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LETTER TO THE EDITOR

Editor's note: Due to a publisher's error, the following response by Amar et al. to the Letter to the Editor by Lohser and Brodsky published in the July 2008 issue (Anesth Analg 2008;107:342) was left out of the July issue. The publisher apologizes for the error.

In Response:

Departments of Anesthesiology and Critical Care Medicine, and Surgery, Clinical Memorial Sloan-Kettering Cancer Center and Weill Medical College of Cornell University; New York, NY, amard{at}mskcc.org

Drs. Lohser and Brodsky1 raise the measurement of left mainstem bronchial diameter as an indicator of proper sizing for left-sided double-lumen tubes (DLT), and suggest that use of this technique in our recent study may have yielded different results. While we don't question the mathematical formulas, none of the clinicians involved in the study practice this method despite over 80 years of cumulative experience successfully placing DLT in an institution where >2000 thoracic procedures are performed each year. Accordingly, our work addressed the prevalent practice at our institution of sizing DLT by height and/or gender. Although the participating anesthesiologists were all initially trained to use conventional methods at a time when fiberoptic bronchoscopy was not readily available, the strength of our study design is that we compared outcomes in a single clinical setting between anesthesiologists whose practice now differs.2 Our data showed that in regard to intraoperative end-points reflecting the adequacy of lung collapse and preservation of oxygenation, both our "conventional" approach and intentional downsizing are comparable. While we appreciate the interpretation by Drs. Lohser and Brodsky that our observed "failure to isolate" temporarily may well have been due to undersized DLT, we maintain our stated conclusion that malposition was responsible.2

With respect to the rare event of DLT causing airway damage, the authors cite their own early data indicating that rupture in particular is most frequently associated with small DLT,3 perhaps due to the need for relative cuff hyperinflation. While we included this citation in our manuscript, we also included references indicating the possibility of trauma from either small or large DLT,4–6 a risk also previously noted by Brodsky and Lemmens7 and cited in our paper. Furthermore, despite use of down-sized DLT we rarely found that more than 3 mL was required to provide an adequate seal. The authors further point to the theoretical increase in auto-PEEP due to downsizing of DLT. While experimental studies have clearly shown differences in the gas flow characteristics between large and small DLT, neither results of the our study nor our extensive clinical experience have given any indication that the 0.6 mm difference between a 35 and 39 FR internal diameter has had any deleterious effects in our patient population. Indeed, our reported incidence of intraoperative hypoxemia and recently published incidence of acute lung injury in 1,428 patients undergoing lung resection are low and consistent with the literature.8

REFERENCES

1. Lohser J, Brodsky JB. Undersizing left double-lumen tubes. Anesth Analg 2008; 107:342[Free Full Text]
2. Amar D, Desiderio DP, Heerdt PM, Kolker AC, Zhang H, Thaler HT. Practice patterns in choice of left double-lumen tube size for thoracic surgery. Anesth Analg 2008;106:379–83[Abstract/Free Full Text]
3. Fitzmaurice BG, Brodsky JB. Airway rupture from double-lumen tubes. J Cardiothorac Vasc Anesth 1999;13:322–9[Web of Science][Medline]
4. Hannallah MS, Benumof JL, Bachenheimer LC, Mundt DJ. The resting volume and compliance characteristics of the bronchial cuff of left polyvinyl chloride double-lumen endobronchial tubes. Anesth Analg 1993;77:1222–6[Abstract/Free Full Text]
5. Wagner DL, Gammage GW, Wong ML. Tracheal rupture following the insertion of a disposable double-lumen endotracheal tube. Anesthesiology 1985;63:698–700[Web of Science][Medline]
6. Kaloud H, Smolle-Juettner FM, Prause G, List WF. Iatrogenic ruptures of the tracheobronchial tree. Chest 1997;112:774–8[Web of Science][Medline]
7. Brodsky JB, Lemmens HJM. Tracheal width and left double-lumen tube size: a formula to estimate left-bronchial width. J Clin Anesth 2005;17:267–70[Web of Science][Medline]
8. Alam N, Park BJ, Wilton A, Seshan VE, Bains MS, Downey RJ, Flores RM, Rizk N, Rusch VW, Amar D. Incidence and risk factors for lung injury following lung cancer resection. Ann Thorac Surg 2007;84: 1085–91[Abstract/Free Full Text]

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