Department of Anesthesia and Intensive Care, Second University of Naples, Naples, Italy.
Eur J Cardiothorac Surg. 2011 Oct;40(4):912-6. doi: 10.1016/j.ejcts.2011.01.070. Epub 2011 Jul 29.
Flexible bronchoscopy is recommended to confirm correct placement of double-lumen tubes used for thoracic anesthesia. However, there is still controversy over routine bronchoscopic confirmation of their position. This study aimed to verify the usefulness of flexible bronchoscopy for confirming the position of double-lumen tubes after blind intubation.
During a 9-month period, consecutive patients undergoing elective oncologic thoracic surgery were prospectively enrolled in the study. All patients were intubated with a left disposable polyvinyl chloride double-lumen tube. Immediately after intubation, clinical verification was made by the anesthesiologist. Then, the endoscopist performed flexible bronchoscopy with a 2.8-mm diameter Olympus(®) video bronchoscope, and verified the position of the double-lumen tube, before positioning the patient. The double-lumen tube was in optimal position, if the bronchial cuff was immediately below the tracheal carina, and there was a clear view of the left subcarina, with unobstructed left upper and lower bronchi. Misplacement of the double-lumen tube was diagnosed when the tube had to be moved (in or out) for more than 0.5 cm to correct its position. Critical malposition meant a double-lumen tube dislocated in the trachea or in the right bronchi, requiring immediate re-intubation under bronchoscopic guidance.
A total of 144 patients (44 women (42%) and 60 men (58%), with a mean age of 51 years (range 25-77 years)) were enrolled in the study. Surgical procedures included 37 right-sided and 31 left-sided thoracotomies, 22 video-assisted thoracoscopic surgeries (VATSs) (16 right-sided and six left-sided), one median sternotomy, six mediastinotomies, and seven miscellaneous procedures. In 66 (63%, 95% confidence interval 53.2-71.8%) cases, there was complete agreement between the anesthesiologist and the endoscopist. The latter diagnosed misplacement of the double-lumen tube in 33 (32%, 95% confidence interval 22.8-40.7%) patients and critical malposition in five (5%, 95% confidence interval 0.7-8.9%) cases.
After blind intubation, 37% of double-lumen tubes required repositioning by means of flexible bronchoscopy, despite positive evaluation made by the anesthesiologist. Our data suggests that initial bronchoscopic assessment should be made with the patient still in the supine position, and confirms that flexible bronchoscopy is useful in verifying the correct position of double-lumen tubes or adjusting possible misplacements, before starting thoracic surgery.
在胸科麻醉中，推荐使用纤维支气管镜来确认双腔管的正确位置。然而，对于双腔管位置的常规支气管镜确认仍存在争议。本研究旨在验证纤维支气管镜在盲插后确认双腔管位置的有用性。
在 9 个月的时间里，连续入组接受择期胸科肿瘤手术的患者进行前瞻性研究。所有患者均使用左侧一次性聚氯乙烯双腔管插管。插管后，麻醉医师立即进行临床确认。然后，支气管镜医师使用 2.8mm 直径的奥林巴斯®视频支气管镜进行纤维支气管镜检查，并在定位患者前确认双腔管的位置。如果支气管套囊正好位于气管隆嵴下方，并且能够清晰地看到左次隆嵴，左上下支气管通畅，即可认为双腔管位置理想。如果需要移动（进入或移出）超过 0.5cm 才能纠正其位置，则诊断为双腔管位置不当。如果双腔管管错位到气管或右侧支气管，需要在支气管镜引导下立即重新插管，则认为是严重错位。
共纳入 144 例患者（44 例女性（42%）和 60 例男性（58%），平均年龄 51 岁（25-77 岁））。手术包括 37 例右侧和 31 例左侧开胸手术、22 例电视辅助胸腔镜手术（VATS）（16 例右侧和 6 例左侧）、1 例正中开胸、6 例纵隔切开术和 7 例其他手术。在 66 例（63%，95%置信区间 53.2-71.8%）患者中，麻醉医师和支气管镜医师的诊断结果完全一致。后者诊断 33 例（32%，95%置信区间 22.8-40.7%）双腔管位置不当，5 例（5%，95%置信区间 0.7-8.9%）为严重错位。
尽管麻醉医师的评估为阳性，但在盲插后，仍有 37%的双腔管需要通过纤维支气管镜重新定位。我们的数据表明，在开始胸科手术前，患者仍处于仰卧位时，应进行初始支气管镜评估，并证实纤维支气管镜在验证双腔管的正确位置或调整可能的错位方面是有用的。
