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Year : 2020  |  Volume : 14  |  Issue : 2  |  Page : 261-262

Deliberate reattempts at blind double lumen tube placement: A grave ethical concern

Department of Anaesthesiology, Sir Ganga Ram Hospital, New Delhi, India

Correspondence Address:
Dr. Akhil Kumar
Department of Anaesthesiology, B-6/11A, Shyam Vihar, Phase 2, Dinpur, Najafgarh, New Delhi - 110 043
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sja.SJA_538_19

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Date of Submission23-Aug-2019
Date of Acceptance23-Aug-2019
Date of Web Publication5-Mar-2020

How to cite this article:
Kumar A, Dutta A, Sharma S, Sood J. Deliberate reattempts at blind double lumen tube placement: A grave ethical concern. Saudi J Anaesth 2020;14:261-2

How to cite this URL:
Kumar A, Dutta A, Sharma S, Sood J. Deliberate reattempts at blind double lumen tube placement: A grave ethical concern. Saudi J Anaesth [serial online] 2020 [cited 2021 Oct 18];14:261-2. Available from:


We read the article by Kumar et al.[1] with heightened interest. Their report highlighted a peculiar cause that led to unsuccessful double lumen tube (DLT) placement in a patient with mediastinal space occupying lesion. Although they eventually succeeded to access the intended left bronchus, we would like to put forth a few disturbing observation pertinent to the case.

It is imperative to ascertain the tracheobronchial anatomy prior to DLT insertion. While scant information was provided about the primary lung pathology, there was no mention at all of the size and position of the mediastinal mass. Mediastinal masses are particularly notorious for causing airway compromise and an absence of visible preoperative large airway symptomatology does not rule out a possibility of distorted tracheobronchial tree. Any attempt to secure a DLT by conventional blind technique in the presence of mediastinal mass-induced contorted airway anatomy is less likely to succeed.

Incidence of left bronchial intubation by L-DLT with blind conventional technique in first attempt as reported by various authors is 75.9%,[2] 84.3%,[3] and 95.4%.[4] In almost all the cases of these studies, invariably after the failure of blind technique, the fiberoptic bronchoscope (FOB) was placed down the bronchial lumen and DLT visually guided into the correct position. None of the studies recommended use of a new DLT in case of failure with first blind attempt to intubate the left bronchus. It is perplexing to understand why, after failing twice, FOB-guided direct visual placement of the first DLT was not undertaken when the scope was readily available. A little rational thinking and prudence on part of the authors could have avoided the needless cost entailed, due to the use of second DLT.

We would also assert that any DLT (right or left) which has been inserted inadvertently, that too twice, in to the opposite bronchus is bound to develop some counter angulation, due to body temperature softening it up and making it vulnerable to take shape of the contralateral mainstem bronchus, with an ensuing loss of normal contour of the bronchial end. In such a DLT the bronchial lumen axis will be more or less aligned with the tracheal lumen axis, resulting in an exaggerated obtuse angle between the two, which was observed by the authors in the first DLT. Although augmentation of the curved tip of the L-DLT has shown to reduce right bronchial misplacement,[5] harboring a preconceived notion that it was the primary reason for successful placement with the second tube and the first tube lacked sufficient angulation due to a manufacturing defect seems to be speculative and disconcerting.

To conclude, a vigilant anesthesiologist, apart from performing anesthesia safety check list, should also assiduously confirm the conformation of airway equipment to set standards prior to its use. In addition, a little awareness of ethical approach to safe clinical practice in vulnerable anesthetised patients will go a long way. The authors clearly violated the ethical principle of non-malificence (do-no-harm; Primum non Nocere) in bringing harm to the patient by their intent to experiment (reattempting with same type and size of DLT), technique (resorting to conventional technique when FOB is available), and the unnecessary added cost (financial harm).

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Conflicts of interest

There are no conflicts of interest.

  References Top

Kumar A, Sinha C, Kumari P, Nupoor N, Kumar S. Misplacement of left-sided double-lumen tubes into the right mainstem bronchus: Decreased bronchial tube angulation is a cause? Saudi J Anaesth 2019;13:262-3.  Back to cited text no. 1
Brodsky JB, Lemmens HJ. Left double-lumen tubes: Clinical experience with 1,170 patients. J Cardiothorac Vasc Anesth 2003;17:289-98.  Back to cited text no. 2
Boucek CD, Landreneau R, Freeman JA, Strollo D, Bircher NG. A comparison of techniques for placement of double-lumen endobronchial tubes. J Clin Anesth 1998;10:557-60.  Back to cited text no. 3
Seo JH, Bae JY, Kim HJ, Hong DM, Jeon Y, Bahk JH. Misplacement of left-sided double-lumen tubes into the right mainstem bronchus: Incidence, risk factors and blind repositioning techniques. BMC Anesthesiol 2015;15:157.  Back to cited text no. 4
Seo JH, Yoon S, Min SH, Row HS, Bahk JH. Augmentation of curved tip of left-sided double-lumen tubes to reduce right bronchial misplacement: A randomized controlled trial. PLoS One 2019;14:e0210711.  Back to cited text no. 5


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