Paediatric Anaesthesia 1996 6: 487–489

Case reportRight bevelled tube for selective left bronchialintubation in a child undergoing rightthoracotomy

ANIS BARAKA MD, FRCA (Hon)

Department of Anesthesiology, American University of Beirut, Beirut, Lebanon

SummaryLeft bronchial intubation was used to achieve selective left lungventilation in a five-year-old child, undergoing thoracotomy forexcision of a hydatid cyst of the right lung. Intubation of the leftmain stem bronchus was easily achieved from the first attempt by aright bevelled tracheal tube. Using a right bevelled tube facilitatesleft bronchial intubation, since the bevel of the tube faces the rightside while its tip lies left to the axis of the trachea. Chestauscultation confirmed selective left lung ventilation. One lungventilation using 1–2% halothane in 100% oxygen was associatedwith SpO2 that ranged between 95–97%, and endtidal PETCO2 rangingbetween 3.9–4.5 kPa (30–35 mmHg). Following excision of thehydatid cyst, the tube was withdrawn above the carina into thetrachea, and two lung ventilation was continued until the end ofsurgery.

Keywords: thoracotomy; one lung ventilation; left bronchialintubation

Introduction side of bronchial intubation. The left bevel of theconventional tracheal tube will favour right bronchial

One lung ventilation is becoming increasingly intubation, while right bevelled tube will favour leftpopular during thoracic surgery in children (1,2). bronchial intubation. The present report utilizes aSelective contralateral bronchial intubation has been right bevelled tube to facilitate selective left bronchialused for one lung ventilation (OLV) in infants (3,4) intubation in a child undergoing right thoracotomy.and in children undergoing thoracotomy for excisionof hydatid cysts of the lung (5) or surgicalmanagement of empyema and bronchopleural fistula Case report(6). Because of the anatomy of the tracheobronchialtree in infants and children, it has been previously The child was a five-year-old male, scheduled for

excision of a hydatid cyst of the right lung. Priorsuggested that the right main stem bronchus is morereadily intubated than the left main bronchus (7,8). to anaesthesia, a conventional Portex left bevelled

tracheal tube (size 5) was changed into right bevelled;However, Baraka et al. (9) have shown that the bevelof the tracheal tube is the main factor determining the the distal end of the tube was cut and modified to

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have about 45° right bevel; the edge was thenpolished and the tube resterilized.

The child was premedicated with meperidine2 mg·kg−1 and atropine 0.3 mg. Anaesthesia wasinduced with propofol 2 mg·kg−1 and rocuronium0.6 mg·kg−1. Following induction of anaesthesia, andwhile the child was in the supine position with thehead and neck in the midline, direct laryngoscopyand orotracheal intubation using the right bevelledtube was performed. The tracheal position of thetube was verified by chest auscultation which showedequal breath sounds on both sides. The tube wasthen pushed down blindly beyond the carina untilbreath sounds were heard on only one side of the

Figure 1chest. Left bronchial intubation was achieved fromIllustrates that the bevel of the tracheal tube is a primary

the first attempt. Chest auscultation verified selective determinant of which bronchus the tube will enter: A. The left-bevelled tracheal tube; its tip lies to the right of the midline of theleft lung ventilation. OLV was maintained usingtrachea, and hence enters readily the right main-stem bronchushalothane 1–2% in oxygen. The child was monitored(R). B. The right-bevelled tracheal tube; its tip lies to the left of

continuously by EKG, pulse oximetry and endtidal the midline of the trachea, and hence enters readily the left main-capnography. Pulse oximetry showed SpO2 that stem bronchus (L).

ranged between 95 and 97%, and endtidalcapnography showed PETCO2 ranging between3.9–4.5 kPa (30–35 mmHg). Following excision of the Different manoeuvres have been used to facilitate

selective left bronchial intubation. This includedhydatid cyst, the tube was withdrawn above thecarina into the trachea, and two lung ventilation was intubation under fluroscopy or by fibreoptic

bronchoscopy. Blind left bronchial intubation can becontinued until the end of surgery.achieved by using a metal stylet to curve the distalend of the tracheal tube to the left (5) or by using adistally curved rubber bougie which is directedDiscussionblindly to the left bronchus and railroading the tubeover the bougie (6). Other manoeuvres includeIn children, it has been shown that the angles of the

tracheobronchial bifurcation totalled approximately positioning the child with his left side up and hishead turned to the right side in order to align the80°; the overall mean of the right bronchial angle is

about 30° while the left bronchial angle is about tracheal with the left main bronchus (3).Brown & Fisk and Block postulated that the right50°. This anatomic tracheobronchial relationship may

explain why the tracheal tube is more likely to enter main bronchus may be readily intubated not onlybecause of the more direct continuity with the trachea,the more vertical and wider right main stem bronchus

than the more obliquely placed and narrower left but also because of the bevel of the tracheal tube (11,12). We have confirmed this postulation, and showedbronchus (7).

Although right bronchial intubation is easier to in anaesthetized children, undergoing nonthoracicsurgery, that the bevel of the tracheal tube is the mainachieve than left bronchial intubation, it is

complicated by a higher frequency of upper lobe factor determining the side of bronchial intubation(Figure 1); using the already available left bevelledcollapse (10). The right upper lobe bronchus arises

near the carina from the right main stem bronchus, tube, the tip of the tube lies to the right of the midlineof the trachea and hence enters readily the rightwhile the left upper lobe bronchus arises further

away from the carina as a bifurcation of the main bronchus, while a right bevelled tube has its tip onthe left and enters readily the left main bronchus (9).trunk, and hence a tube pushed selectively down

one bronchus is more likely to obstruct the orifice of The present report implements clinically ourprevious finding that the bevel of the tracheal tubethe right upper lobe bronchus than that of the left.

1996 Arnette Blackwell SA, Paediatric Anaesthesia, 6, 487–489

LEFT BRONCHIAL INTUBATION IN CHILDREN 489

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1996 Arnette Blackwell SA, Paediatric Anaesthesia, 6, 487–489