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LETTER TO THE EDITOR

Unusual Defect in a Double-Lumen Endotracheal Tube

Department of Anaesthesia; Christian Medical College and Hospital; Vellore; Tamil Nadu, India; sanjib{at}cmcvellore.ac.in

To the Editor:

Chen et al. (1) and Lewer et al. (2) described manufacturing defects in double-lumen endotracheal tubes (DLT). We encountered an unusual defect in a DLT, detected by fiberoptic bronchoscopy.

A 35-year-old woman with bronchiectasis of the left lung underwent general anesthesia for pnemonectomy. Inspection of our reusable red rubber DLT before anesthesia did not reveal any defects. After anesthetic induction, we intubated the patient’s trachea with a right-sided, red, rubber DLT (Robert Shaw, F 35, Willy Rusch AG, Germany) in one attempt, without difficulty or stylet. Chest auscultation revealed equal breath sounds. We confirmed proper placement by clamping each lumen and confirming single-lung ventilation by auscultation.

We then attempted to confirm the correct placement of the DLT with a fiberoptic bronchoscope (3). When we tried to pass the bronchoscope into the right-sided lumen, it was blocked and our vision was obstructed. We withdrew the tube and exchanged it with another of the same caliber. Surgery proceeded uneventfully.

We passed a stylet through the first DLT to identify the location of the obstruction, but found none. We therefore split the tube to examine the site of obstruction. As shown in Figure 1, one side of the bronchial lumen had a tear leading to formation of a movable flap. This defect, hidden by the bronchial bifurcation, might have been caused during prior use of the DLT, or perhaps during sterilization.

View larger version (121K): [in this window] [in a new window]   Figure 1. Cut-section of the bronchial lumen showing the torn segment shaped like a triangular flap.

Reusable, red, rubber DLTs are used in developing countries of the world. It is not possible to visually inspect the interior of an opaque DLT, and this defect was not readily visualized on examination of the exterior. We propose a new step in Chen et al.’s (1) algorithm of identification of high airway pressures with a DLT. If a reusable, opaque, red, rubber DLT is used, verify the patency of both lumens with fiberoptic bronchoscopy before endotracheal intubation.

REFERENCES

1. 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]
2. Lewer BM, Karim Z, Henderson RS. Large air leak from an endotracheal tube due to a manufacturing defect. Anesth Analg 1997;85:944–5.[Web of Science][Medline]
3. Benumof JL. The position of a double-lumen tube should be routinely determined by fiberoptic bronchoscopy. J Cardiothorac Vasc Anesth 1993;7:513–14.[Medline]

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