, Azorin J, Tremblay B, Destable MD, Lajos PS, Valeyre D. Videothoracoscopic lung biopsy in diffuse infiltrative lung diseases: a 5-year surgical experience. Ann Thorac Surg
4. Valeyre D, Braumer M, Cadranel J. Diagnostic approach in infiltrative lung diseases. Rev Prat
5. Campos JH. Effects on oxygenation during selective lobar versus total lung collapse with or without continuous positive airway pressure. Anesth Analg
6. Benumof JL, Partridge BL, Salvatierra C, Keating J. Margin of safety in positioning modern double-lumen endotracheal tubes. Anesthesiology