A novel technique of differential lung ventilation in the critical care setting
© Yamakawa et al; licensee BioMed Central Ltd. 2011
Received: 10 February 2011
Accepted: 5 May 2011
Published: 5 May 2011
Differential lung ventilation (DLV) is used to salvage ventilatory support in severe unilateral lung disease in the critical care setting. However, DLV with a double-lumen tube is associated with serious complications such as tube displacement during ventilatory management. Thus, long-term ventilatory management with this method may be associated with high risk of respiratory incidents in the critical care setting.
We devised a novel DLV technique using two single-lumen tubes and applied it to five patients, two with severe unilateral pneumonia and three with thoracic trauma, in a critical care setting. In this novel technique, we perform the usual tracheotomy and insert two single-lumen tubes under bronchoscopic guidance into the main bronchus of each lung. We tie the two single-lumen tubes together and suture them directly to the skin. The described technique was successfully performed in all five patients. Pulmonary oxygenation improved rapidly after DLV induction in all cases, and the three patients with thoracic trauma were managed by DLV without undergoing surgery. Tube displacement was not observed during DLV management. No airway complications occured in either the acute or late phase regardless of the length of DLV management (range 2-23 days).
This novel DLV technique appears to be efficacious and safe in the critical care setting.
Differential lung ventilation (DLV) was reported for the first time in 1931 as a technique for use in thoracic anesthesia . Since then, DLV has been used to salvage ventilatory support in patients with severe unilateral lung disease in the critical care setting [2, 3]. The indications for DLV in the critical care setting have not yet been thoroughly established compared to those in thoracic anesthesia . Although Valverde et al. reported that DLV may be a safe technique with few complications , displacement of the double-lumen tube during DLV management reportedly occurs in up to 32% of cases when the patient's position is changed . Thus, long-term ventilatory management with this method may be associated with high risk of respiratory incidents in the critical care setting. We devised a novel DLV technique using two single-lumen tubes and evaluated the efficacy and safety of this technique in a critical care setting.
Materials and methods
A novel DLV technique was applied to five patients with severe hypoxemia refractory to conventional ventilation and application of positive end-expiratory pressure. Two patients had severe unilateral pneumonia, and the other three patients suffered thoracic trauma: one with unilateral pneumothorax and massive air leakage, one with massive hemoptysis due to pulmonary contusion, and one with tracheal rupture at the carina.
This study followed the principles of the Declaration of Helsinki. The ethics committee at our institution does not require its approval or informed consent for retrospective studies such as this study.
In our novel technique, a commercially available double-lumen tube is not used.
1. We perform the usual tracheotomy.
2. We insert a single-lumen tube (7.5-mm ID) under bronchoscopic guidance into the main bronchus of the unaffected lung.
3. We then extend the tracheotomy site using two blunt hooks to secure space for insertion of the second tube. We quickly but carefully insert a second single-lumen tube (7.0-mm ID) under bronchoscopic guidance into the main bronchus of the affected lung.
4. We ascertain proper anatomical position of both tubes by bronchoscopy and chest X-ray.
5. Finally, we tie the two single-lumen tubes together with silk suture and suture them directly to the skin.
6. Differential ventilator settings using two ventilator circuits are applied to each lung asynchronously. As a rule, administration of neuromuscular blockade is not necessary.
Characteristics of the Patients Undergoing our DLV Technique
Length of DLV (days)
Length of mechanical
Tracheal rupture of carina
The described technique was successfully performed in all five patients. Complications such as tube displacement, tube obstruction, and tracheal or bronchial injury were not observed regardless of the length of DLV management (range 2-23 days). One patient with unilateral pneumonia died due to septic shock on day 2 of DLV. The four remaining patients were followed up after the end of DLV management, and none experienced complications of airway stenosis after DLV.
Our DLV technique allowed successful ventilatory management of all five patients without complications. These results demonstrate that this novel technique may be effective for ventilatory support in critically ill patients requiring DLV management.
Patient 5 presented with tension pneumopericardium, bilateral pneumothorax, and massive subcutaneous emphysema due to carinal laceration . Operative repair of the tracheal injury could not be performed because of the patient's severe respiratory insufficiency and coagulopathy. Thus, we chose to treat the patient non-operatively, and the initial use of our DLV technique was in this patient. Successful treatment of this patient indicated that our technique could be efficacious in the critical care setting. Here, we examine the efficacy and safety of this technique after its application in five patients.
Although the double-lumen tube of the conventional DLV technique is mainly used in the intensive care setting, serious complications such as tube displacement have been described . Accordingly, there is the need for deep sedation and sometimes neuromuscular blockers for patients on DLV using the double-lumen tube to prevent tube displacement by patient movement or coughing. However, the routine use of neuromuscular blockade is not recommended in mechanically ventilated patients because of complications associated with its use [8, 9].
Our DLV technique has several advantages over the conventional DLV method using a double-lumen tube.
1) It is difficult for tube displacement to occur with our method. In case of proximal displacement, it is difficult for bilateral ventilation to occur, unlike with the double-lumen tube, because the cuffs of the two single-lumen tubes prevent their movement above the carina. In case of distal displacement, unilateral ventilation will never occur, unlike with the double-lumen tube, because the distal end of each tube is located within a main bronchus. In addition, there is little influence from head movements because tube fixation is by direct suture at the tracheotomy site . A major reason for the difficulty in displacing the tubes is the firm suturing of each tube to the skin. Our technique allows frequent change of patient position and suctioning of secretions, and administration of neuromuscular blockade is unnecessary to prevent tube displacement.
2) Because the internal diameter of each tube used in our technique is larger than the individual tube diameters in the double-lumen tube, a regular bronchoscope and suction tubing can be used. In addition, risk of tube occlusion is reduced.
3) The two cuffs used in our technique doubly isolate the relatively healthy lung from harmful contaminants in the contralateral diseased lung, whereas with the double-lumen tube, the diseased lung is isolated from the contralateral lung by only one cuff.
4) Ours is the only technique to provide non-operative management of carinal laceration. The advantages of safety and efficacy offered by our DLV technique would be especially appreciated in the critical care setting rather than during surgical anesthesia because of the potentially long period of DLV use generally required in the critical care setting.
Because the performance of tracheotomy is a burden for the patient, the use of our DLV technique should be limited to the rescue of the patients with life-threatening respiratory conditions.
We acknowledge several limitations in this study. First, the design of this study was a case series, and there was no control. The influence of different pathophysiologic issues, such as severity of respiratory failure, lung pathology, and cause of admission to the intensive care unit, on the safety and efficacy of our DLV technique require further evaluation. Second, the sample size in this study was small, and the follow-up period was short. Although we experienced no technical difficulties in insertion of the two tubes or airway complications in either the acute or late phase, further study is required to evaluate the safety of this technique, especially in patients with a narrow trachea such as women and adolescents.
Our novel DLV technique using two single-lumen tubes may have several advantages of safety and efficacy over the conventional double-lumen tube during the long period of DLV use in the critical care setting.
No one other than the authors contributed substantially to the performance of this study or to the drafting of the manuscript. The authors received no funding for this study.
- Tuxen D: Independent lung ventilation. Principles and Practice of Mechanical Ventilation. Edited by: Tobin MJ. 1994, New York, McGraw-Hill, 571-588.Google Scholar
- Glass DD, Tonnesen AS, Gabel JC, Arens JF: Therapy of unilateral pulmonary insufficiency with a double lumen endotracheal tube. Crit Care Med. 1976, 4 (6): 323-326. 10.1097/00003246-197611000-00010.PubMedView ArticleGoogle Scholar
- Anantham D, Jagadesan R, Tiew PE: Clinical review: Independent lung ventilation in critical care. Crit Care. 2005, 9 (6): 594-600. 10.1186/cc3827.PubMedPubMed CentralView ArticleGoogle Scholar
- Siegel JH, Stoklosa JC, Borg U, Wiles CE, Sganga G, Geisler FH, Belzberg H, Wedel S, Blevins S, Goh KC: Quantification of asymmetric lung pathophysiology as a guide to the use of simultaneous independent lung ventilation in posttraumatic and septic adult respiratory distress syndrome. Ann Surg. 1985, 202 (4): 425-439. 10.1097/00000658-198510000-00004.PubMedPubMed CentralView ArticleGoogle Scholar
- Díaz-Regañón Valverde G, Fernández-Rico R, Iribarren-Sarrias JL, Ortiz-Piquer M, Blanco-Huelga C, Garijo-Catalina MA, Morrondo-Valdeolmillos P, Ortiz-López R: Synchronized independent pulmonary ventilation in the treatment of adult respiratory distress syndrome. Rev Esp Anestesiol Reanim. 1997, 44 (10): 392-395. In SpanishPubMedGoogle Scholar
- Inoue S, Nishimine N, Kitaguchi K, Furuya H, Taniguchi S: Double lumen tube location predicts tube malposition and hypoxaemia during one lung ventilation. Br J Anaesth. 2004, 92 (2): 195-201. 10.1093/bja/aeh055.PubMedView ArticleGoogle Scholar
- Nakamori Y, Hayakata T, Fujimi S, Satou K, Tanaka C, Ogura H, Nishino M, Tanaka H, Shimazu T, Sugimoto H: Tracheal rupture diagnosed with virtual bronchoscopy and managed nonoperatively: a case report. J Trauma. 2002, 53 (2): 369-371. 10.1097/00005373-200208000-00031.PubMedView ArticleGoogle Scholar
- Kress JP, Hall JB: Sedation in the mechanically ventilated patient. Crit Care Med. 2006, 34 (10): 2541-2546. 10.1097/01.CCM.0000239117.39890.E3.PubMedView ArticleGoogle Scholar
- Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL: Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med. 2008, 36 (1): 296-327. 10.1097/01.CCM.0000298158.12101.41.PubMedView ArticleGoogle Scholar
- Alberti A, Valenti S, Gallo F, Vincenti E: Differential lung ventilation with a double-lumen tracheostomy tube in unilateral refractory atelectasis. Intensive Care Med. 1992, 18 (8): 479-484. 10.1007/BF01708585.PubMedView ArticleGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.