Practice patterns in choice of left double-lumen tube size for thoracic surgery

BACKGROUND: Some anesthesiologists choose smaller than body size-appropriate left sided double-lumen tubes (DLTs) ("down-size") for lung isolation in an attempt to limit the risk of airway trauma. There are few data on the effects of DLT size on intraoperative outcome measures. METHODS: In 300 adults undergoing thoracic surgery requiring lung isolation, we conducted a prospective pilot study to evaluate whether the use of 35 FR DLT, regardless of gender and/or height (care standard of two investigators), was associated with a similar incidence of intraoperative hypoxemia, lung isolation failure, or need for DLT repositioning during surgery (noninferiority) than with the conventional goal of inserting the largest possible DLT (care standard of two other investigators). DLT insertion position was immediately confirmed with fiberoptic bronchoscopy after direct laryngoscopic placement and after lateral positioning. RESULTS: The combined incidence of transient hypoxemia, inadequate lung isolation, or need for DLT repositioning during surgery did not differ among patients receiving 35, 37, or 39 FR DLT, regardless of gender or height. Despite the high frequency of 35 FR DLT use, 2% of patients required further down-sizing due to the inability to introduce the DLT into the left mainstem bronchus or when no inflation of the bronchial cuff was needed for lung isolation. CONCLUSIONS: Under the conditions of this pilot study, the use of smaller than conventionally sized DLT was not associated with any differences in clinical intraoperative outcomes.