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LETTERS TO EDITOR
Year : 2021  |  Volume : 22  |  Issue : 1  |  Page : 110-111
 

Confirmation of double-lumen tube position with ultrasound during COVID-19: Need of the hour!


Department of Onco.Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India

Date of Submission09-Oct-2020
Date of Acceptance13-Dec-2020
Date of Web Publication22-Feb-2021

Correspondence Address:
Dr. Nishkarsh Gupta
Department of Onco-Anaesthesia and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_159_20

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How to cite this article:
Agarwal S, Gupta N, Kumar V, Bharti SJ. Confirmation of double-lumen tube position with ultrasound during COVID-19: Need of the hour!. Indian Anaesth Forum 2021;22:110-1

How to cite this URL:
Agarwal S, Gupta N, Kumar V, Bharti SJ. Confirmation of double-lumen tube position with ultrasound during COVID-19: Need of the hour!. Indian Anaesth Forum [serial online] 2021 [cited 2021 May 9];22:110-1. Available from: http://www.theiaforum.org/text.asp?2021/22/1/110/309829




Sir,

Precise positioning of double-lumen tube (DLT) is important for effective lung isolation in thoracic surgeries. Various methods to confirm DLT position include chest movements, auscultation, lung ultrasound (LUS), electrical impedance tomography, and fiberoptic bronchoscopy (FOB). In recent years, LUS has emerged as a noninvasive, simple, and effective technique to confirm lung isolation following DLT placement.[1]

During the COVID-19 pandemic, it is difficult to auscultate lungs wearing personal protective equipment (PPE) kit. Confirmation using fiberoptic may increase the risk of opening the airway, and using LUS for DLT confirmation may be more relevant.

We report a case posted for transthoracic esophagectomy (TTE) where LUS helped in confirmation of the DLT position. A 60-year-old male with a history of Parkinson's disease on multiple drugs was posted for TTE. The patient had a difficult airway with mouth opening of 2 fingers, Mallampati Grade 3, and missing teeth. Anesthesia was induced with fentanyl 2 mcg/kg, propofol 2 mg/kg, and rocuronium 0.9 mg/kg, and a 39 Fr left-sided DLT was placed using a videolaryngoscope. The correct placement of DLT was confirmed using a disposable fiberoptic scope. Thereafter, LUS was performed between the second and the fourth intercostal space in the mid-clavicular line and between the fifth and sixth intercostal space in the anterior axillary line to see for lung sliding sign. When the tracheal lumen was clamped, lung sliding was seen on the left side, while with bronchial lumen clamped, it was seen on the right side. These findings were confirmed on M mode where a “seashore” sign was seen if ventilation occurred and a “bar code” sign was seen on the side where ventilation did not occur.

Then, the patient was placed in a lateral position, and DLT position was reconfirmed using disposable fiberoptic scope and LUS. The patient was reversed, extubated, and shifted to the intensive care unit for observation.

LUS is a reliable technique to assess lung isolation and it is better than auscultation. Audibility of breath sounds is affected by factors such as tidal volume, the thickness of the chest wall, noise in the operation theater, and sensitivity of stethoscope, while LUS provides a digital image that can be shared simultaneously.[2] Besides, removing PPE kit for auscultation would increase the chances of exposure to infection.

FOB remains the gold standard for confirmation of anatomical position of DLT, but routine use of bronchoscopy is not recommended during COVID-19 pandemic due to high aerosol-generation potential.[2],[3] As of now, a recommendation cannot be made for the use of LUS as an alternate to FOB confirmation. However, bronchoscopy should be done with disposable scopes and with a silent airway with no airflow.[4],[5]

Transthoracic ultrasound has been recommended as an alternative valuable tool to confirm the DLT position. The present pandemic has further supported the use of lung USG for DLT confirmation. USG of the lung should be the standard of care for confirmation of DLT placement in addition to FOB confirmation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Alvarez-Diaz N, Amador-Garcia I, Fuentes-Hernandez M, Dorta-Guerra R. Comparison between transthoracic lung ultrasound and a clinical method in confirming the position of double-lumen tube in thoracic anaesthesia. A pilot study. Rev Esp Anestesiol Reanim 2015;62:305-12.  Back to cited text no. 1
    
2.
Parab SY, Kumar P, Divatia JV, Sharma K. A prospective randomized controlled double-blind study comparing auscultation and lung ultrasonography in the assessment of double lumen tube position in elective thoracic surgeries involving one lung ventilation at a tertiary care cancer institute. Korean J Anesthesiol 2019;72:24-31.  Back to cited text no. 2
    
3.
Wahidi MM, Shojaee S, Lamb CR, Ost D, Maldonado F, Eapen G, et al. The use of bronchoscopy during the COVID-19 pandemic: CHEST/AABIP guideline and expert panel report. Chest 2020;158:1268-81.  Back to cited text no. 3
    
4.
Tryphonopoulos P, Faul MC, Gagne S, Moffett S, Byford L, Thompson C. COVID-19 and one-lung ventilation. Anesth Anal 2020;131:e90-1.  Back to cited text no. 4
    
5.
Şenturk M, Tahan MR, Szegedi LL, Marczin N, Karzai W, Shelley B, et al. Thoracic anesthesia of patients with suspected or confirmed 2019 novel coronavirus infection: Preliminary recommendations for airway management by the European Association of Cardiothoracic Anaesthesiology Thoracic Subspecialty Committee. J Cardiothorac Vasc Anesth 2020;34:2315-27.  Back to cited text no. 5
    




 

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