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A Way for Endotracheal Tube Extension for Endobronchial Intubation
KD Harnagle, Ajit Baviskar, GS Sarate

Patients occasionally present for surgery requiring (isolation of lung) endobronchial intubation (e.g. Bronchopleural fistula). In some conditions due to surgical requirement or pathological condition or non availability of necessary equipments obviate the use of double lumen tubes. In such instance a single lumen endotracheal tube may not be long enough to safely accomplish endobronchial intubation.

Here we describe such a case in which we were required to extend an ordinary endotracheal tube as length was not enough, and the technique by which this was achieved.

Case Report

A 56 year old male patient, who was an operated case of right pnemonectomy, developed a bronchopleural and oesophageal-pleural fistula. He weighed 70 kgs and stood 6 feet tall. Closure of the fistulae was planned.

Anaesthesia plan was to use a DLT for ventilation and isolation of the left lung to conduct the case. After routine IV induction, a 39 number left side portex DLT was passed, but it was found that the left lung could not be isolated and even after inflation of the bronchial cuff there was wasted ventilation from the fistula. Presuming that a 39 number tube may be large for the patient a 37 number rush left DLT was passed with same results. A single lumen portex 7.5 number ET tube was passed after this, but the results were same. The patient was extubated. It was further decided that a visually guided DLT should be attempted.

On fibre optic bronchoscopy, a large fistula which included the carina, with no right bronchial stump was seen. As there was no paediatric fibre optic bronchoscope available in the OT, a DLT could not be passed. So a 7.5 portex ET tube was passed under guidance of an adult fibre optic bronchoscope. The tube was placed in the left main bronchus and the cuff was inflated. At this stage the proximal end of the tube was flushing with the angle of the mouth. On ventilating the patient, there was a leak again from the fistula. The tube could not be pushed further inside as there was no length left proximally, so another piece of portex tube was connected with the help of straight metal connector of the DLT. The tube was then advanced further for 5 cms., after which the tube couldnot be passed any further. On inflation of the cuff there was compete isolation of the left lung which could not be ventilated without any leak, in both upper and lower lobes.


DLT is a common device used for isolation and to separate ventilation of the lung. Some of the pathological conditions, surgical requirements and non availability of certain gadgets obviate the use of DLT. As in our case, it was the large broncho-pleural fistula involving the carina with no right bronchial stump and also the non availability of paediatric bronchoscope.

The total length of the tube passed in this following case was 39 cms, with help of an extension. A Rusch DLT 37 number has the length of 34 cms, this could not have isolated the lung even if passed and placed correctly. The portex DLT 39 number which is 41 cms in length if passed under visual guidance could have isolated the left lung. Since a paediatric bronchoscope was not available it (DLT 39 no.) couldnot be used. An adult bronchoscope freely passes through 7.5 number portex ET tube. This 7.5 number portex ET tube was used for endobronchial intubation, and it was then realized that the length of the tube (34 cms) was not adequate enough for proper endobronchial placement. Hence, an attachment was necessary to increase the length of the tube. We used a straight metal connector of the DLT and another piece of portex tube to achieve the adequate length (39 cms) of the tube.

In 1989, Holzman has described the extension of an ET tube with a modified 15 mm adaptor to connect the two segments of this extended tube. In the same year Bragg et al, had described modification for extension for endobronchial intubation in which he used two portex ET tubes without a connector.

In conditions where a long length single lumen ET tube is needed and not commonly available or there is non availability of certain equipments, the use of a straight metal connector of DLT with a piece of portex tube is a reliable and easy technique to increase the length of the tube.
1. Bragg CL, Vukelich GR. Endotracheal tube extension for endobronchial intubation; anesthesia analgesia, 1989; 69 : 548-9
2. Dorsh JA. Understanding anesthesia equipments, 4th edition.
3. Miller RD, Anesthesia. 5th Edition.
4. Holzman RS. A tracheal tube extension for emergency tracheal reanastomosis; anesthesiology; 1989; 70 : 170-1.

Action on angina

‘ACTION provides support for the long-term treatment of the symptoms of angina in patients already on b blockers and nitrates’

Calcium antagonists are widely prescribed for angina pectoris. Philip Poole-Wilson and colleagues undertook the ACTION trial to investigate the effects of nifedipine on long-term clinical outcome in patients with stable angina. In a Comment paper, Bruce Psaty and Curt Furberg note that 80% of patients were taking b blockers and caution that these results might not have ben achieved if long-acting nifedipine had been used as first-line monotherapy for stable angina.

Lancet, 2004; 4 : 817, 849.


Treating acute COPD at Home is as Good and Cheaper

Hospital at home schemes are safe, effective, and cheaper than inpatient care in hospitals for treating many patients with acute exacerbation of chronic obstructive pulmonary disease (COPD), and free up hospital beds. A systematic review by Ram and colleagues identified seven randomised controlled trials (with 754 patients) comparing hospital at home schemes with in patient treatment. Mortality and hospital readmission were similar in the two groups of patients. Two studies that compared costs showed that hospital at home care was substantially cheaper than inpatient care.

BMJ, 2004; 329 : 315.