Double Lumen Endobronchial Tubes

1. DOUBLE LUMEN TUBESDOUBLE LUMEN TUBES

2. INTRODUCTIONINTRODUCTION
• The development of double lumen tubes
between 1950s and 1960s was a response to
fast growing capabilities in thoracic surgery.
• The Bjork and Carlens bronchospirometric
double lumen tube was first used during
anaesthesia in 1950.

3. DATE NAME DISTINCTIVE CHARACTERSTICS BRONCHIAL
INTUBATIO
N
TECHNIQUE
1950 Carlens Double lumen catheter with two inbuilt curves tracheal
and a bronchial cuff for left main bronchus, carinal hook
and cross sectional shape oval in horizontal plane
Blind
1959 Bryce
Smith
Modification of carlens catheter with no carinal hook,
cross sectional shape oval in horizontal plane
Blind
1960 Bryce
smith and
Salt
Right sided version of Bryce Smith tube possessing slit in
the endobronchial cuff. No carinal hooks
Blind
1960 White Right sided version of Carlens catheter possessing slit in
the endobronchial cuff and a carinal hooks
Blind
1962 Robert
Shaw
Right and left DLT larger lumen, slotted right endo
bronchial cuff, no carinal hook, cross sectional shape, D
shaped in horizontal plane.
Blind
1979 National
Catheter
corpn.
Right and left Robert Shaw type disposable DLT, with low
pressure high volume cuff
Blind

4. ABSOLUTE INDICATIONS FOR LUNG SEPARATIONABSOLUTE INDICATIONS FOR LUNG SEPARATION

5. RELATIVE INDICATIONSRELATIVE INDICATIONS

6. METHODS OF LUNG SEPARATIONMETHODS OF LUNG SEPARATION
• DOUBLE-LUMEN ENDOBRONCHIAL TUBESDOUBLE-LUMEN ENDOBRONCHIAL TUBES
– Robert-Shaw (R or L), Carlens (R), White (L)
– Carlens and White both have carinal hooks
– From 35Fr to 41Fr (35, 37, 39, 41)
– 26Fr smallest size
• Used for children as young as 8 years
– 28Fr and 32Fr used for pediatric patients 10 and older
• BRONCHIAL BLOCKERSBRONCHIAL BLOCKERS
– Single-lumen tracheal tubes w/ a bronchial blocker (Univent)
– Arterial embolectomy catheter (ie Fogarty)
• SINGLE-LUMEN ENDOBRONCHIAL TUBESSINGLE-LUMEN ENDOBRONCHIAL TUBES
– Gordon-Green tube (carinal hook)

7. DLT
• Type:
– Carlens, a left-sided + a carinal hook
– White, a right-sided Carlens tube
– Bryce-Smith, no hook but a slotted cuff/Rt
– Robertshaw, most widely used
• All have two lumina/cuffs, one
terminating in the trachea and the
other in the mainstem bronchus
• Right-sided or left-sided available
• Available size: 41,39, 37, 35, 28 French
(ID=6.5, 6.0, 5.5, 5.0 and 4.5 mm
respectively)

8. LEFT DLT…
• Most commonly used
• The bronchial lumen is longer, and a simple round
opening and symmetric cuff .Better margin of
safety than Rt DLT
• Easy to apply suction and/or CPAP to either lung
• Easy to deflate lung
• Lower bronchial cuff
volumes and pressures
• Can be used
– Left lung isolation:
clamp bronchial +
ventilate/ tracheal lumen
– Right lung isolation:
clamp tracheal +
ventilate/bronchial
lumen

9. …Left DLT
• More difficult to insert (size and curve, cuff)
• Risk of tube change and airway damage if kept in
position for post-op ventilation
• Contraindication:
– Presence of lesion along DLT pathway
– Difficult/impossible conventional direct vision intubation
– Critically ill patients with single lumen tube in situ who
cannot tolerate even a short period of off mechanical
ventilation
– Full stomach or high risk of aspiration
– Patients, too small (<25-35kg) or too young (< 8-12 yrs)

10. LUNG SEPARATION is achieved by
either;
-Double lumen ETT (DLT)
-Bronchial blocker
-Endobronchial tube

11. Anatomy of the Tracheobronchial Tree

12. Double Lumen Endobronchial
Tubes

13. FEATURES OF DLTFEATURES OF DLT
RUL, right upper lobe; LUL, left upper lobe

14. Carlens DLT Robertshaw DLT

15. DIFFERENT TYPES OF DLTDIFFERENT TYPES OF DLT
Carlens White Bryce Smith Robertshaw
lumen
hook + + - -
side Lt Rt Lt & Rt Lt & Rt

17. Basic pattern of a Right-Sided DLT

18. Rt Lt

19. Lt

20. DLT PLACEMENT
• Prepare and check tube
– Ensure cuff inflates and deflates
• Lubricate tube
• Insert tube with distal concave curvature facing anteriorly
• Remove stylet once through the vocal cords
• Rotate tube 90 degrees (in direction of desired lung)
• Advancement of tube ceases when resistance is encountered.
Average lip line is 29 ± 2 cm.
• *If a carinal hook is present, must watch hook go through cords to
avoid trauma to them.

21. DLT PLACEMENT
• Check for placement by auscultation
• Inflate tracheal cuff- expect equal lung ventilation
• Clamp the white side (marked "tracheal" for left-sided tube) and remove
cap from the connector
– Expect some left sided ventilation through bronchial lumen, and some
air leak past bronchial cuff, which is not yet inflated
• Slowly inflate bronchial cuff until minimal or no leak is heard at uncapped
right connector
– Go slow- it only requires 1-3 cc of gas and bronchial rupture is a risk
• Remove the clamp and replace the cap on the tracheal side
• Check that both lungs are ventilated
• Selectively clamp each side, and expect visible chest movement and audible

22. DLT PLACEMENT
• Checking tube placement with the fiberoptic bronchoscope
• Several situations exist where auscultation maneuvers are impossible
(patient is prepped and draped), or when they do not provide
reliable information (preexisting lung disease so that breath sounds
are not very audible, or if the tube is only slightly malpositioned)
• The double-lumen tube's precise position can be most reliably
determined with the fiberoptic bronchoscope
• In patients with double-lumen tubes whose position seemed
appropriate to auscultations, 48% had some degree of malposition.
So always check position with fiberoptic
• After advancing the fiberoptic scope thru the “tracheal” tube you
should see the “bronchial blue balloon” in a semi lunar shape, just
peeking out of the bronchus

23. DLT Placement

24. Right DLT: bronchoscopic view

25. Another indication for DLT: Reexpansion
pulmonary edema

26. PASSAGE OF THE LEFT-SIDED DLT

27. GUIDE FOR LENGTH AND SIZE OF DLTGUIDE FOR LENGTH AND SIZE OF DLT
LENGTH OF TUBE
For 170 cm height, tube depth of 29 cm
For every 10 cm height change , 1 cm depth change
Patient characteristics Tube size (Fr gauge)
Tracheal width (mm):
18
16
15
14
41
39
37
35
Patient height
4’ 6”-5’5”
5’5”-5’10”
5’11”-6’4”
35-37
37-39
39-41
Patient age (year)
13-14
12
10
8
35
32
28 (lt only)
26 (lt only)

28. CHECK POSITION OF LT -DLT
Checklist for tracheal
placement
A. Inflate tracheal cuff
B. Ventilate rapidly by hand
C. Check that both lungs are
being ventilated
D. If not, withdraw 2-3 cm &
repeat
Checklist for Lt side
A. Inflate lt cuff > 2ml
B. Ventilate and check
bilateral breath sounds
C. Clamp rt tube
D. Check unilateral (lt)
breath sounds
Checklist for Rt side
A. Clamp lt tube
B. Check unilateral
(rt) breath sounds

29. Major Malpositions of a Lt- DLT
Both cuffs
inflated
Clamp Rt lumen
Both cuffs
inflated
Clamp Lt lumen
Deflate Lt cuff
Clamp Lt lumen
Left
None /Very minimal
left
Left
Right
Both
Both
None / Very minimal
Both
Right
None /Very minimal
Right
Breath Sounds Heard
Lt

30. To ensure correct position of DLT clinically :
 breath sounds are
- normal (not diminished) &
- follow the expected unilateral pattern with unilateral clamping
 the chest rises and falls in accordance with the breath sounds
 the ventilated lung feels reasonably compliant
 no leaks are present
 respiratory gas moisture appears and disappears with each tidal
ventilation
N.B even if the DLT is thought to be properly positioned by clinical
signs, subsequent FOB may reveal an incidence of malposition ( 38 -78
%)

31. FOB picture of Lt - DLT

32. FOB picture of Rt DLT

33. Relationship of FOB Size to Adult DLT
FOB Size (mm)
(OD)
Adult DLT Size
(French)
Fit of FOB inside DLT
5.6 All sizes Does not fit
4.9
41
39
37
35
Easy passage
Moderately easy passage
Tight fit, need lubricant, hard
push
Does not fit
3.6–4.2 All sizes Easy passage

34. Other Methods to Check DLT Position
 Chest radiograph
May be more useful than conventional auscultation and clamping in some
patients, but it is always less precise than FOB. The DLT must have
radiopaque markers at the end of rt and lt lumina.
 Comparison of capnography
Waveform and ETCO2 from each lumen may reveal a marked discrepancy
(different degree of ventilation).
 Surgeon
May be able to palpate, redirect or assist in changing dlt position from
within the chest (by deflecting the dlt away from the wrong lung, etc..).

35. Adequacy for Sealing (air Bubble test )

36. ADVANTAGESADVANTAGES
 Relatively easy to place
 Allow conversion back and forth from OLV to two-
lung ventilation
 Allow suctioning of both lungs individually
 Allow CPAP to be applied to the non-dependent lung
 Allow PEEP to be applied to the dependent lung
 Ability to ventilate around scope in the tube

37. DISADVANTAGESDISADVANTAGES
• Cannot take patient to PACU or the Unit
• Must be changed out for a regular ETT if post-op
ventilation
• Correct positioning is dependent on appropriate size for
height of patient
Length of trachea

38. COMPLICATIONS OF DLTCOMPLICATIONS OF DLT
 Impediment to arterial oxygenation for OLV
 Tracheobronchial tree disruption, due to
-Excessive volume and pressure in bronchial balloon
-Inappropriate tube size
-Malposition
 Traumatic laryngitis (hook)
 Inadvertent suturing of the DLT

39. TO AVOID TRACHEOBRONCHIAL TREE DISRUPTION …
1. Be cautious in patients with bronchial wall abnormalities.
2. Pick an appropriately sized tube.
3. Be sure that tube is not malpositioned ; Use FOB.
4. Avoid overinflation of endobronchial cuff.
5. Deflate endobronchial cuff during turning.
6. Inflate endobronchial cuff slowly.
7. Inflate endobronchial cuff with inspired gases.
8. Do not allow tube to move during turning.

40. RELATIVE CONTRAINDICATIONS TO USE OF DLTRELATIVE CONTRAINDICATIONS TO USE OF DLT
 Full stomach (risk of aspiration);
 Lesion (stricture, tumor) along pathway of dlt (may be traumatized);
 Small patients;
 Anticipated difficult intubation;
 Extremely critically ill patients who have a single-lumen tube already in place and
who will not tolerate being taken off mechanical ventilation and peep even for a
short time;
 Patients having some combination of these problems.
Under these circumstances, it is still possible to separate the lungs by :
-using a single-lumen tube + FOB placement of a bronchial blocker ; or
-FOB placement of a single-lumen tube in a main stem bronchus.

41. Bronchial Blockers
(With Single-Lumen Endotracheal Tubes)
 Lung separation can be effectively achieved with the use of a
single-lumen endotracheal tube and a FOB placed bronchial
blocker.
 Often necessary in children as DLTs are too large to be used in
them. The smallest DLT available is a left-sided 26 Fr tube,
which may be used in patients 8 -12 years old and weighing
25 -35 kg.
 Balloon-tipped luminal catheters have the advantage of
allowing suctioning and injection of oxygen down the central
lumen.

42. INDICATIONS FOR USE OF BRONCHIAL BLOCKERS
1st
LIMITATIONS TO DLT
( severely distorted airway, small patients , anticipated difficult intubation)
2nd
TO AVOID A RISKY CHANGE OF DLT TO SINGLE-LUMEN TUBE
• whenever postoperative ventilation is anticipated
• in cases of thoracic spine surgery in which a thoracotomy in the supine or
LDP is followed by surgery in the prone position.
3rd
SITUATIONS IN WHICH BOTH LUNGS MAY NEED TO BE BLOCKED
(e.g., bilateral operations, indecisive surgeons).

43. TYPES OF BRONCHIAL BLOCKERSTYPES OF BRONCHIAL BLOCKERS
Univent bronchial blocker system
Arndt endobronchial blocker
Cohen Flexitip Endobronchial Blocker
BB independent of a single-lumen tube

44. UNIVENT BRONCHIAL BLOCKER SYSTEMUNIVENT BRONCHIAL BLOCKER SYSTEM

45. Univent Tube...
• Developed by Dr. Inoue
• Movable blocker shaft in
external lumen of a single-lumen
ET tube

46. STEPS OF FOB-AIDED METHOD OF POSITIONING THE UNIVENT BRONCHIALSTEPS OF FOB-AIDED METHOD OF POSITIONING THE UNIVENT BRONCHIAL
BLOCKER IN LT MAIN STEM BRONCHUSBLOCKER IN LT MAIN STEM BRONCHUS
One- or two-lung ventilation is achieved simply by inflating or deflating,
respectively, the bronchial blocker balloon

47. ADVANTAGES OF THE UNIVENT BRONCHIAL BLOCKER TUBEADVANTAGES OF THE UNIVENT BRONCHIAL BLOCKER TUBE
( RELATIVE TO DLT )( RELATIVE TO DLT )
1. Easier to insert and properly position.
2. Can be properly positioned during continuous ventilation and
in the lateral decubitus position.
3. No need to change the tube when turning from the supine to
prone position or for postoperative mechanical ventilation.
4. Selective blockade of some lobes of each lung.
5. Possible to apply CPAP to non ventilated operative lung.

48. Limitations to the Use of Univent Bronchial Blocker
LIMITATION SOLUTION
1. Slow inflation time (a) Deflate BB cuff and administer +ve pressure breath
through the main single lumen;
(b) carefully administer one short high pressure (20–30 psi)
jet ventilation
2. Slow deflation time (a) Deflate BB cuff and compress and evacuate the lung
through the main single lumen;
(b) apply suction to BB lumen
3. Blockage of BB
lumen
( blood, pus,..)
Suction, stylet, and then suction
4. High-pressure cuff Use just-seal volume of air
5. Leak in BB cuff Make sure BB cuff is subcarinal, increase inflation volume,
rearrange surgical field

49. Univent Tube

50. WIRE-GUIDED ENDOBRONCHIALWIRE-GUIDED ENDOBRONCHIAL
BLOCKERSBLOCKERS

51. ARNDT ENDOBRONCHIAL BLOCKER SETARNDT ENDOBRONCHIAL BLOCKER SET
• Invented by Dr. Arndt, an anesthesiologist
• Ideal for diff intubation, pre-existing ETT and postop
ventilation needed
• Requires ETT > or = 8.0 mm
• Similar problems as Univent
• Inability to suction or ventilate the blocked lung

52. ADVANTAGESADVANTAGES
• Quickly and precisely navigate the airway
• The guide wire loop couples the pediatric fiberoptic bronchoscope and the wire-
guided endobronchial blocker
– yet both remain able to move independently of each other and the pediatric
fiberoptic bronchoscope may navigate the airway independent of its role in
carrying the endobronchial blocker
• The pediatric bronchoscope acts as a guide, allowing the endobronchial blocker to
be advanced over it into the correct position
• In addition, the wire-guided endobronchial blocker allows one-lung ventilation
with a single-lumen endotracheal tube
– Thus, one-lung ventilation is not dependent on installing a special device in the
airway, such as a double-lumen tube or a Univent endotracheal tube
– Allows one-lung ventilation in the critically ill patient in whom reintubation
may be difficult or impossible and in patients with a known difficult airway
requiring fiberoptic intubation with a conventional endotracheal tube
– Unnecessary to convert from a conventional double-lumen endotracheal tube
to a single-lumen tube at the end of surgery

53. DISADVANTAGESDISADVANTAGES
• Satisfactory bronchial seal and lung separation are sometimes difficult to
achieve
• The “blocked” lung collapses slowly (and sometimes incompletely)
• The balloon may become dislodged during surgery and enter the trachea
proper, causing a complete airway obstruction
– In situations of acute increases in airway pressure, the endobronchial
blocker balloon should be immediately deflated and the blocker re-
advanced
– It will then re-enter the correct segment (as the tip remains in the
correct bronchus and only the proximal balloon portion has entered the
trachea)
– In this case, a pediatric fiberoptic bronchoscope should be re-introduced
into the airway and the balloon re-positioned
– In order to prevent barotrauma, the initial balloon inflation volume
should not be exceeded
– It is important that the balloon be fully deflated when not in use and
only be re-inflated with the same volume used during positioning and

54. INDICATIONS FOR WIRE-GUIDEDINDICATIONS FOR WIRE-GUIDED
ENDOBRONCHIAL BLOCKERS VS. DLTENDOBRONCHIAL BLOCKERS VS. DLT
• Critically ill patients
• Rapid sequence induction
• Known and unknown difficult airway
• Postoperative intubation
• Small adult and pediatric patients
• Obese adults

55. Wire-Guided Endobronchial Blockers

56. Wire-Guided Endobronchial Blockers

57. Wire-Guided Endobronchial Blockers

58. Arndt endobronchial blocker
[Wire guided Endobronchial Blocker (WEB)]

61. Cohen Flexitip Endobronchial Blocker

62. Lung separation with a single-lumen tube, FOB, and Rt lung
bronchial blocker

63. BRONCHIAL BLOCKERS THAT ARE INDEPENDENT OF ABRONCHIAL BLOCKERS THAT ARE INDEPENDENT OF A
SINGLE-LUMEN TUBESINGLE-LUMEN TUBE
ADULTSADULTS
 Fogarty (embolectomy) catheter with a 3 ml balloon.
 It includes a stylet so that it is possible to place a curvature at the distal tip to
facilitate entry into the larynx and either mainstem bronchus .
 Balloon-tipped luminal catheters (such as foley type) may be used as bronchial
blockers.
VERY SMALL CHILDRENVERY SMALL CHILDREN (10 kg or less)
 Fogarty catheter with a 0.5 ml balloon
 Swan-ganz catheter (1 ml balloon)
* These catheters have to be positioned under direct vision; a FOB method is
perfectly acceptable; the FOB outside diameter must be approximately 2 mm to
fit inside the endotracheal tube (3 mm internal diameter or greater).
Otherwise, the bronchial blocker must be situated with a rigid bronchoscope.
* Paediatric patients of intermediate size require intermediate size occlusion
catheters and judgment on the mode of placement (i.E., Via rigid versus FOB).

64. Fogarty Embolectomy Catheters

65. FOGARTY EMBOLECTOMY CATHETERFOGARTY EMBOLECTOMY CATHETER
• Single-lumen balloon tipped catheter with a removable stylet
• In the parallel fashion, the Fogarty catheter is inserted prior to intubation
• In the co-axial fashion, the Fogarty catheter is placed through the
endotracheal tube
• Both techniques require fiberoptic bronchoscopy to direct the Fogarty
catheter into the correct pulmonary segment
• Once the catheter is in place, the balloon is inflated, sealing the airway
• Clinical limitations to the Fogarty technique
– Difficult to direct and cannot be coupled to a fiberoptic bronchoscope
– No accessory lumen for either removal of gas from the blocked segment or
insufflation of oxygen to reverse hypoxemia
– Ventilate w/ 100% O2 prior to balloon inflation to aid in gas removal

66. DISADVANTAGES OF A BLOCKER THAT IS INDEPENDENT OFDISADVANTAGES OF A BLOCKER THAT IS INDEPENDENT OF
THE SINGLE-LUMEN TUBE AS COMPARED WITH DLTTHE SINGLE-LUMEN TUBE AS COMPARED WITH DLT
 Inability to suction and/or to ventilate the lung distal to the
blocker.
 Increased placement time.
 The definite need for a fiberoptic or rigid bronchoscope.
 If bronchial blocker backs out into the trachea, the seal
between the two lungs will be lost and the trachea will be at
least partially obstructed by the blocker, and ventilation will
be greatly impaired.

67. ENDOBRONCHIAL INTUBATION WITH SINGLE-LUMEN TUBESENDOBRONCHIAL INTUBATION WITH SINGLE-LUMEN TUBES
 In adults often the easiest,quickest way for lung separation in
patients presenting with haemoptysis , either
-BLIND, OR
-FOB , OR
-guidance by surgeon from within chest
 In children it may be the simplest way to achieve OLV
DISADVANTAGESDISADVANTAGES
 Inability to do suctioning or ventilation of operative side.
 Difficult positioning bronchial cuff with inadequate ventilation of
 Rt upper lobe after Rt endobronchial intubation.

68. IN SUMMARY….
DLT is the method of choice for lung separation in most adult
patients.
The precise location can be determined by FOB .
In situations where insertion of a DLT may be difficult and/or
dangerous, separating the lungs is achieved either with a single-
lumen tube alone or in combination with a bronchial blocker (e.g.,
the Univent tube).
Therefore, regardless of what method of lung separation chosen,
there is a real need of a small-diameter FOB (for checking the
position of the DLT, placing a single-lumen tube in a mainstem
bronchus, and placing a bronchial blocker) .