Video double-lumen tubes: how much room for improvement can they provide?

It’s been a long way since the success of intrathoracic surgery lied in how quickly the rib cage was closed (1). The iatrogenic pneumothorax was the main restriction to the evolution of this field, and anesthesiology practitioners had a lot to do with how this issue was overcome (2).

Back at the turn of the previous century, Brauer was not entirely wrong when he tried to solve this with a positive pressure chamber around the patient’s head (in fact, helmet interfaces for non-invasive ventilation are not that far off), but further changes in airway instrumentation were necessary instead. Rudolph Matas managed to join up several advances that led to a revolution (3): he used the O’Dwyer laryngeal tube (4) together with an intermittent positive pressure ventilation system, which he later improved by introducing a chloroform administration channel to the airway. For sure this basic scheme sounds familiar to any anesthesiologist. However, the placement of these devices had to be done blindly. Although Jackson described the first intubating laryngoscope, the Magill, Flagg, and Macintosh (5) devices were described during the first half of the 20th century.

Last, but not least, the first endotracheal tubes were designed around 1900. After the addition of the tracheal cuff by Guedel in 1928 (6), only the problem of lung isolation remained. Gale et al. described the technique of endobronchial intubation with a standard rubber tube, advancing it up to the bronchus of the ventilated lung (7). Along with many surgical advances, this allowed for numerous previously unthinkable procedures, such as pneumonectomies or esophagectomies in the 1930s.

Many further improvements in pulmonary isolation arose quickly from then on: bronchial selective block was first described in 1936 by Archibald (8), and Rovenstine designed a single-lumen double-cuffed tube that allowed for alternative bipulmonar and selective ventilation in the healthy lung (9). It was in 1949 when Carlens published the use of double-lumen tubes (DLTs), although these were first used for anesthesia purposes by Bjork in 1950 (10). Subsequently, the most notable evolutions occurred in the development of devices with less risk of airway injury and less tendency to collapse, with the change from rubber to plastic, which reduced the kinking effect and improved expiratory flow. The Robertshaw tube meets these characteristics and remains the prototype of the modern DLT. It was first introduced in 1962 (11). Pharmacological advances have also allowed deeper anesthetic planes, muscle relaxation, and intraoperative apnea.

However, the innovations in airway management for thoracic surgery in recent years have been limited to the improvement of pre-existing devices, whether bronchial blockers (BB) or DLTs. At least it does not seem to be the only field where this phenomenon occurs (12). In fact, the most paradigmatic change in this field in recent years might be the performance of intrathoracic interventions in spontaneous ventilation without orotracheal intubation: a comeback to the roots (13).

The arrival of video double-lumen tubes (VDLTs) with an embedded camera was one of the most original proposals. The VivaSight (VivaSight 2DL, Ambu, Vallerup, Denmark) VDLT allows for continuous visualization of the carina once the tube is inserted into the trachea, which eases the management of lung separation through early detection and correction of its malposition during surgery (14). Does it achieve it? It seems so. The data obtained by Palaczynski et al. (15) point to an easier intubation, a faster procedure, and a less frequent need for FiberOptic Bronchoscopy (FOB), among others.

In addition, VDLTs are manufactured keeping internal diameters and cross-sectional areas nearly similar to conventional DLTs (16,17), unlike single-lumen Vivasight tubes, in which the lumen becomes narrower due to the optics system and the placement of BB might lead to clinically relevant flow limitation.

Although the use of BB is considered non-inferior to that of DLTs for lung isolation or separation (18), and the use of airway exchangers is well-defined in the literature as a valid strategy for placement of a DLT through it after intubation of a single tube in cases of difficult airway (19), the reality of clinical practice still points out to a clear preference for DLTs and a greater than expected difficulty with the use of exchangers for this purpose (20) (although not for switching to a single tube after thoracic surgery).

It is not a straightforward task to assess the real clinical relevance of the finding of a reduction in intubation time from 125 to 44 seconds in a standard context, figures that are practically comparable to those reported in previous studies studies (14,21). In a scheduled surgery scenario, the safe time in apnea after a standard preoxygenation should be greater than this interval in most cases, and a difference of 81 seconds within the entire perioperative time is minimal from an economic or operation theatre occupation point of view. But time-sensitive scenarios should not be lost sight of, since the relevance of these seconds can be key in emergent surgery, or a physiologic or anatomic difficult airway setting as well. Furthermore, the VivaSight camera itself might be an extra cognitive aid in order to check the correct advance of the tube alongside the airway and even the direction to the glottis during laryngoscopy, although it cannot replace the capnogram, the visual inspection of the thorax or the auscultation in any case. However, it is such a difficult task to obtain high-quality prospective evidence in this area, such as dispelling the doubt as to whether this benefit in seconds can be extrapolated to an emergency setting since there are many other factors that can hinder clinical management and decision-making. The distal camera of the Vivasight single tubes, despite its limitations, or videolaryngoscopes can also be useful tools in this regard (22).

Nevertheless, the most remarkable difference to previous evidence is the percentage of FOB usage both for intubation and for repositioning of the DLT. Palaczynski et al. report a much lower need than previous studies since it was not necessary in any case of the VDLT group and only in 20.5% of the conventional DLT group (15). This again raises the issue of the real need for systematic FOB to verify the location of the DLTs, and even to reposition them, provided that airway management is performed by experienced professionals (as seems to be the case). Once again, the reality of clinical practice clashes with the “classic recommendations” that recommend the systematic use of FOBs to verify the correct placement of the DLTs (23).

According to the clinical experience of the authors of this editorial, the presence of secretions or blood remains is a cumbersome problem that sometimes requires the use of FOB for its management. In any case, except in specific situations, VDLTs could virtually eliminate the need for FOB, particularly in cases of complicated anatomy or previous thoracic surgery, provided that a DLT is a right device for airway management. Other high-priority lung separation or isolation situations, or those where dislodgement of the DLT could be detrimental, like during parenchymal lung stapling or high-output air-leak repairs, could be other clear cases of superiority of VDLTs. Left bronchoalveolar lavage, especially in the case of alveolar proteinosis, could be the clearest example. Perhaps the speed for adequately repositioning the tube, especially without the need to introduce a FOB with the consequent loss of PEEP and functional residual capacity, is more decisive in an intraoperative urgent situation than during a scheduled peri-intubation period.

Despite this, the latest asseverations should lead the reader to the conclusion that the clinical and economic superiority of VDLTs might be restricted to several specific situations, such as those mentioned. The difference in FOB usage reported by the authors is still higher than the limit of 6.6% proposed by Larsen et al. (24), but the more experienced operator, the lesser the need for FOB verification and the lesser the economic superiority. Moreover, the rate of tube repositioning in the study by Palaczynski et al. is higher in the VDLT group, pretty close to statistical significance (15).

The authors’ approach to the safety problem is also interesting, as the risk of airway injury secondary to the melting of the plastic material of the tube was reported (25). Although the manufacturer’s actions seem to have been satisfactory in this regard, it remains to be elucidated whether most recent reports regarding the high risk of cuff rupture may pose a further limitation to a widespread use of these devices.

Thus, it seems that VDLTs provide some room for improvement in airway management in thoracic surgery. Anesthesia practitioners must be critical and cautious when interpreting the clinical relevance of the findings in their favor, as well as when applying their advantages in situations not directly considered in clinical studies. However, it is in these time-sensitive situations that the potential benefits may be the greatest.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-70/coif). The authors have no conflicts of interest to declare.

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