Misplacement of left-sided double-lumen tubes into the right mainstem bronchus: Decreased bronchial tube angulation is a cause?

Sir,

For one-lung ventilation during thoracic surgery, a left-sided double-lumen endobronchial tube (DLT) is preferred over a right-sided DLT because of its greater margin of safety for correct positioning in the left mainstem bronchus (LMB).[1] DLTs can be advanced into the mainstem bronchus either blindly or under fiberoptic bronchoscopy (FOB) guidance. Blind advancement may result in the misplacement of left-sided DLTs into the right mainstem bronchus (RMB). Misplacement of left-sided DLTs into the RMB may cause blockade of right upper lobe ventilation, which may result in its collapse.[2]

Here, we report a case of misplacement of left-sided DLT into RMB in a 45-year-old female patient posted for removal of mediastinal mass and right lower lobe lobectomy. A written informed consent was obtained from the patient relative. Anesthesia was induced with fentanyl 2 μg/kg, propofol 2 mg/kg, and vecuronium 0.08 mg/kg. The trachea was intubated with 35-F, left-sided DLT (Blueline endotracheal tube, Portex, Smiths Medicals, Mexico) for one-lung ventilation. A 90° counterclockwise rotation after crossing glottis was done to place the bronchial tip into LMB. On auscultation, we found misplacement of left-sided DLT in RMB, which was confirmed by FOB. The DLT was re-advanced blindly while turning the patient's head to the right with the DLT 180° counterclockwise rotated, but again we found its misplacement into RMB. The DLT was taken out and the trachea was re-intubated with another DLT of same size. This time the placement of DLT was successful and was confirmed by FOB. On inspecting the first DLT, we noticed that the angulation of distal bronchial tip was reduced significantly in comparison to the new DLT of same size, as shown in Figure 1.

Figure 1

Difference in the angulation of two double-lumen endobronchial tubes

Discussion

Techniques used to prevent misplacement of left-sided DLT into RMB include 90° counterclockwise rotation after crossing glottis, re-advancement with turning the patients’ head to the right with the DLT 180° counterclockwise rotated, and using FOB. The entire procedure was performed while supplying 100% oxygen and each step lasted no more than 10 s. DLT misplacement occurs more frequently in females, in patients of short stature or with narrow trachea and bronchi, and when small-sized DLTs are used.[3] The larger internal diameter and vertical divergence from the carina of the RMB makes the chances of DLT migration into RMB more common.

In our case, misplacement of left-sided DLT into RMB was due to loss of bronchial tip curvature. On literature search, we found no recommendations from the manufacturer regarding the curvature of bronchial tube. The curvature can be modified using a stylet, which is usually removed when the tip crosses the glottis during intubation. The angulation is important for the correct placement of the DLT, and hence, there should be a checklist specifying the angle/curvature for the safe and correct placement of the tube.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.