Discussions for Module 13: Management of One-Lung Ventilation

Questions are answered by module author: Dr. Sharon Davies, MD FRCPC

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What is the best approach to placing a double lumen tube/achieving lung separation in a patient with a difficult airway?

In a pt undergoing left lobectomy is the choice of right sided DLT ok? as it is easy to place rt sided DLTs?

Regarding selection of double lumen tube ( bronchocath) is it same for europeans and asians? or is it one size below for asians?I need EVB reply. Thank you

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Question #1:

 

What is the best approach to placing a double lumen tube/achieving lung separation in a patient with a difficult airway?

6/4/2010 12:50:26 PM, Anonymous

 

 

Dr. Slinger replies:

The best method to obtain lung isolation in a patient with a difficult airway is first to place a single-lumen endotracheal tube, either awake with topical anesthesia or after induction of anesthesia with appropriate intubation visual aids. Then depending on the difficulty of the initial intubation and the context of the case, either use a bronchial blocker through the single-lumen tube or change the single-lumen tube to a double-lumen tube with a tube exchange catheter and a video-laryngoscope.

 

Question #2:

 

In a pt undergoing left lobectomy is the choice of right sided DLT ok? as it is easy to place rt sided DLTs

21/6/2010 12:50:26 PM, Anonymous

 

 

Dr. Slinger replies:

Yes it is quite acceptable to use a right-sided double-lumen tube for a left thoracotomy. Some centers do it routinely: Ehrenfeld J, et al. Performance Comparison of Right- and Left-Sided Double-Lumen Tubes Among Infrequent Users. JCVA 2010 , 24: 588-61

Question #3:

 

What I/E ratio during one lung ventilation should we suggest? 

 

 

 

Dr. Slinger replies:

I think a 1:2 i:e ratio is reasonable place to start

Question #4:

 

In a pt undergoing left lobectomy is the choice of right sided DLT ok?
as it is easy to place rt sided DLTs 

 

 

Dr. Slinger replies:

Yes it is quite acceptable to use a right-sided double-lumen tube for a left thoracotomy. Some centers do it routinely: Ehrenfeld J, et al. Performance Comparison of Right- and Left-Sided Double-Lumen Tubes Among Infrequent Users. JCVA 2010 , 24: 588-61.

Question #5:

 

Thanks a lot Dr Slinger for this wonderful teaching module. Just wanted to inquire about the routine in extubatingpatients after thoracotomies at the University of Toronto. Do you change the DLT to a single lumen tube/supra glottic device, or take the DLT directly. Do you extubate the pts under deep Anesthesia or when fully awake?!! Thanks a lot again

 

 

 

Dr. Slinger replies:

Thank you for the question:

The large majority of thoracic surgery patients are extubated in the operating room directly from a double-lumen tube provided they are “AWaC” (alert, warm and comfortable). If there is a need for prolonged ventilation post-operatively in complicated surgery we will usually change to a single-lumen tube in the operating room during general anesthesia using a video-laryngoscope and tube exchange catheter if there is any question of a difficult airway. Peter

Question #6:

 

Regarding selection of double lumen tube ( bronchocath) is it same for europeans and asians? or is it one size below for asians?I need EVB reply. Thank you.

1/21/2012 1:45:26 PM, Anonymous

 

 

Dr. Slinger replies:

It seems that the selection criteria for Asians and Europeans for DLT size according to height is appropriate. However many Asians particularly females may be less than 150cm and are below the criteria that I use (i.e: Females < 160 cm= 35F) . ( Ref. Chow MYH, et al. Anesth Analg 1998; 87: 158-60). Tracheal width may be a better predictor of DLT size than height. For these very short females a 32F DLT may be more appropriate, however many pediatric bronchoscopes will not pass through the lumens of a 32F DLT. For very short patients, I try to measure the left mainstem bronchus diameter on CT scan. If the LMS bronchus is >9.5mm diameter I will use a 35F DLT and a 32F if it the diameter is smaller. Best wishes: Peter

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