title: Positioning of a double-lumen endobronchial tube without the aid of any instruments: an implication for emergency management.
abstract: BACKGROUND
  Lung isolation and preservation of normal lung are the first lines of therapy in life-threatening massive hemoptysis. If bleeding continues but the side of origin is uncertain, use of a double-lumen tube (DLT) is reasonable. Utilizing a blind method to locate the bronchial cuff of a left-sided DLT without using any instrument, a DLT (Broncho-Cath, Mallinckrodt Medical Ltd., Athlone, Ireland) was successfully positioned without delay in a patient with massive hemoptysis, where auscultation could be misleading or useless and fiberoptic bronchoscope (FOB) was inapplicable. This study was performed to discern whether this blind method could substitute for FOB verification or auscultation in most circumstances where these two methods are unavailable or inapplicable.
  
  
  METHODS
  After receiving informed consent and hospital ethics board approval, 58 elective thoracic surgical patients, aged 17 to 67 years, were enrolled in the study and divided into two groups. A conventional method using an FOB was used to locate the left-sided DLT in 29 patients (group 1). In the other 29 patients (group 2), the blind manual method was used. The left-sided DLT was inserted until some resistance was felt, at which time the bronchial cuff was inflated with approximately 2.0 mL of air. While gently holding the pilot with thumb and index finger of the nondominant hand, the DLT was slowly withdrawn until an abrupt decrease of pilot pressure was sensed. At that moment, the bronchial cuff was deflated, and the DLT was advanced approximately 1.5 cm; using an FOB, its position was checked by an independent observer not involved in positioning the DLT. Success was defined as the point when the proximal margin of the carina was within the margin of safety for the DLT, which is defined as the difference between the length of the left main bronchus and the length of the tube between the proximal margin of the left bronchial cuff and the left lumen tip. Postoperative FOB was performed to evaluate bronchial injury.
  
  
  RESULTS
  In 26 of 29 patients (group 2), the position of the DLT was bronchoscopically confirmed to be a success. The other three cases were deemed to be too shallow; specifically, the bronchial cuffs were slightly herniated onto the carina (acceptable position). This method was more traumatic than FOB-guided DLT intubation (conventional method) (p = 0.001); however, the most severe damage was erosion.
  
  
  CONCLUSIONS
  This method, which requires no specific instrument and no time-consuming technique, can be taught easily and may be used in a situation where the rapidity of lung isolation or collapse is the key to saving life. We conclude that this blind method can be an alternative to the FOB and/or auscultation for the positioning of DLT in an emergency situation.
authors.affiliation: Department of Anesthesiology and Clinical Research Institute, Seoul National University Hospital, Korea. bahkjh@plaza.snu.ac.kr
authors.forename: J H
authors.initials: JH
authors.lastname: Bahk
authors.forename: Y J
authors.initials: YJ
authors.lastname: Lim
authors.forename: C S
authors.initials: CS
authors.lastname: Kim
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001314:Auscultation; D001999:Bronchoscopy; D004638:Emergency Treatment / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D004867:Equipment Design; D005260:Female; D005336:Fiber Optic Technology; D006469:Hemoptysis / Q000000981:diagnostic imaging / Q000628:therapy*; D006801:Humans; D007442:Intubation, Intratracheal / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011859:Radiography; D013997:Time Factors; D016896:Treatment Outcome