Sequential rotation to insert a left double-lumen endotracheal tube using the GlideScope®
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KeywordsVocal Cord Direct Laryngoscopy Left Main Bronchus Sequential Rotation Bronchial Lumen
To the Editor:
The GlideScope® videolaryngoscope (GVL) (Verathon, Bothell, WA, USA) allows the glottic opening to be visualized easily. However, it poses difficulties when double-lumen endotracheal tubes (DLT) are advanced into the trachea.1,2 This suggests that the traditional method of advancing the DLT may be insufficient if used with the GVL. A combination of several factors can decrease the operator’s ability to manipulate this tube proficiently, including the complex shape of the DLT,3 the angulation of the GVL blade, and the indirect viewing of the airway.4
A main feature of the DLT is the presence of a concave distal and a concave proximal curvature. Under direct laryngoscopy, the conventional method of insertion entails advancing the tube with the distal curvature directed anteriorly. Once the bronchial tip passes the vocal cords, the DLT is rotated 90° counter clockwise, a rotation that facilitates the alignment of the bronchial tip with the left main bronchus.3
With the GVL, advancement of a single-lumen tube through the glottis may be difficult or impossible, because it tends to advance anteriorly and thus nearly perpendicular to the axis of the trachea.5 This difficulty can also arise during an attempt to advance a DLT with the GVL, because the distal concave curvature directs the tip of the bronchial lumen more anteriorly.
Contrary to the conventional method of inserting the DLT where only its alignment with the main bronchus is considered, when using the GVL, the absent line-of-sight must be taken into account during the procedure. Therefore, we suggest aligning the DLT with the trachea first—not with the bronchus—to guarantee the insertion of the bronchial cuff into the trachea. While this is accomplished with the first rotation, the second rotation helps to align the bronchial tip with the axis of the bronchus and to move the tip away from the posterior wall of the trachea while advancing the tube until final depth.
So far, we have successfully used this DLT sequential rotation in a dozen patients without complications. The GVL was used in two patients after a failed intubation with the conventional laryngoscope, and it was used in the remaining patients as a primary airway device after suspecting a potentially difficult direct laryngoscopy. All the intubations were accomplished on first attempt.
This technique complements the traditional method of advancing the DLT, because it takes into consideration both the advantages and shortcomings of the GVL. With the expanded use of videolaryngoscopy in our clinical practice, we must adapt conventional procedures to the new technologies.
We sincerely thank Mr. Jeffrey Loerch, BA, CMI for his excellent work in preparing the related medical illustrations.
Source of financial support
Provided solely from departmental sources.
Conflicts of interest
Video Sequential rotation to insert a left double-lumen endotracheal tube (DLT) using the GlideScope® (available as Electronic Supplementary Material).(WMV 4232 kb)
- 3.Slinger PD, Campos JH. Anesthesia for thoracic surgery. In: Miller RD (Ed.). Miller’s Anesthesia, 7th ed., vol. 2. New York: Churchill Livingstone; 2009: 1833-8.Google Scholar