Lung Isolation Versus Lung Separation: Double-Lumen Tubes

  • Laszlo L. Szegedi
  • Marc LickerEmail author


The separation of the lungs today means a completed “anatomical” sealing as obtained with a double-lumen tube (DLT), and the isolation of the lung means a “functional” sealing as with a bronchial blocker (BB). In the first case, there are some absolute indications in which a protective strategy for the contralateral lung is needed, including potentially life-threatening conditions. Maintenance of adequate gas exchange, prevention of soiling/flooding the other lung with contaminated material/blood and avoidance of barotrauma are best achieved with DLTs in these situations. Some specific surgical interventions require lung separation with a DLT. In all the other situations, in which lung separation is a relative indication, lung isolation with a BB could be best considered. Overall, the DLT remains the gold standard technique in various surgical procedures requiring lung separation/isolation and are favored by most thoracic anesthesiologists worldwide. This chapter discusses the differences between lung isolation and lung separation, their respective indications, as well as the means of achieving it. Double-lumen tubes (either right or left sided) are presented with their advantages/disadvantages as compared to bronchial blockers.


Anesthesia One-lung Ventilation (OLV) Lung separation Lung isolation Double-lumen tubes (DLTs) Bronchial blockers (BBs) 


  1. 1.
    Brodsky JB, Lemmens HJ. The history of anesthesia for thoracic surgery. Minerva Anestesiol. 2007;73(10):513e24.Google Scholar
  2. 2.
    Rovenstine E. Anesthesia for intrathoracic surgery: the endotracheal tube and endobronchial techniques. Surg Gynecol Obstet. 1936;63:325e30.Google Scholar
  3. 3.
    Macintosh R, Leatherdale RA. Bronchus tube and bronchus blocker. Br J Anaesth. 1955;27(11):556e7.Google Scholar
  4. 4.
    Pardolesi A, Park B, Petrella F, Borri A, Gasparri R, Veronesi G. Robotic anatomic segmentectomy of the lung: technical aspects and initial results. Ann Thorac Surg. 2012;94(3):929e34.Google Scholar
  5. 5.
    Iwata H. Minimally invasive pulmonary surgery for lung cancer, up to date. Gen Thorac Cardiovasc Surg. 2013;61(8):449e54.Google Scholar
  6. 6.
    Rocco G. One-port (uniportal) video-assisted thoracic surgical resections--a clear advance. J Thorac Cardiovasc Surg. 2012;144(3):S27e31.Google Scholar
  7. 7.
    Steenwyk B, Lyerly R 3rd. Advancements in robotic-assisted thoracic surgery. Anesthesiol Clin. 2012;30(4):699e708.Google Scholar
  8. 8.
    Campos JH. Which device should be considered the best for lung isolation: double-lumen endotracheal tube versus bronchial blockers. Curr Opin Anaesthesiol. 2007;20(1):27e31.Google Scholar
  9. 9.
    Della Rocca G, Langiano N, Baroselli A, Granzotti S, Pravisani C. Survey of thoracic anesthetic practice in Italy. J Cardiothorac Vasc Anesth. 2013;27(6):1321e9.Google Scholar
  10. 10.
    Eldawlatly A, Turkistani A, Shelley B, El-Tahan M, Macfie A, Kinsella J. Anesthesia for thoracic surgery: a survey of middle eastern practice. Saudi J Anaesth. 2012;6(3):192e6.Google Scholar
  11. 11.
    Shelley B, Macfie A, Kinsella J. Anesthesia for thoracic surgery: a survey of UK practice. J Cardiothorac Vasc Anesth. 2011;25(6):1014e7.Google Scholar
  12. 12.
    Campos JH. Update on tracheobronchial anatomy and flexible fiberoptic bronchoscopy in thoracic anesthesia. Curr Opin Anaesthesiol. 2009;22(1):4e10.Google Scholar
  13. 13.
    Campos JH, Hallam EA, Ueda K. Training in placement of the left-sided double-lumen tube among non-thoracic anaesthesiologists: intubation model simulator versus computer-based digital video disc, a randomised controlled trial. Eur J Anaesthesiol. 2011;28(3):169e74.Google Scholar
  14. 14.
    Bustamante S, Bose S, Bishop P, Klatte R, Norris F. Novel application of rapid prototyping for simulation of bronchoscopic anatomy. J Cardiothorac Vasc Anesth. 2013;28(4):1122–5.PubMedGoogle Scholar
  15. 15.
    Failor E, Bowdle A, Jelacic S, Togashi K. High-fidelity simulation of lung isolation with double-lumen endotracheal tubes and bronchial blockers in anesthesiology resident training. J Cardiothorac Vasc Anesth. 2014;28:865–9.PubMedGoogle Scholar
  16. 16.
    Campos JH. Progress in lung separation. Thorac Surg Clin. 2005;15:71–83.PubMedGoogle Scholar
  17. 17.
    Cohen E. Pro: the new bronchial blockers are preferable to double-lumen tubes for lung isolation. J Cardiothorac Vasc Anesth. 2008;22:920–4.PubMedGoogle Scholar
  18. 18.
    Campos JH. An update on bronchial blockers during lung separation techniques in adults. Anesth Analg. 2003;97:1266–74.PubMedGoogle Scholar
  19. 19.
    Cohen E. The Cohen flexitip endobronchial blocker: an alternative to a double lumen tube. Anesth Analg. 2005;101:1877–9.PubMedGoogle Scholar
  20. 20.
    Narayanaswamy M, Lacroix M, Kanellakos G, et al. A clinical comparison of three designs of bronchial blockers with double-lumen tubes for lung isolation. Anesth Analg. 2007;104:123.Google Scholar
  21. 21.
    Prabhu MR, Smith JH. Use of the Arndt wire-guided endobronchial blocker. Anesthesiology. 2002;97:1325.PubMedGoogle Scholar
  22. 22.
    Kamaya H, Krishna PR. New endotracheal tube (univent tube) for selective blockade of one lung. Anesthesiology. 1985;63:342–3.PubMedGoogle Scholar
  23. 23.
    Slinger P. Con: the new bronchial blockers are not preferable to double-lumen tubes for lung isolation. J Cardiothorac Vasc Anesth. 2008;22(6):925e9.Google Scholar
  24. 24.
    Harris K, Chalhoub M, Maroun R, Elsayegh D. Endotracheal tube exchangers: should we look for safer alternatives? Heart Lung J Crit Care. 2012;41(1):67e9.Google Scholar
  25. 25.
    McLean S, Lanam CR, Benedict W, Kirkpatrick N, Kheterpal S, Ramachandran SK. Airway exchange failure and complications with the use of the Cook Airway Exchange Catheter(R): a single center cohort study of 1177 patients. Anesth Analgesia. 2013;117(6):1325e7.Google Scholar
  26. 26.
    Seymour AH, Prasad B, McKenzie RJ. Audit of double-lumen endobronchial intubation. Br J Anaesth. 2004;93:525–7.PubMedGoogle Scholar
  27. 27.
    Brodsky JB, Lemmens HJ. Tracheal width and left double-lumen tube size: a formula to estimate left bronchial width. J Clin Anesth. 2005;17:267–70.PubMedGoogle Scholar
  28. 28.
    Brodsky JB, Benumof JL, Ehrenwerth J, et al. Depth of placement of left double-lumen endobronchial tubes. Anesth Analg. 1991;73:570–2.PubMedGoogle Scholar
  29. 29.
    Bahk JH, Oh YS. Prediction of double-lumen tracheal tube depth. J Cardiothorac Vasc Anesth. 1999;13:370–1.PubMedGoogle Scholar
  30. 30.
    Merli G, Guarino A, Della Rocca G, et al. Recommendations for air way control and difficult air way management in thoracic anesthesia and lung separation procedures. Minerva Anesthesiol. 2009;75:59–96.Google Scholar
  31. 31.
    Cohen E, Benumof JL. Lung separation in the patient with a difficult airway. Curr Opin Anesthesiol. 1999;12:29–35.Google Scholar
  32. 32.
    Arndt GA, Buchika S, Kranner PW, et al. Wire-guided endobronchial blockade in a patient with a limited mouth opening. Can J Anaesth. 1999;46:87–9.PubMedGoogle Scholar
  33. 33.
    Benumof JL. Difficult tubes and difficult airways. J Cardiothorac Vasc Anesth. 1998;12:131–2.PubMedGoogle Scholar
  34. 34.
    Klafta JM, Ovassapian A. Lung separation and the difficult airway. Probl Anesth. 2001;13:69–77.Google Scholar
  35. 35.
    Campos JH, Hallam EA, Van Natta T, Kernstine KH. Devices for lung isolation used by anesthesiologists with limited thoracic experience. Anesthesiology. 2006;104:261–6.PubMedGoogle Scholar
  36. 36.
    Dumans-Nizard V, Liu N, Laloe PA, Fischler M. A comparison of the deflecting-tip bronchial blocker with a wire-guided blocker or left-sided double-lumen tube. J Cardiothorac Vasc Anesth. 2009;23:501–5.PubMedGoogle Scholar
  37. 37.
    Mourisse J, Liesveld J, Verhagen A, van Rooij G, van der Heide S, Schuurbiers-Siebers O, et al. Efficiency, efficacy, and safety of EZ-blocker compared with left-sided double-lumen tube for one-lung ventilation. Anesthesiology. 2013;118:550–61.PubMedGoogle Scholar
  38. 38.
    Knoll H, Ziegeler S, Schreiber JU, Buchinger H, Bialas P, Semyonov K, et al. Airway injuries after one-lung ventilation: a comparison between double-lumen tube and endobronchial blocker: a randomized, prospective, controlled trial. Anesthesiology. 2006;105:471–7.PubMedGoogle Scholar
  39. 39.
    Campos JH, Reasoner DK, Moyers JR. Comparison of a modified double-lumen endotracheal tube with a single-lumen tube with enclosed bronchial blocker. Anesth Analg. 1996;83:1268–72.PubMedGoogle Scholar
  40. 40.
    Campos JH, Massa FC. Is there a better right-sided tube for one-lung ventilation? A comparison of the right-sided double-lumen tube with the single-lumen tube with right-sided enclosed bronchial blocker. Anesth Analg. 1998;86:696–700.PubMedGoogle Scholar
  41. 41.
    Bauer C, Winter C, Hentz JG, Ducrocq X, Steib A, Dupeyron JP. Bronchial blocker compared to double-lumen tube for one-lung ventilation during thoracoscopy. Acta Anaesthesiol Scand. 2001;45:250–4.PubMedGoogle Scholar
  42. 42.
    Grocott HP, Darrow TR, Whiteheart DL, Glower DD, Smith MS. Lung isolation during port-access cardiac surgery: double-lumen endotracheal tube versus single-lumen endotracheal tube with a bronchial blocker. J Cardiothorac Vasc Anesth. 2003;17:725–7.PubMedGoogle Scholar
  43. 43.
    Lehmann A, Zeitler C, Lang J, Isgro F, Kiessling AH, Boldt J. A comparison of the Arndt endobronchial blocker with a double lumen tube in robotic cardiac surgery. Anasthesiol Intensivmed Notfallmed Schmerzther. 2004;39:353–9.PubMedGoogle Scholar
  44. 44.
    Zhong T, Wang W, Chen J, Ran L, Story DA. Sore throat or hoarse voice with bronchial blockers or double-lumen tubes for lung isolation: a randomised, prospective trial. Anaesth Intensive Care. 2009;37:441–6.PubMedGoogle Scholar
  45. 45.
    Campos JH, Hallam EA, Ueda K. Lung isolation in the morbidly obese patient: a comparison of a left-sided double-lumen tracheal tube with the Arndt(R) wire-guided blocker. Br J Anaesth. 2012;109:630–5.PubMedGoogle Scholar
  46. 46.
    Ruetzler K, Grubhofer G, Schmid W, Papp D, Nabecker S, Hutschala D, et al. Randomized clinical trial comparing double-lumen tube and EZ-blocker for single-lung ventilation. Br J Anaesth. 2011;106:896–902.PubMedGoogle Scholar
  47. 47.
    Venkataramanappa V, Boujoukos AJ, Sakai T. The diagnostic challenge of a tracheal tear with a double-lumen endobronchial tube: massive air leak developing from the mouth during mechanical ventilation. J Clin Anesth. 2011;23:66–70.PubMedGoogle Scholar
  48. 48.
    Yuceyar L, Kaynak K, Canturk E, Aykac B. Bronchial rupture with a left-sided polyvinylchloride double-lumen tube. Acta Anaesth Scand. 2003;47:622–5.PubMedGoogle Scholar
  49. 49.
    Sakuragi T, Kumano K, Yasumoto M, Dan K. Rupture of the left main-stem bronchus by the tracheal portion of a double-lumen endobronchial tube. Acta Anaesth Scand. 1997;41:1218–20.PubMedGoogle Scholar
  50. 50.
    Yoshimura T, Ueda K, Kakinuma A, Nakata Y. Difficulty in placement of a left-sided double-lumen tube due to aberrant tracheobronchial anatomy. J Clin Anesth. 2013;25:413–41.PubMedGoogle Scholar
  51. 51.
    Wiser SH, Hartigan PM. Challenging lung isolation secondary to aberrant tracheobronchial anatomy. Anesth Analg. 2011;112:688–92.PubMedGoogle Scholar
  52. 52.
    Klein U, Karzai W, Bloos F, et al. Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia. Anesthesiology. 1998;88:346–50.PubMedGoogle Scholar
  53. 53.
    Benumof JL. The position of a double lumen-tube should be routinely determined by fiberoptic bronchoscopy. J Cardiothorac Vasc Anesth. 2001;7:513–4.Google Scholar
  54. 54.
    Klein U, Karzai W, Bloos F, et al. Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia: a prospective study. Anesthesiology. 1998;88:346–50.PubMedGoogle Scholar
  55. 55.
    Brodsky JB. Fiberoptic bronchoscopy need not to be a routine part of double-lumen tube placement. Curr Opin Anesthesiol. 2004;17:7–11.Google Scholar
  56. 56.
    Campos JH. Update on tracheobronchial anatomy and flexible fiberoptic bronchoscopy in thoracic surgery. Curr Opin Anesthesiol. 2009;22:4–10.Google Scholar
  57. 57.
    Benumof JL. Airway exchange catheters: simple concept, potentially great danger. Anesthesiology. 1999;91:342–4.PubMedGoogle Scholar
  58. 58.
    DeLima L, Bishop M. Lung laceration after tracheal extubation over a plastic tube changer. Anesth Analg. 1991;73:350–1.PubMedGoogle Scholar
  59. 59.
    Baraka AS. Tension pneumothorax complicating jet ventilation via Cook airway exchange catheter. Anesthesiology. 1999;91:557–8.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of AnesthesiologyCentre Hospitalier Universitaire de CharleroiCharleroiBelgium
  2. 2.Department of AnesthesiologyHôpitaux Universitaires de GeneveGenevaSwitzerland

Personalised recommendations