Double-Lumen Endotracheal Tube Placement

Absolute Indications

• Lung isolation
• Infection (prevent contamination of the non-affected lung)
• Pulmonary hemorrhage
• Control of the distribution of ventilation
• Bronchopleural fistula (to prevent air volume loss through the fistula)
• Bronchopleural cutaneous fistula (to prevent air volume loss through the fistula)
• Surgical opening of major conducting airway
• Giant unilateral cyst or bulla
• Life-threatening hypoxemia from unilateral pulmonary process
• Unilateral bronchopulmonary lavage

Relative Indications

• Surgical exposure (strong indication)
• Thoracic aortic aneurysm
• Pneumonectomy
• Upper lobectomy
• Mediastinal exposure
• Thoracoscopy
• Surgical exposure (moderate indication)
• Middle and lower lobectomy
• Subsegmental resection
• Esophageal resection
• Procedures on the thoracic spine
• Post-cardiopulmonary bypass status after removal of totally occluding chronic unilateral pulmonary emboli
• Severe hypoxemia from unilateral pulmonary process
• Requirement for differential ventilation for critical care

Absolute Contraindications

• Patient refusal
• Airway (especially laryngeal or tracheal) mass that may be occluding, dislodged, traumatized, or hemorrhaging

Relative Contraindications

• Patients requiring rapid intubation to prevent aspiration of gastric contents
• Patients who are likely to be difficult to intubate

• Laryngoscope
• Fiberoptic bronchoscope—small diameter
• Soft-tipped airway clamp
• Double-lumen endotracheal tube of appropriate size and configuration
• Lubricant (e.g., Surgilube or 2% lidocaine jelly)
• Capnograph or colorimetric end-tidal CO₂ detector
• Adhesive tape

The trachea is a fibrocartilaginous tube that begins in the neck below the glottis and lies anterior to the esophagus.The anterior aspect of the trachea is defined by a series of C-shaped rings of cartilage. The thoracic portion of the trachea extends approximately 5-6 cm before terminating at the carina where it divides into the right and left mainstem bronchi. The mainstem bronchi pass inferolaterally from the carina and are also supported by cartilaginous C-shaped rings. It should be noted that in the trachea, the rings are incomplete, and the posterior wall of the trachea is ringless. The rings become almost circumferential in the bronchi. This difference allows differentiation of the tracheal airway from that of a bronchus via fiberoptic visualization of the rings to determine whether they are C-shaped or circumferential.

The right main bronchus is wider and shorter then the left bronchus, approximately 2.5 cm versus 5 cm, and has a more vertical angle. It divides into 3 segmental bronchi supplying the right upper, middle, and lower lobes of the lung. The takeoff of the right upper lobe bronchus varies considerably but usually occurs very close to the right upper lobe bronchus.

The left main bronchus divides into two segments, the left superior and left inferior branches, supplying the left upper lobe and lingula and the left lower lobe, respectively.

• When removing the DLET at the end of the procedure, first suction each lumen of the tube. Carefully deflate both cuffs, and remove the tube while giving a positive-pressure breath.
• In patients who require a single-lumen tube for postoperative ventilation, the tube may be inserted under direct laryngoscopy following removal of the DLET when no airway difficulty is expected.
• A properly sized airway exchange catheter may facilitate re-intubation. After suctioning both lumens and ensuring an appropriate level of anesthesia, pass the exchange catheter down either lumen of the DLET and gently remove the DLET over it, ensuring that the exchange catheter is left in place. Place a single-lumen endotracheal tube over the exchange catheter and gently insert. A laryngoscope placed to lift the tongue off of the posterior pharynx may ease placement.
• Airway edema during surgery or resulting from placement of the DLET can make airway management more difficult than during the original DLET placement.

• Failed intubation
• Malposition of the tube during surgery with inadequate lung isolation, hypoxemia, or herniation of the endobronchial cuff causing contralateral obstruction
• Traumatic injury to the airway during placement or removal
• Hoarseness
• Sore throat
• Ecchymosis of the mucous membranes
• Arytenoid dislocation
• Vocal cord rupture
• Vocal cord paralysis
• Tracheal or bronchial laceration
• Tracheobronchial rupture
• Pneumothorax
• Hemorrhage
• Tracheal or bronchial tissue necrosis due to excessive pressure in the DLET cuffs
• Recurrent laryngeal nerve injury
• Amputation of the hook from a Carlens tube and resulting airway foreign body