Bronchial Tube [WORK]

When a person breathes, air comes in through the nose or mouth and then goes into the trachea (windpipe). From there, it passes through the bronchial tubes, which are in the lungs. These tubes let air in and out of your lungs, so you can breathe. The bronchial tubes are sometimes referred to as bronchi or airways.

bronchial tube

Your bronchi (BRAWN-kai) are the large tubes that connect to your trachea (windpipe) and direct the air you breathe to your right and left lungs. They are in your chest. Bronchi is the plural form of bronchus. The left bronchus carries air to your left lung. The right bronchus carries air to your right lung. Your bronchi are an essential part of your respiratory system. As you breathe and your lungs expand, your bronchi distribute the air within your lung.

Your tracheobronchial tree looks like an upside-down tree with the trachea as the trunk and the bronchi representing the branches. The tubes of the right and left main bronchi divide into smaller segments as they move deeper into your lungs. Similarly, tree branches divide and get smaller and smaller, before ending in the leaves.

When a person breathes, air taken in through the nose or mouth then goes into the trachea (windpipe). From there, it passes through the bronchial tubes, into the lungs, and finally back out again. The bronchial tubes, which branch into smaller tubes called bronchioles, are sometimes referred to as bronchi or airways. People with asthma have bronchial tubes that are inflamed. This means that the airways swell and produce lots of thick mucus. The bronchial tubes are also overly sensitive, or hyperreactive, to certain things like exercise, dust, or cigarette smoke. This causes the muscles around the bronchial tubes to tighten up. The combination of inflammation and muscle tightening narrows the airways and makes it difficult to breathe.

When you breathe in, the air travels down through your trachea (windpipe). It then goes through two tubes to your lungs. These tubes are your bronchi. Bronchial disorders can make it hard for you to breathe.

Bronchitis is an inflammation of the lining of your bronchial tubes, which carry air to and from your lungs. People who have bronchitis often cough up thickened mucus, which can be discolored. Bronchitis may be either acute or chronic.

Often developing from a cold or other respiratory infection, acute bronchitis is very common. Chronic bronchitis, a more serious condition, is a constant irritation or inflammation of the lining of the bronchial tubes, often due to smoking.

A double-lumen tube (DLT) is an endotracheal tube designed to isolate the lungs anatomically and physiologically. Double-lumen tubes (DLTs) are the most commonly used tubes to provide independent ventilation for each lung. One-lung ventilation (OLV) or lung isolation is the mechanical and functional separation of the 2 lungs to allow selective ventilation of only one lung. The other lung that is not being ventilated passively deflates or is displaced by the surgeon to facilitate surgical exposure for non-cardiac operations in the chest such as thoracic, esophageal, aortic and spine procedures. This activity reviews the use of the DLT, its indications, contraindications, and complications in thoracic surgery.

Objectives:Describe how a double-lumen tube is inserted during surgery.Review the indications for a double-lumen tube.Summarize the complications of a double-lumen tube.Outline interprofessional team strategies to ensure proper placement of the double-lumen tube during thoracic surgery and improving patient outcomes.Access free multiple choice questions on this topic.

A double-lumen tube (DLT) is an endotracheal tube designed to isolate the lungs anatomically and physiologically.[1] Double-lumen tubes (DLTs) are the most commonly used tubes to provide independent ventilation for each lung. One-lung ventilation (OLV) or lung isolation is the mechanical and functional separation of the 2 lungs to allow selective ventilation of only one lung. The other lung that is not being ventilated passively deflates or is displaced by the surgeon to facilitate surgical exposure for non-cardiac operations in the chest such as thoracic, esophageal, aortic and spine procedures. It can also be used during minimally invasive cardiac surgery and in disease processes affecting 1 lung to prevent soiling from the contralateral lung. DLTs also allows bronchial toilet without interrupting ventilation.

Due to the larger size and more complex design than the single lumen tube (SLT), intubation with a DLT can be a challenge, even in a patient with a normal airway. Use of a DLT is therefore relatively contraindicated in a patient with[4]:

Distorted airway anatomy due to tortuosity or lesion extending into the airway is a contraindication to placement of DLT. In certain instances, such as where conversion to an SLT may be needed at any time during surgery or the need to re-intubate for postoperative mechanical ventilation is warranted, it is advisable to choose an SLT with a bronchial blocker for lung isolation. The need to re-intubate with an SLT may be risky due to the presence of airway edema.

DLTs specially designed for patients with a tracheostomy (double-lumen tracheostomy tube set) are commercially available. They have the same design as conventional DLTs but are shorter and curved between the intratracheal and extra tracheal parts.[5][6] however, its use is limited.

DLTs have 2 endotracheal tubes (ETT) that are "bonded" together, to allow each tube to ventilate a specific lung. The DLT can be left-sided or right-sided depending on the main stem bronchus which its distal (longer) lumen is designed to fit in. The longer lumen (bronchial lumen) is designed to reach the main stem bronchus while the shorter lumen (tracheal) ends in the distal trachea. [Figure 1] There are several types of double lumen tubes. However, all are similar in design and made of Polyvinyl chloride. Most DLTs have color-coded cuffs and pilot balloons. The bronchial cuff, which is typically a high-pressure low volume cuff, and its pilot balloon are blue, while the tracheal cuff which is a high volume low-pressure cuff, and its pilot balloon are clear.[7][8]

The DLT is supplied in a package containing the tube with a stylet, connector, and suction catheters. Depending on the manufacturer, they may also come with an apparatus to provide continuous positive airway pressure (CPAP) to the non-ventilated lung. There are different manufacturers.

The margin of safety is higher for the placement of left-sided DLT due to the longer length of the left main stem bronchus. Placement of a right-sided DLT is more challenging with a lower safety margin due to the short length of the right mainstem bronchus and the origination of the right-upper lobe bronchus 1.5 to 2 cm from the carina.[11] Right-sided DLT, as a result, incorporates a modified cuff, or slot on the endobronchial side that allows ventilation of the right upper lobe. Placement of a right-sided DLT needs to be positioned to align with the takeoff of the right upper lobe. (Figure 1)

Because of the higher safety margin, a left-sided DLT is commonly used. However, right-sided DLT may be preferred when it is important to avoid manipulation of left bronchus or when left bronchus is narrowed or has anatomical variations, left pneumectomy, left lung transplant, left mainstem bronchus stent or suspected disruption of the left tracheobronchial tree.

When preparing the DLT for use, both the trachea and bronchial cuffs should be inflated to check for leaks and symmetrical cuff inflation. Consider adding water-soluble lubricant to the stylet and insert the stylet into the bronchial side, ensuring that the stylet is not protruding beyond the tube. The connector, which connects DLT to the ventilator circuit should be assembled and ready before intubation. A fiberoptic Bronchoscope should be available to confirm the position of the DLT.[12] Knowledge of the tracheobronchial anatomy is very helpful in confirming correct placement of the DLT.

There is a lack of objective guidelines in the proper selection of DLT sizes; 39-Fr and 41-Fr tubes are used for adult males while 35-Fr and 37-Fr DLTs are used for adult females. A properly-sized DLT is one in which the main body of the tube passes without resistance through the glottis and advances easily within the trachea and in which the bronchial component passes into the intended bronchus without difficulty.[13]

For blind insertion of a DLT, first, perform a direct laryngoscopy and visualize the vocal cords. Visualization of the vocal cords is important as these tubes are large and placement more challenging than placing an SLT. Once the vocal cords are visualized, gently advance the DLT with the tip of the bronchial concave curve facing anteriorly through the vocal cords until the bronchial cuff passes through the cords. The tube is then turned 90 degrees to the left when using a left-sided DLT, and to the right when using a right-sided DLT, and advanced until it meets resistance. Once the DLT is well positioned, inflate the tracheal cuff and ensure ventilation of both lungs by both inspection and auscultation. Verify correct placement by checking ventilation through the bronchial lumen. First, inflate the bronchial cuff 1ml at a time until leak stops. Clamp off gas flow through the tracheal lumen at the Y connector and open the tracheal sealing cap to air. Check whether you can isolate the other lung through the tracheal lumen, by clamping off the gas flow through the bronchial lumen.[14]

The DLT can also be positioned using fiberoptic bronchoscopy. Using a fiberoptic bronchoscope through the bronchial lumen and guiding the DLT over fiber-optic scope increases the accuracy of placement.

Once inserted, the DLT is connected to the ventilator circuit via the DLT connector, and the detection of ETCO2 confirms placement in the trachea after both cuffs are inflated to seal leaks. No more than 3 mL of air should be required to create a seal in the bronchial cuff. Cuff pressures should be measured to prevent airway injury. Confirmation of correct positioning of the DLT can be done by auscultation or with fiberoptic bronchoscopy. Auscultation and bilateral chest wall movement is first confirmed. On clamping the endobronchial lumen limb connector, breath sounds should be absent from the corresponding side of the lung if the endobronchial lumen is in the correct bronchus. On clamping the endotracheal limb connector and ventilating through the endobronchial lumen, breath sounds should be absent from the opposite side of the chest. 041b061a72