Right-sided double-lumen tubes: need for design improvement and better insertion technique?

To the Editor: Sazak et al. (1) recently published a randomized study comparing 2 right-sided double-lumen tubes (R-DLTs) from different manufacturers. Assessing R-DLTs’ positions by bronchoscopy, they showed a 40% to 50% nonoptimal placement in the supine position and a 30% to 35% nonoptimal placement following turning the patient in lateral decubitus without any statistically significant difference between the 2 different groups. Some 5 years ago, we published a randomized study comparing the original R-DLT, Broncho-Cath® from Mallinckrodt Medical, to an on-site modified (enlarged lateral orifice) R-DLT (2). Evaluation by bronchoscopy immediately after mobilizing the patient in lateral decubitus showed that the standard R-DLT position was nonoptimal in 63% compared to 23% for the modified R-DLT (P = 0.0121) and remained nonoptimal after optimizing the position in 26% for the standard R-DLT in contrast to only 3% with the modified tube (P = 0.0109). Although the studies’ endpoints were different, they added to the early publication from McKenna et al. (3) and clearly demonstrated that the classic design of the R-DLT is inadequate. By contrast, our on-site modified R-DLT seemed to be superior to the classical design in regard to the alignment of the lateral orifice of the tube with the origin of the right upper lobe (RUL). Sazak et al. also reported some problems with the blind insertion of R-DLTs. In our study, we also described an insertion technique that we have been using for more than 20 years with very good results. Accordingly, immediately after crossing the vocal cords with the R-DLT tip, we introduce a fiberoptic bronchoscope (FOB) inside the bronchial lumen. A preliminary visualization of the right bronchial tree is then performed. After locating the RUL origin, the FOB is kept in position. Next, the R-DLT is gently glided over the FOB until the lateral orifice is aligned with the RUL origin. In our opinion, this technique allows an easy, fast, and safe R-DLT placement. We agree with the authors that R-DLTs have limited definite indications. However, to be proficient if one of those indications arises, anesthesiologists should frequently practice intubation with R-DLTs. The availability of an optimized R-DLT would help the safe utilization of this essential tool. P.S. Recently a Chinese company announced the production of a R-DLT with an enlarged lateral orifice (http:// www.ecvv.com/product/2979029.html). We hope that it will soon be available in the occidental world. Received: 28.11.2012 Accepted: 01.01.2013 Published Online: 02.01.2014 Printed: 24.01.2014 Letter to the Editor