Use of the 26-French double-lumen tube for lung isolation in children.

Techniques for lung isolation in small children are limited to mainstem intubation and the use of bronchial blockers. Although the Marraro tube is a customized double-lumen tube for infants, the smallest commercially available double-lumen tube is 26 French (Rüsch Bronchoparts, Teleflex Medical, Athlone, Ireland). Reviews of pediatric lung isolation techniques recommend the 26-French double-lumen tube (26F DLT) for patients 8 to 10 years and older. However, there is only occasional mention of the actual use of the 26F DLT in the literature. From 2007 to 2012, 54 of the 26F DLTs were purchased by this department and 18 were used by the author. The medical records for these 18 patients were reviewed after approval by the institutional review board and after waiver for consent was granted. Fourteen patients underwent intubation with a 26F DLT for surgical procedures. Five procedures were scheduled thoracotomies, 6 procedures were completed thoracoscopically, and 3 procedures started thoracoscopically but were converted to open for surgical reasons. One patient with pulmonary alveolar proteinosis underwent 4 nonsurgical procedures with whole-lung lavage. He previously had undergone intubation with larger double-lumen tubes and had developed subglottic stenosis requiring surgical dilation. Only left-sided double-lumen tubes were used. Placement was confirmed with a 2.2-mm fiberoptic bronchoscope (LFP Olympus, Olympus America Inc., Center Valley, PA). Lung isolation was successful in all cases. Eleven times the left lung was ventilated, 7 times the right. Eleven of 14 patients undergoing a surgical procedure had an epidural placed. All patients were extubated successfully at the end of their procedure. No airway injuries were recorded. Of particular interest were the age, weight, and height distribution (Table 1). The patient who previously had developed subglottic stenosis after use of larger DLTs was 15 years at the time of intubation with the 26F DLT and had two separate sessions with rightand left-lung lavage on consecutive days 6 months apart. He was 47.9 kg/151 cm and 51 kg/ 155 cm, respectively. The other 14 patients were between 7 years 3 months and 12 years 3 months old, weighed between 25.6 and 45.1 kg, and were between 129 and 146 cm tall. Studies of the airway dimensions in children show that both the trachea and mainstem bronchi are seldom round, with a wide range in transverse or anteroposterior dimensions. Bronchial diameter also is unreliably predictable from the tracheal diameter. Because of the incomplete tracheobronchial rings, trachea and bronchi to a certain degree may adapt to the shape of an inserted tube; however, this may not be true for the level of the cricoid cartilage.