Acta Anaesthesiol Taiwan 2010;48(1):4144

C ASE R EPO RT

Application of a Double-lumen Tube for

One-lung Ventilation in Patients With
Anticipated Difficult Airway
Chih-Kai Shih, Yi-Wei Kuo, I-Chen Lu, Hong-Te Hsu, Koung-Shing Chu,
Fu-Yuan Wang*
Department of Anesthesiology, Kaohsiung Medical University Hospital, and Faculty of Medicine,
College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, R.O.C.

Received: Oct 13, 2008

Revised: Jan 15, 2009
Accepted: Jan 20, 2009
KEY WORDS:
intubation, intratracheal:
double-lumen tubes;
pulmonary ventilation:
one-lung;
tracheostomy

One-lung ventilation (OLV) is essential in some surgical situations. The use of doublelumen tubes (DLTs) can achieve OLV more quickly and more easily than bronchial
blockers. The management of a difficult airway is a challenge for anesthesiologists
when, at the same time, OLV is needed for a surgical procedure. This report describes
the successful application of DLTs in two patients with difficult airways, and who
were scheduled for pulmonary decortication. Case 1 already had a permanent tracheostomy, while Case 2 had oral cancer with an extremely limited mouth opening
and needed elective tracheostomy for anesthesia. Nasal intubation of Case 2 was
done with fiberoptic-guided intubation with the patient awake. OLV was achieved
uneventfully after inserting the DLT directly through the tracheostomy in both
cases. We also describe the appropriate use of airway devices for OLV, focusing on
patients with an anticipated difficult airway.

1. Introduction
One-lung ventilation (OLV) is a useful technique in
many thoracic surgeries where collapse or isolation
of one lung is necessary. Several devices are available to facilitate OLV, including double-lumen tubes
(DLTs), bronchial blockers and Foley catheters, as
previously reported.14 Generally, these devices
are inserted via the oral cavity into the main bronchus of the lung subjected to the operation. The
position of these devices can be confirmed visually

by fiberoptic bronchoscopy (FOB) or by auscultation of breathing sounds with a stethoscope. Some

difficulties may occur in some patients with a difficult airway, particularly patients whose oral cavity is not suitable for tracheal intubation. Several
clinical reports have described methods for managing such situations.26 Here, we report two cases
with a difficult airway who were scheduled to undergo thoracic surgery. The DLT was inserted directly
through the tracheostomy and intraoperative OLV
was successfully achieved in both cases. We also

*Corresponding author. Department of Anesthesiology, Kaohsiung Medical University Hospital, 100 Tzyou 1st Road,
Kaohsiung 807, Taiwan, R.O.C.
E-mail: kaninkmu@yahoo.com.tw
2010 Taiwan Society of Anesthesiologists

42
discuss the appropriate use of OLV airway devices,
particularly in patients with anticipated difficult
airway.

2. Case Reports
2.1. Case 1
A 40-year-old man with hypopharyngeal carcinoma
had undergone total laryngectomy and permanent
tracheostomy before this admission. He was scheduled for a right pulmonary decortication procedure
due to lung empyema. Because the patients airway
could only be kept patent through the tracheostomy,
we used a small pediatric face mask for preoxygenation through the tracheostomy (Figure 1). The tracheostomy was well-covered and sealed with this
mask, and ventilation was fine. General anesthesia
was induced with fentanyl (1 g/kg), propofol (2 mg/
kg) and rocuronium (0.5 mg/kg). A size 28 DLT was
inserted through the tracheostomy and correct
placement was confirmed by FOB. The intraoperative OLV was performed smoothly. After completing
surgery, the DLT was replaced with a tracheostomy
tube. The patient was transferred to an intensive
care unit for postoperative care.

C.K. Shih et al
administration of fentanyl (100 g), the nasal canals and the oropharynx were anesthetized with
6% cocaine (60 mg) and 10% lidocaine spray (1 spray/
10 kg), respectively. The nostril with least resistance, as identified during nasal packing, was chosen for nasal intubation. Sensory blockade of the
trachea was achieved by intratracheal injection of
3 mL of 2% lidocaine. Then, the anesthesiologist
began the nasal intubation with a fiberoptic scope
(Olympus ENF XP 4.5 mm; Olympus, Tokyo, Japan)
encased in the lumen of a 7.0 mm tracheal tube.
Once the nasal tracheal intubation was complete
and the nasal endotracheal tube was secured,
general anesthesia was induced with intravenous
propofol (100 mg) and rocuronium (25 mg), and
maintained with sevoflurane in oxygen. The surgeons did the tracheostomy and then inserted a
size 28 DLT through the freshly created tracheostomy stoma (Figure 2). The correct placement of
the DLT was confirmed by FOB. Isolation of the left
lung was successfully achieved and the DLT was replaced by a traditional tracheostomy tube after
completing the surgery.

3. Discussion

A 35-year-old man weighing 50 kg had suffered

from oral squamous cell carcinoma and had an extremely limited mouth opening. He was scheduled
for pulmonary decortication due to left lung empyema. The patients anticipated difficult airway
was initially managed by nasal intubation via a
FOB, with the patient awake. After intravenous

Oral cancer is a relatively prevalent disease in

Taiwan. It may lead to airway difficulties in the late
stage of the disease. These anticipated problems
could result from pathologic changes of the oral
anatomy, or by cancer therapies, such as surgery and
radiotherapy. We encountered two cases with difficult airways, in which the oral cavities were not
suitable for DLT insertion. In such circumstances,
tracheostomy is necessary, but performed reluctantly,
for successful airway management. In the present

Figure 1 The infant-sized facial mask used to cover

the tracheostomy.

Figure 2 Placement of a size 28 double-lumen tube

through a fresh tracheostomy in Case 2.

2.2. Case 2

Double-lumen tube for difficult airway

cases, we separated the two lungs by DLT via the
tracheostomy, and all airway instrumentation was
performed via the tracheostomy in both cases. Two
methods of anesthetic management must be used
in such situations. First, the DLT must be successfully inserted via the tracheostomy.1 Second, a bronchial blocker is needed to isolate the diseased lung
via the tracheostomy tube.2,4,5
DLT is frequently used in thoracic surgery, particularly in procedures that need a placid lung on
the operative side by OLV. An increasing number of
cases are presenting with difficult airways, meaning standard oral intubation is not possible.7 Such
cases pose a challenge to anesthesiologists who must
perform OLV for the surgical procedure. Bronchial
blockers can also be placed via the tracheostomy
tube in such situations.2,5,8 We decided to use DLT
in our cases because DLT offers several advantages
over bronchial blockers to separate the lungs in some
surgical procedures. Some of the advantages of DLT
over bronchial blockers are discussed below.
First, a DLT is easier and faster to place than
bronchial blockers because its placement is almost
identical to that of an ordinary endotracheal tube.
Thus, any practitioner with experience of endotracheal tube placement can quickly learn to place a
DLT. Second, a DLT is cheaper than the bronchial
blockers and is reimbursed by the National Health
Insurance in Taiwan. Third, displacement of the DLT
from its correct location is less likely than with bronchial blockers because its shape is solid, limiting unwanted movement, and it can be securely attached
to the lips by adhesive tape. Bronchial blockers are
more prone to displacement when they are subjected
to inflation and deflation. Fourth, a DLT has larger
capacity cuffs for re-inflation and the airway pressure can be effectively controlled while the lung
on the surgical side is re-inflated. Fifth, FOB is not
essential to confirm the correct placement of the
DLT, an important factor because FOB is an expensive instrument and may not be available in all operating rooms. In some cases, we can confirm the
placement of the DLT by auscultation of breathing
sounds with a stethoscope if FOB is unavailable. On
the other hand, FOB is required in most cases to
aid correct placement of bronchial blockers.
A cuffed tracheostomy endotracheal tube is conventionally used for ventilation in lieu of an ordinary
tracheostomy tube during the induction of anesthesia in patients with a tracheostomy. However, conducting this procedure may elicit a coughing reflex
and induce uncomfortable sensations. We noticed
that some infantile round face masks were suitable
for covering and sealing the tracheostomy stoma.
Thus, we considered these masks useful for the induction of anesthesia in tracheostomy cases, without changeover of the ordinary tracheostomy tube.

43
In fact, patients could be well ventilated with this
method. This method can also be used in emergency
situations in the event of tube function failure
(e.g. kinking) or if an appropriately sized tube is
not immediately available. Ventilation through the
tracheostomy via a face mask can be an expedient
in critical situations.
We usually place a size 28 DLT through the tracheostomy stoma (sizes 2832 are suitable for tracheostomy). FOB is a helpful tool to confirm correct
placement of the tube. We can also use a stethoscope for auscultation of breathing sounds to check
the position if FOB is unavailable or if the proximal
lens is blurred due to the presence of blood or other
secretions.
In Case 2, a size 28 DLT was placed by the thoracic surgeons immediately after the tracheostomy
was prepared. We checked the position of the tube
by FOB, and found that the tube was correctly
placed. Although the surgeons were actually inexperienced of placing a DLT, the tube was successfully and smoothly placed. It is relatively easy to
place a DLT through the stoma as compared with
placing a bronchial blocker because the former
can be done without the aid of FOB. In both cases
presented here, the DLT was replaced by a size 8
tracheostomy tube after surgery. No specific perioperative complications were noted. To prevent unwanted displacement of the DLT, we secured it with
adhesive tape (Figure 2).

4. Conclusion
Securing the airway is the first priority for patients
with a difficult airway. For cases in which an existing tracheostomy prevents oral intubation for DLT,
a suitably sized DLT can be placed via the tracheostomy stoma because, in our experience, this technique has a higher cost-benefit ratio compared with
the placement of bronchial blockers. OLV can be
successfully performed in patients with a difficult
airway using these methods. We strongly recommend the use of FOB to confirm that the DLT is positioned correctly. Traditional cuffed tracheostomy
tubes of various sizes should be available in case
of any emergency.

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