Which
sided double-lumen endobronchial tube should be used for this patient?
There is no one correct answer to this
question. Different approaches to the choice of double-lumen endobronchial tube
depend on the side of thoracotomy. In this case of a left thoracotomy, either a
left- or right-sided tube can be selected. These authors agree that left-sided
tube placement is more prudent in this situation. In the adult, the left
mainstem bronchus is 4–5 cm in length, compared with 2–3 cm for the right
mainstem bronchus. The right upper lobe bronchus is more likely to be
accidentally occluded by the endobronchial tube than is the left upper lobe
bronchus. Resection of the left lung will necessitate continuous ventilation of
the right lung. Obstruction of the right upper lobe bronchus would likely lead
to hypoxemia during one-lung ventilation. For this reason, some
anesthesiologists routinely place a left-sided double-lumen tube, regardless of
the side of thoracotomy, unless this is specifically contraindicated by the
presence of a diseased left mainstem bronchus, or if the bronchus will likely
become part of the surgical field.
Some anesthesiologists routinely place the
endo-bronchial tube on the side ipsilateral to pulmonary resec-tion. With this
arrangement, obstruction of the upper lobe bronchus by the endobronchial tube
is not as likely to cause hypoxemia because this is the lung to be deflated
during one-lung ventilation. Also, before chest closure, reinflation of the
remaining lung ipsilateral to the tube can be verified by direct inspection.
Failure to reinflate the upper lobe is treated by deflation of the bronchial
cuff so that it can be ventilated from the tracheal lumen. Alternatively, the
double-lumen tube can be withdrawn until the distal end of the endobronchial
tube is proximal to the upper lobe bronchial orifice. In the case of a
pneu-monectomy, the tube must be withdrawn to a position where the distal end
of the tube is in the trachea before divi-sion of the main bronchus. Withdrawal
may also become necessary if the intubated bronchus is involved in the surgery.
A different approach used by a smaller
percentage of anesthesiologists is to routinely place the double-lumen tube
into the nonoperative side. This strategy prevents damage from placing the tube
into a diseased bronchus. Placement of a right-sided tube for a left
thoracotomy, however, may lead to hypoxemia during one-lung ventilation, as
discussed.
Our approach is to place a left-sided
double-lumen tube for both left and right thoracotomies, unless contraindicated
by anatomy or pathology. However, during a right thoracotomy performed under
this arrangement, misplacement of the endobronchial tube too distal in the left
bronchus will occlude the left upper lobe, predisposing the patient to
hypoxemia dur-ing one-lung ventilation. This is because only the left lower
lobe will be ventilated during right lung deflation.
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