Algorithms for successful repositioning of misplaced left-sided double-lumen tube inserted during lung/thoracic surgery.

Sir,

Insertion of double-lumen tubes (DLTs) (Mallinckrodt) is challenging and is carried out in lung, chest wall, mediastinal, and spine surgeries. DLTs are generally inserted for lung isolation and one lung ventilation in thoracic surgery.[1] It is particularly employed for lung cancer surgeries (pneumonectomies). The indications for insertion of left- and right-sided DLTs are distinct and defined. There have been several instances of misplacement[2] of DLT during various stages of thoracic anesthesia. An experienced thoracic anesthesiologist is recommended for successful repositioning of a misplaced DLT. Left-sided DLTs are more commonly placed due to their greater safety margin[3] as compared to right-sided DLTs. Left-sided DLT can sometimes wrongly enter the right bronchus during placement. Confirmation of its position and tube readjustment is a risky procedure, which must be done under the guidance of a fiber-optic bronchoscope.[4] We hereby present a set of four algorithms for repositioning of a left-sided DLT accidentally misplaced into the right main bronchus. The supplemental use of a direct laryngoscope in addition to fiber-optic bronchoscope during tube readjustment is also highlighted. An experienced thoracic anesthesiologist supported by a second anesthesiologist is recommended for a successful outcome.[5] Care should be taken to ensure adequate patient oxygenation and hemodynamic stability during the repositioning. There is risk of loss of airway, hypoxia, bronchospasm, rupture of DLT cuff, airway trauma, and even dislodgement of fragile cancerous tissue during repositioning.[6] These algorithms may prove helpful in the training of anesthesia residents in thoracic anesthesia. Step-wise following of these four algorithms can ensure a safe and successful tube repositioning, with improved outcomes in all thoracic surgeries, including lung resections [Figures 1–4].

Figure 1

Pyramidal algorithm for preparations to manage left-sided doublelumen tube misplaced into right bronchus

Figure 4

Flowchart algorithm suggesting use of both direct laryngoscope and fiber-optic bronchoscope guidance in misplaced double-lumen tube readjustment and position confirmation

Flow chart algorithm citing options for readjustment or reinsertion of misplaced double-lumen tube using fiber-optic bronchoscope guidance and with or without direct laryngoscopy

Flow chart algorithm highlighting double-lumen tube railroading technique over fiber-optic bronchoscope and use of direct or videolaryngoscopy for misplaced double-lumen tube repositioning

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.