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Double Lumen Endotracheal Tubes

Bailey Freeman, DNP, CRNA and Angela Mordecai

Quick Facts
Procedure
Confirmation Steps
Documentation Requirements
Scope Guide

Quick Facts

  • Double-lumen endotracheal tubes (DLT) are used for lung isolation and one-lung ventilation (OLV).

 

  • Two parallel lumens: one for the trachea and one for a main bronchus (left or right).

 

  • Left-sided DLT are more commonly used than right-sided DLT.
    • May be used to isolate either the left or the right lung.

 

  • Right-sided DLT are designed with a special port to ventilate the right upper lobe.
    • Proper positioning is critical; misalignment of tube can prevent ventilation to the right upper lobe (RUL).
    • Used for: left-sided pneumonectomy, sleeve resection, or when left mainstem bronchus is compressed/distorted.

 

Indications

Lung isolation may be used in patients undergoing thoracic, esophageal, cardiac, vascular, or spine surgery to optimize surgical access while maintaining one-lung ventilation (OLV).

  • Provide motionless, accessible operative field.
  • Prevent contralateral lung contamination from hemorrhagic/purulent material.
  • Enable differential lung ventilation.

 

Contraindications

  • Difficult airways (consider Bronchial Blocker instead).
  • Full-stomach patients.
  • Emergency/rapid intubation scenarios.

 

Typical double lumen tube (DLT) and appropriate positioning within the trachea and mainstem bronchi. Arrows indicating where to clamp each of the tracheal and bronchial lumens. Adapted from Pellechi J, DuBois S, Harrison M. Updates to Thoracic Procedures: Perioperative Care and Anesthetic Considerations. In: Updates in Anesthesia – The Operating Room and Beyond [Working Title]. October 2022. DOI: 10.5772/intechopen.107468. Licensed under CC BY 3.0.

 

Procedure

Equipment Needed:

  1. Appropriately sized DLT (For details on size selection, see SCOPe Guide).
  2. Direct or video laryngoscope.
  3. Flexible fiberoptic bronchoscope (small diameter).
  4. Lubricated stylet (goes in endobronchial lumen).
  5. Soft-tipped clamp.
  6. Assembled Y-connector (included in the DLT package).
  7. Backup airway equipment in case of difficult placement.

Technique

Blind Technique

  1. Perform laryngoscopy (direct or video).
  2. Gently insert tube with bronchial lumen facing patient’s toes (bronchial lumen concavity facing anteriorly).
  3. Pause at level of vocal cords.
  4. Advance endobronchial cuff just past the vocal cords, then remove the stylet.
  5. Turn DLT 90 degrees to left (or right, if right-sided) as you advance.
  6. Continue to advance tube into trachea so that tracheal cuff passes vocal cords.
  7. Advance DLT to approximately 29 cm depth at teeth for patients ≥170 cm, or when resistance is met.
  8. Inflate tracheal cuff and ensure bilateral lung ventilation.
  9. Inflate bronchial cuff to approximately 3ml, or minimal air to seal.
  10. Ensure that each lung can be isolated. Clamp appropriate lumen at Y connector/open port to air.

Bronchoscopy Guided Technique

  1. Lubricate fiberoptic bronchoscope.
  2. Thread DLT (endobronchial lumen) onto bronchoscope.
  3. Pass DLT through vocal cords under direct visualization.
  4. Guide to appropriate bronchus under direct visualization.

Confirmation Steps

Confirm placement with fiberoptic bronchoscope both immediately after placement & after positioning.

Confirmation (Left DLT)

  • Insert scope through tracheal lumen:
    • Should see fully inflated bronchial cuff located at least 5 to 10 mm below the carina inside the left mainstem bronchus.
    • Ensure that bronchial cuff is not herniated out of the bronchus.
  • Insert scope through bronchial lumen:
    • Should see entrances to left upper and lower lobe bronchi.

 

The optimal position of the left-sided double-lumen tube (DLT), as seen with a fiberoptic bronchoscope. (A) View from the tracheal lumen of the unobstructed entrance of the right mainstem bronchus. (B) View from the tracheal lumen of the right upper bronchus. (C) View from the bronchial lumen of the left upper (above) and left lower (below) lobe bronchi. Used with permission from Campos JH.3

 

Confirmation (Right DLT)

  • Insert scope through the tracheal lumen:
    • Should see inflated endobronchial cuff just below the tracheal carina.
    • Identify the entrance of the right main bronchus and right upper lobe bronchus.

 

 

The optimal position of a right-sided double-lumen endotracheal tube. (A) Shows the take-off of the right-upper bronchus with three segments (apical, anterior, and posterior) when the fiberoptic bronchoscope emerges from the opening slot located in the endobronchial lumen. (B) Shows an unobstructed view of the entrance of the right middle and right lower lobe bronchus when the fiberscope is passed through the endobronchial lumen. (C) Shows a view of tracheal carina to the right edge of the blue balloon fully inflated, and to the left, an unobstructed view of the entrance of the left-mainstem bronchus when the fiberscope is advanced through the tracheal lumen. Used with permission from Campos JH.2

 

Documentation Requirements

  • DLT size used.
  • Placement technique.
  • Confirmation method.
  • Any complications.
  • Cuff volumes (tracheal and bronchial).

SCOPE GUIDE

Strategies

  • Early recognition of malposition.
  • Regular reassessment of ventilation throughout case.
  • Clear communication with surgical team.
  • Backup airway plan.
  • Choose proper size DLT.

Size Selection/Considerations

  • Height/sex-based selection:
    • Females: 35-37 Fr.
    • Males: 39-41 Fr.
  • Consider individual variations based on:
    • Extremes of height.
    • Tracheal/bronchial diameter: radiological studies or ultrasound measurements.
    • Previous airway interventions.

Clinical Optimization

Troubleshooting

  • Insertion difficulties
    • Use bronchoscope guidance.
    • Consider bougie technique.
    • Use a lubricated stylet.
    • Lightly lubricate DLT.
    • Optimize positioning.
    • Once tracheal cuff is past the vocal cords, rotate DLT towards bronchus that is to be cannulated, turn patient’s head to opposite side to more easily advance DLT.
  • Inadequate lung isolation
    • Use suction catheter (usually included in DLT package) to more quickly/more completely deflate lung if needed.
    • Verify position of DLT.

Pearls

Preparation

  • Keep fiberoptic bronchoscope immediately available.
  • Create and maintain organized equipment setup.
  • Complete equipment checks before starting.
  • Have backup airway devices ready and accessible.

Technical Considerations

  • Secure DLT with tape to prevent any movement.
  • For lung isolation: clamp the ADAPTOR, never the tube itself.
  • During maintenance phase:
    • Reduce pressure in the 3cc endobronchial cuff.
      • This reduces airway trauma risk.
      • Lung isolation maintains as air follows path of least resistance.
  • Know that in emergencies, a standard ETT can be advanced into the target lung.

Management

  • Never use 100% oxygen in patients with prior bleomycin exposure.
  • Verify DLT position regularly throughout the case.
  • Address any hypoxia immediately when detected.
  • Maintain clear, ongoing communication with the surgical team.

Monitoring

  • Combine clinical assessment with bronchoscopic visualization.
  • Pay attention to subtle position changes.
  • Stay ahead of potential complications.
  • Watch the surgical field for feedback about positioning.

Quick Resources

The correct position where the semilunar blue cuff is in view at the carina and the incorrect position in which that cuff edge is not seen by the fiberoptic bronchoscope. DLT, Double-lumen tube. With Permission from Campos JH.2

 

 

(a) Sheridan right-sided DLT. (b) Mallinckrodt right-sided DLT. (c) View of the right mainstem bronchus showing the bronchus intermedius toward the center of the photo and the smaller right upper lobe orifice to the right. (d) The three segments of the right upper lobe (the “cloverleaf” view). Reproduced with permission from Campos JH. Lung Isolation. In: Slinger P (ed). Principles and Practice of Anesthesia for Thoracic Surgery. Springer Nature Switzerland AG; 2019. [DOI: 10.1007/978-3-030-00859-8_16].

 

 

Reproduced with permission from Campos JH. Lung Isolation. In: Slinger P (ed). Principles and Practice of Anesthesia for Thoracic Surgery. Springer Nature Switzerland AG; 2019. [DOI: 10.1007/978-3-030-00859-8_16].

 

 

References

This work adapts content from FOAMed Medical Education Resources by LITFL (Life in the Fast Lane), licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. The original work can be found at https://litfl.com.

  1. Nickson C. Selective Lung Ventilation. Life in the Fast Lane. Published July 5, 2024. Accessed January 28, 2025. https://litfl.com/selective-lung-ventilation/
  2. Life in the Fast Lane. Double-lumen Endotracheal Tube (DLT). Published 2020. Updated 2024. Accessed January 28, 2025. https://litfl.com/double-lumen-endotracheal-tube-dlt/
  3. Campos JH. Separation of the lung: Double-lumen endotracheal tubes and endobronchial blocker. In: Cohen E (ed). Cohen’s Comprehensive Thoracic Anesthesia. 1st edition. Philadelphia, PA. Elsevier. 2022: 213-39.
  4. Campos JH. Lung isolation in patients with a difficult airway in thoracic anesthesia. In: Cohen E (ed). Cohen’s Comprehensive Thoracic Anesthesia. 1st edition. Philadelphia, PA. Elsevier. 2022: 240-8.
  5. Campos J. Lung isolation. In: Slinger P (ed). Principles and Practice of Anesthesia for Thoracic Surgery. 2nd edition. Switzerland. Springer Nature. 2019: 283-309.
  6. Campos JH. Which device should be considered the best for lung isolation: Double-lumen endotracheal tube versus bronchial blockers. Curr Opin Anaesthesiol. 2007; 20:27-31.
  7. Campos JH, Musselman ED, Hanada S, Ueda K. Lung isolation techniques in patients with early stage or long-term tracheostomy: A case series report of 70 cases and recommendations. J Cardiothorac Vasc Anesth. 2019; 33: 433-9.

Media Attributions

  • Typical-double-lumen-tube-DLT-and-appropriate-positioning-within-the-trachea-and.ppm © Updates in Anesthesia – The Operating Room and Beyond [Working Title]. October 2022. DOI: 10.5772/intechopen.107468. Licensed under CC BY 3.0.
  • Leftsided © Used with permission from Campos JH.3
  • Rightsided © Used with permission from Campos JH.3
  • Bronchthrutrachea © With Permission from Campos JH.2
  • a-Sheridan-right-sided-DLT-b-Mallinckrodt-right-sided-DLT-c-View-of-the-right © Reproduced with permission from Campos JH. Lung Isolation. In: Slinger P (ed). Principles and Practice of Anesthesia for Thoracic Surgery. Springer Nature Switzerland AG; 2019. [DOI: 10.1007/978-3-030-00859-8_16].
  • Displays-the-external-and-internal-diameters-of-the-differ-ent-sizes-of-DLTs-and-the © Reproduced with permission from Campos JH. Lung Isolation. In: Slinger P (ed). Principles and Practice of Anesthesia for Thoracic Surgery. Springer Nature Switzerland AG; 2019. [DOI: 10.1007/978-3-030-00859-8_16].

License

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