One lung ventilation (OLV) has become a standard procedure for the vast majority of interventions in pulmonary surgery (1). There are many variations of double-lumen tubes (DLT) which differ in shape and material, but all remained the basic structure (2). Most commonly used are left sided DLTs which are placed into left main bronchus and right or left lung can be insulated. Left sided DLTs can have a hook which is placed on the carina to prevent displacement of the tube. The carinal hook may help to prevent distal migration of the entire tube, but poses a risk of airway trauma and can make placement of the DLT through the glottis more difficult (3,4,5,6,7). DLTs without the hook are more gentle and easier to place, but the mobilization of the tube during surgery is more common.
The use of double-lumen tubes with a hook is large in Europe and quite unknown in United States. Each anaesthesiologist decides individually which kind of DLT to use as the literature is poor, containing only few case reports. There is only one study where they have compared both techniques but no difference was found (8). The purpose of our study was to compare these DLTs with and without a hook.
Keywords: double-lumen tube, carinal hook, pulmonary surgery.
Material and Methods
Fifty-four patients undergoing lung resection were included in the randomized, controlled, single-blinded study. Recruited patients were randomly allocated to each group (hook/without hook). Demographic data, all data according to the procedure, the tube used, and difficult intubation criteria were recorded. Complications according to intubation and position of the tube were recorded.
Anaesthetic technique was the same in the both groups (9,10). DLT without the hook was inserted with the following technique: after the bronchial cuff was passed the vocal cords, the stylet was removed and the tube was rotated 90 º towards left. The tube with the hook, after passing the bronchial cuff trough the vocal cords, was rotated for 180 degrees to the left and removed the stylet and when the hook passed the vocal cords, the tube was rotated for 90 degrees back to the right and push it into the bronchus. Following formula was used for the right depth: height (cm)/10 + 12 (cm) of the tube without the hook. The tube with hook was inserted into the bronchus so that hook was placed on the carina and stopped. The right position of the tube was confirmed auscultatory and endoscopic using flexible intubation video endoscope. The time needed for tube insertion was measured.
After the surgery we asked the patients about the sore throath, hoarseness, haemoptysis and their satisfaction.
Baseline characteristics were well balanced between the groups. Time to place DLT was shorter in the group without hook (P=0.01). The incidence of adequate position at the first attempt was higher in the group with hook and reposition rate was higher in the group without hook (P=0.04). Patients in both groups suffered similar incidences of hoarseness, sore throat or postoperative haemoptysis (P = 0.44). Satisfaction of the patients was higher in the group without hook (0.03).
When a DLT is used, the presence of a carinal hook gives advantage by the right positioning of the tube, but neither tube takes more advantages or complications. Satisfaction of the patients was higher in the group without hook.
Trial Registration: ClinicalTrials.gov NCT02857504.
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