This document discusses options for lung isolation during surgery, including double lumen tubes (DLTs) and bronchial blockers. It provides details on: 1) The history and development of DLTs from the 1950s onward, including specific DLT designs like the Carlens tube. 2) Guidance on proper DLT placement using bronchoscopy to position the endobronchial cuff below the carina in the left or right bronchus. 3) Both advantages and disadvantages of DLTs and bronchial blockers for lung isolation are outlined. Positioning DLTs requires bronchoscopy while blockers can be placed through a standard endotracheal tube but dislodge

1. Double lumen tube

2. indications for one-lung ventilation

4. OPTIONS FOR LUNG ISOLATION

5. DOUBLE-LUMEN ENDOTRACHEAL
TUBES
• Essentially two single lumen tubes bonded
together and designated either as right or left
sided.
• History: Thedevelopment of double lumen tubes
between 1950sand1960swasaresponseto fast
growing capabilities in thoracicsurgery.
• Carlens DLT for lung surgery in 1950 was a
landmark in the development of thoracic
anesthesia.

6. • In the 1960s, Robertshaw introduced design
modifications for separate left- and rightsided
DLTs, removing the carinal hook and using
larger lumina.
• In the 1980s, manufacturers introduced
disposable DLTs made of polyvinyl chloride
based on the design of the Robertshaw DLT.

7. Specific DLT
• CARLENS DOUBLE LUMEN TUBE: 1950
left sided; with carinal hook; cross sectional
shape oval in horizontal plane.

9. • Bryce smith DLT: 1959
Modification of carlens catheter with no
carinal hook.

10. • White double lumen tube: 1960
Right sided version of Carlens catheter
possessing slit in the endobronchial cuff and a
carinal hooks.

12. • Robert shaw double lumen tube: 1962
Right and left DLT
larger lumen, slotted right endobronchial cuff,
no carinal hook,
cross sectional D shaped in horizontal plane.

15. • Silbroncho double lumen tube:
made of silicone
bronchial segment is wire reinforced distal to
the tracheal cuff. It increases the flexibility and
prevent kinking; also makes tube position easy
to determine on x-ray.

17. DIFFERENTTYPESOFDLT

19. Anatomy of the Tracheobronchial Tree

21. Methods for Single-Lung Ventilation in Pediatric Patients Gregory B. Hammer, MD*†, Brett G. Fitzmaurice,
MD*, and Jay B. Brodsky, MD* Departments of *Anesthesia and †Pediatrics, Stanford University Medical
Center, Stanford, California

22. • LENGTH OF TUBE:
Height(cm)/10 + 12
For 170 cm height, tube depth of 29cm
For every 10 cm height change , 1 cm depth
change

23. Methods of Insertion

25. Positioning of Double-Lumen Tubes
• Auscultation alone is unreliable for confirmation of proper
DLT placement. Auscultation and bronchoscopy should
both be used each time a DLT is placed.
• Fiberoptic bronchoscopy is performed first through the
tracheal lumen to ensure that the endobronchial portion of
the DLT is in the left bronchus and that there is no bronchial
cuff herniation over the carina after inflation. Through the
tracheal view, the blue endobronchial cuff ideally should
be seen approximately 5 mm below the tracheal carina in
the left bronchus. It is crucial to identify the takeoff of the
right upper lobe bronchus through the tracheal view. Going
inside this right upper lobe with the bronchoscope should
reveal three orifices (apical, anterior, posterior). This is the
only structure in the tracheobronchial tree that has three
orifices

30. • malpositioning
• airway trauma

31. Advantages of Double Lumen Tubes
• Easier to position
• Can be positioned without bronchoscopy
• Less time is required to position as compared with EBB
• More rapid lung collapse as compared with EBB
• Less likely to be displaced as compared with EBB
• Allows either lung to be ventilated, collapsed, and re-
expanded
• Each lung can be suctioned adequately
• Each lung can be inspected with a bronchoscope
• Continuous positive airway pressure (CPAP) can be
easily applied to operated lung
• Enables independent lung ventilation in ICU.

32. Disadvantages of Double Lumen Tubes
• It may be impossible to place a DLT in a patient with a difficult
airway
• The large size and design of DLTs can cause airway damage during
insertion, prolonged use, and removal
• There can be a problem in proper placement especially if the
tracheal or bronchial anatomy is severely distorted
• Lesions within the trachea, like tumors, are relative
contraindications to DLT placement
• If patient’s condition necessitates mechanical ventilation
postoperatively, changing a DLT to a single-lumen ETT at the end of
surgery can be hazardous
• Intubated patient from ICU coming for a surgery requiring lung
isolation would require change of single-lumen ETT to a DLT, which
can be dangerous in patients who are fluid resuscitated and have
airway edema, those with cervical spine injuries, difficult airways,
and in those that cannot tolerate periods of apnea
• DLTs are manufactured in limited sizes 28, 35, 37, 39, and 41 French
and are often too big for the majority of pediatric patients
• Lumens of DLTs are narrow as compared to single lumen tube.

33. BRONCHIAL BLOCKERS
• In 1935, Archibald used a rubber bronchial blocker to
facilitate lung surgeries first time in history.

36. EZ bronchial blocker

38. Advantages of Blockers
• Unlike double lumen tubes, EBB adds no further complexity to intubation
• Offers a distinct advantage in the intubation of difficult upper airways
• Useful in pediatric patients in whom the tracheobronchial size may not
accommodate even the smallest double lumen tube
• Lung isolation in distorted neck (e.g. burns contracture, postradiation) and
tracheobronchial anatomy (by extraluminal tumors or thoracic aortic
aneurysm etc.), where positioning of DLT is difficult or impossible
• EBB can be inserted through DLT intraoperatively as a rescue method in
case of failed lung isolation using DLT
• Repositioning is possible in lateral decubitus, if the blocker is
malpositioned after giving position for thoracotomy
• Rupture of the tracheal cuff during intubation is not an uncommon
problem when using DLTs, which, on occasion, requires the use of multiple
DLT tubes. This problem is not seen with the use of EBB
• EBB can be used when ETT is already in place (oral, nasal, tracheostomy)
• Not necessary to change ETT if postoperative ventilation required
• Allows selective lobar blockade
• Useful for patients requiring nasotracheal intubation.

39. Disadvantages of Blockers
• Tedious final placement after intubation • Final placement to achieve adequate lung
isolation takes little longer than DLT insertion and requires bronchoscopic guidance
• Difficult to place when bronchoscopic visualization is limited by massive hemoptysis
• EBBs cannot be used when the side of the bleeding is unknown in case of
intrapulmonary hemorrhage
• Dislodgement is more common with bronchial blockers than in DLTs during positioning
and surgical manipulation of lung
• By blocking up the pathological side, it is difficult to monitor continued bleeding or
secretions
• Lung collapse is slower though final quality of surgical exposure is similar with both DLTs
and EBBs
• Inclusion of bronchial blocker or distal wire loop of Arndt blocker in stapler during lung
surgery has been reported and requires good communication between the surgeon and
anesthetist
• Inflated balloon may slip in trachea causing blockade of ETT and obstruction to
ventilation
• Due to very narrow suction channel suctioning of blood or thick secretions is difficult
• Bronchial blockers present the potential risk of perforating a bronchus or lung
parenchyma
• Sizes not available for children less than 1 year.

40. Endobronchial tube