Single lumen endotracheal intubation with carbon dioxide insufflation for lung isolation in thoracic surgery

Double lumen tube (DLT) intubation is used for lung isolation but is not without disadvantages including increased intubation time, anesthesia expertise, risk of airway trauma, and costs over single lumen tube (SLT) intubation. SLT intubation with CO₂ insufflation can be used as an alternative for lung isolation. We reviewed our experience with this technique during thoracoscopic surgery.

We performed a retrospective review of a prospectively maintained IRB-approved database from 2009 to 2018. Operations were performed with CO₂ insufflation up to 15 mmHg. Indications for surgery, operative details, intraoperative complications, pathology, and postoperative complications were reviewed.

We identified 123 patients (70 females [57%]) with a median age of 40 years (range 16-80 years) and a median BMI of 26.2 kg/m² (range 15-59 kg/m²) that underwent minimally invasive thoracoscopic procedures with this technique. Procedures included: mediastinal mass resection or biopsy (41%), sympathectomy (37%), wedge resection (10%), first rib resection (6%), diaphragm plication (2%), segmentectomy (2%), decortication (2%), pleural biopsy (2%), and pericardial cyst resection (1%). Median operative time was 90 min (range 25-584 min) and median intraoperative blood loss was 10 mL (range 2-200 mL). Intraoperative hemodynamic parameters were obtained at procedure start, 1 h after CO₂ insufflation, and at procedure completion: we observed significant changes in heart rate and systolic blood pressure (P = 0.027 and P < 0.001, respectively) although clinically inconsequential. Mean end-tidal CO₂ 1 h after insufflation was 36.6 ± 4.5 mmHg. There were no intraoperative complications and no conversions to a DLT. Median length of stay was 1 day (range 0-14 days). Five complications (4%) were observed and no mortalities.

SLT intubation and CO₂ insufflation is a feasible and safe alternative to DLT intubation for lung isolation. This can be a useful strategy to accomplish lung isolation for some thoracoscopic procedures, in particular when expertise for DLT placement is unavailable.