Lung separation allows the anesthesiologist to provide one-lung ventilation (OLV) in patients undergoing lung resection surgery. It is also utilized to facilitate access to other thoracic structures such as the heart, the esophagus, mediastinal lymph nodes, the thoracic aorta, and the thoracic vertebrae.1,2 In addition to facilitating surgical exposure, lung separation is also indicated for prevention of contamination of the contralateral lung from bleeding, pus material, or saline lavage (in cases of hemoptysis, purulent drainage, and lung lavage, respectively), and to allow positive pressure ventilation and adequate gas exchange in the presence of a large bronchopleural fistula.
Two main techniques are used for lung separation. The first one involves a device made of disposable polyvinylchloride material, the double-lumen endotracheal tube (DLT).3 The DLT is a bifurcated tube with both an endotracheal and an endobronchial lumen and can be used to achieve isolation of either the right or left lung. The second technique involves blockade of a mainstem bronchus to allow lung collapse distal to the occlusion.4
This chapter reviews the insertion techniques and complications for both types of devices and will provide some practical recommendations for their safe and effective use.
Double-lumen endotracheal tubes (DLT) have been used in thoracic anesthesia for lung separation and one-lung ventilation (OLV) for more than 50 years, since the report of Carlens and Bjork in 1950.5 They provide excellent operating conditions when sized and placed correctly, and allow access to both ventilated and collapsed lungs for secretion clearance, independent ventilation, and bronchoscopic inspection. Today they are the commonest method of securing lung isolation and are available in sizes ranging from 26 to 41 F, with the Bronco-Cath DLT from Mallinckrodt being the most popular in North America. Other manufacturers include Argyle (Sheridan), Rusch and Portex. The Silbroncho, a newer DLT by Fuji Systems, is also available in a left-sided version only (Figure 5–1A). This device features a shorter, wire-reinforced endobronchial tip and a reduced bronchial cuff size.6 This design should provide a greater margin of safety, although its clinical effectiveness has not been reported.
A. The Silbroncho left-sided DLT. B. The Cliny right-sided DLT. Notice the long oblique bronchial cuff and the two ventilation slots for the right upper lobe (arrows). (Reproduced with permission from Campos J. Lung isolation. In: Slinger P., ed. Principles and Practice of Anesthesia for Thoracic Surgery. New York: Springer, 2011, p. 235. Copyright © Springer Science + Business Media, LLC 2011.)
Traditionally, thoracic anesthesiologists would place a DLT on the side contralateral to the surgical procedure. However, before the advent of routine fiberoptic bronchoscopy, incorrect placement was common and lead to a high incidence of avoidable hypoxemia secondary to right upper lobe obstruction. In light of this, it became the norm ...