Anesth Analg 2006;103:1057-1058
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000239057.20561.11
LETTER TO THE EDITOR
Editor-in-Chief Steven L. Shafer
Another Defect in Right-Angle Double Connector Resulting in High Peak Inspiratory Pressure During One Lung Anesthesia: A Simple and Practical Approach for Rapid Detection
Thomas Koshy, MD,
Prabhat Kumar Sinha, MD, and
Arun Vijayakumar, MD
Department of Anaesthesiology; Sree Chitra Tirunal Institute for Medical Sciences & Technology; Thiruvananthapuram, Kerala, India; pksinha{at}sctimst.ac.in (Koshy, Sinha, Vijayakumar)
To the Editor:
Chen et al. describes an unusual defect in both limbs of the OPTI-PORTTM Right Angle Double Swivel Connector, and recommends an algorithm for its identification (1). We recently encountered a similar defect that resulted in difficult ventilation and high peak inspiratory pressure (PIP), however, the defect occurred in only one of the swivel connections. We developed a simple and practical algorithm for quick detection of any defect proximal to double-lumen endotracheal tube (DLT). Our algorithm is also useful in differentiating defects and malposition of a DLT from lung disease as a cause of high airway pressure.
A 66-year-old woman weighing 55 Kg, 150 cm tall, was scheduled for right middle lobectomy. She was intubated with a 37F left-sided DLT (Mallinckrodt, Mallinckrodt Medical Athlone, Ireland). After confirming proper position of the DLT using "single connector technique"(2) and fiberoptic bronchoscopy, we encountered inadequate ventilation and high PIP, when ventilating the left lung. We changed the OPTI-PORT connector which corrected the problem. Examination of the OPTI-PORT connector revealed a membranous flap protrusion with a slit-like opening causing near total obstruction in one of the limbs.
With the single connector technique, the anesthesia circuit is first connected to the bronchial limb of DLT with a conventional angle connector, and ventilation is checked. Then, the angle connector is transferred to tracheal limb of DLT to check ventilation of the other lung. There is no clamping and unclamping in this technique (2,3), whereas in "conventional" double connector technique, alternate clamping and unclamping of the tracheal and bronchial limbs is required as ventilation is checked in each hemithorax (4).
Based on this experience, we propose a simple algorithm to identify and to help prevent recurrence of such mishaps with DLT (Fig. 1). We believe this algorithm is more practical than that proposed by Chen and colleagues.
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Figure 1. A simple and practical algorithm for rapid identification of high airway pressure with DLT.  = diagnosis; DLT = double lumen tube; FOB = fiberoptic bronchoscopy; and PIP = peak inspiratory pressure.
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Footnotes
Dr. Wamp did not reply.
REFERENCES
- Chen HS, Jawan B, Tseng, CC, et al. Difficult ventilation with a double-lumen endotracheal tube. An unusual manufacturing defect. Anesth Analg 2005;101: 1094–7.[Abstract/Free Full Text]
- Pfitzner J, Alexander HI, Hung PK. The single connector technique for initial placement of double-lumen tubes. Anaesth Intensive Care 2004;32:685–92.[Web of Science][Medline]
- Miller RD. Anesthesia. 5th ed. Philadelphia: Churchill Livingstone, 2000.
- Benumof JL, Alfery DD. Anesthesia for thoracic surgery. In: Miller RD, ed. Anesthesia. 5th ed. Philadelphia: Churchill Livingstone, 2000:1695.
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