Double Lumen Tubes | DLTs

Last modified: 26 September 2022, 5:11:02 PM AEST

Gems1 / 17

Left DLTs sometimes preferred to avoid occlusion of RUL bronchus
Left DLT usually adequate
Right DLT
- much less common
- L pneumonectomy
- has an irregularly shaped cuff
- very small margin of safety
Best to insert deep and pull back
- this way there is only one way to go (pull back)
need plan for blind insertion where FOB not possible
- in extremis / haemorrhage / optical obstruction

Description2 / 17

tracheal cuff
long endobronchial portion (also cuffed)
Right DLTs have an additional aperture in the bronchial cuff to allow ventilation of RUL

Indications (Absolute)3 / 17

prevent contamination of healthy lung
- lung abscess, pulmonary haemorrhage, secretions
control distribution of ventilation
- bronchopleural fistula
- major cyst / bulla
- traumatic bronchial disruption
facilitate single lung lavage
- cystic fibrosis
- pulmonary alveolar proteinosis

Indications (Relative)4 / 17

Improve surgical access
- Thoracic Aortic Aneurysm
- Lung volume reduction surgery
- Minimally invasive cardiac surgery
- Upper lobectomy
- VATS
Improve surgical access (weaker)
- Oesophageal surgery
- Middle and lower lobectomy
- Mediastinal mass reduction

Indications (Right DLT)5 / 17

Surgery involving Left Main Bronchus
- Left pneumonectomy
- Left lung transplant
- Left tracheobronchial disruption
- Left sided thoracoscopic surgery
Distorted anatomy LMB
- Aneurysm of descending thoracic aorta
- Tumour compression of left main bronchus

Risks / disadvantages6 / 17

Trauma
- endobronchial tree, larynx, supraglottic structures
Malposition
- in too far
  - collapse of unventilated segment
  - occlusion of tube tip
- not in far enough
  - failure to isolate lung
  - persistent leak through tracheal lumen
Tension PTX
- dependent lung during OLV from high ventilating pressures / volumes

Setup7 / 17

Depth8 / 17

Size / Diameter9 / 17

Insertion = clinical10 / 17

hold DLT with bronchial curve concave anteriorly
pass tip / blue bronchial cuff past cords
remove rigid stylet
insert further
- insert until bump is just proximal to cords
- rotate 180 degrees to move bump (tracheal bevel) away from posterior commissure
  - into the wider anterior commissure
- insert bump past cords
- rotate 180 degrees back
advance and rotate 90 degrees to intended side
- this is to move the tube into the desired bronchus
- rotate left for left-sided DLT
- rotate right for right-sided DLT
stop when resistance met
- ie. hold-up in bronchus
- usually 29 cm for 170 cm adult = 12 + height/10

Check position = Clinical / "blind"11 / 17

Failure rates
- Experienced = 1/20
- Inexperienced = 1/5
1: Check tracheal cuff
- Inflate tracheal cuff + ventilate
- look at equal chest wall movement
- auscultate for equal bilateral AE
2: Check bronchial cuff
- clamp tracheal catheter mount + open its port
- inflate bronchial cuff until loss of leak
3: Check tracheal cuff again
- unclamp tracheal catheter mount and close its port
- clamp bronchial catheter mount and open its port

Check position = FOB12 / 17

FOB through TRACHEAL port
- DLT is in correct bronchus
  - navigate into RMB and RUL for trifurcation
  - navigate into LMB and ensure 5 cm without branching
- cuff is endobronchial
- tracheal lumen is above the carina
FOB through BRONCHIAL port
- LEFT = look for secondary carina and 5 cm without branching
- RIGHT = adjust depth until ventilating hole is opposite RUL

Insertion = FOB13 / 17

DLT in wrong bronchus14 / 17

Difficult DLT15 / 17

One plan
- SLT + 2 x Cook Exchange Catheter 11 Fr (yellow)
- Remove SLT
- Pass DLT (one through tracheal, one through bronchial lumen)
- One of the CEC will sit in posterior commissure, enabling the DLT to glide over and past cords

Tracheostomy / laryngectomy requiring OLV16 / 17

References17 / 17