To the Editor:-The recent article by Klein et al. [1]was very enlightening in showing the high incidence of malpositioned double-lumen tubes (DLTs) after blind intubation and patient positioning. They suggested that routine bronchoscopy is recommended after intubation and after patient positioning. We agree with Klein et al. [1]that malpositioning of DLTs is a serious problem, and fiberoptic bronchoscopy definitely is helpful in confirming DLT position. However, we take exception to their recommendation that the routine use of bronchoscopy is a diagnostic and therapeutic tool in placing DLTs. We agree with Brodsky, [2]Burk, [3]and Grum [4]that fiberoptic bronchoscopy is an adjunct that can be used to improve care when necessary in special cases.

Before publication of the article by Klein et al., [1]we performed a similar study of DLT displacement after patient positioning in 80 patients undergoing elective thoracotomy requiring left DLT placement. [5]Fiberoptic assessment was used to confirm DLT positioning and to measure the distance of displacement. Our results showed that after patient positioning, there were 52.5% tube displacements, and all were proximally malpositioned. Our method differs from that of Klein et al. [1]in that we purposely placed the bronchial cuff closer to the upper lobe orifice before patient positioning. A discrepancy of approximately 1 cm was seen compared to the method of Klein et al. [1]We thought that because a majority of tube displacements after patient positioning are proximal, a more distal initial placement allows the tube to be placed in the correct position as it was withdrawn proximally during patient positioning. Furthermore, it is always easier to pull out a malpositioned tube than it is to advance it forward.

In the past 10 years, we performed more than 3,000 cases of DLT placement in our hospital using this approach. Our experience has been that fiberoptic bronchoscopy is seldom necessary if continuous vigilance is given to bilateral auscultation, bronchial cuff palpation, and observation for the changes in airway pressure.

Ka Shun Cheng, M.D.

Lecturer of Anesthesiology;

Rick Sai Chuen Wu, M.D.

Associate Professor of Anesthesiology

Peter P.C. Tan, M.D.

Professor of Anesthesiology; Department of Anesthesiology; Chang Gung University and Chang Gung Memorial Hospital; Kweishan, Taoyuan; Taiwan, R.O.C.

(Accepted for publication July 7, 1998.)

Klein U, Karzai W, Bloos F, Wohlfarth M, Gottschall R, Fritz H, Gugel M, Seifert: Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia. Anesthesiology 1998; 88:346-50
Brodsky JB: Fiberoptic bronchoscopy should not be a standard of care when positioning double-lumen endobronchial tubes (letter). J Cardiothorac Vasc Anesth 1994; 8:373-5
Burk WJ III: Should a fiberoptic bronchoscope be routinely used to position a double-lumen tube (letter)? Anesthesiology 1988; 68:826
Grum DF, Porembka D: Misconceptions regarding double-lumen tubes and bronchoscopy (letter). Anesthesiology 1988; 68:826-7
Cheng KS, Tan PPC: The incidence of double-lumen tubes displacement after positioning of patients during anesthesia. Acta Anaesth Sinica 1996; 34:75-80