Would you use a right- or left-sided DLT?
Answer:
A left-sided DLT is preferred for most procedures. The left mainstem bronchus is much longer than the right (approximately 5.0 to 5.5 cm vs. 1.5 to 2.0 cm), allowing small movements of the tube without obstructing a bronchial division. The variable origin of the right upper lobe (1.5 to 2.0 cm below carina) may complicate maintaining a good placement of a right-sided tube. Nevertheless, in an institution where the use of right-sided DLTs is routine, no difference was found in the incidence of hypoxemia, hypercarbia, or high airway pressures between patients managed with left or right DLTs, even when infrequent users were studied. A right-sided DLT is specifically indicated in the case of pathology involving the left mainstem bronchus, such as large exophytic lesions, significant bronchial stenosis, tracheobronchial disruption, endobronchial stent, and distortion by an adjacent tumor or a thoracoabdominal aneurysm. Other indications include left pneumonectomy, sleeve resection, or lung transplantation to avoid the presence of a foreign body in the surgical field that could be included in the staple line or prevent suturing of the lung. At the end of a pneumonectomy, the stump can be protected from positive pressure ventilation by leaving the tracheal side clamped until the patient returns to spontaneous ventilation; for a left lung transplant or a sleeve resection, the right lung can be ventilated when the bronchus is open during the reconstruction phase. The only absolute contraindication for right-sided DLTs use is the presence of an anomalous takeoff of the right upper bronchus above the tracheal carina, commonly referred to as a 'pig bronchus.' The presence of any right mainstem lesion may also preclude the use of this lung isolation device.
Reference(s):
- Campos JA. Lung isolation. In: Slinger P, ed. Principle and Practice of Anesthesia for Thoracic Surgery. Cham, Switzerland: Springer; 2019:283-309.
- Ehrenfeld JM, Mulvoy W, Sandberg WS. Performance comparison of right- and left-sided double-lumen tubes among infrequent users. J Cardiothorac Vasc Anesth. 2010;24(4):598-601.
- Gropper MA, Cohen NH, Eriksson LI, et al, eds. Miller’s Anesthesia. 9th ed. Philadelphia, PA: Elsevier; 2020:1663-1700.
- Pedoto A. How to choose the double lumen-tube size and side: the eternal debate. Anesthesiol Clin. 2012;4:671-681.