Right upper lobe anatomy revisited: a computed tomography scan study

The double lumen tube (DLT) has become the most popular way to isolate the lungs for thoracic surgery. The variable anatomy of the right main stem bronchus (RMSB) seems to be the main reason clinicians are unwilling to use the right-sided DLT (R-DLT). The factors that could compromise the adequate ventilation of the right lung are mostly the variable length of the RMSB and the misalignment of the lateral orifice of the R-DLT in regard to the right upper lobe bronchus (RULB). The objectives of this study were to validate an alternative method to estimate the RMSB length, and to determine the distribution of the angulation of the ostium of the RULB.

From high-resolution computed tomography scans of the thorax of 106 consecutive patients, the length of the RMSB was measured using Kim's method and the carina-to-carina method. The angle between the RULB origin and the lateral aspect of the RMSB was also measured. All these measurements were correlated and inter-observer variation documented.

From the Kim's method, the mean (standard deviation [SD]) length of the RMSB was 25.5 (4.7) mm. From the alternative carina-to-carina method, the mean (SD) length of RMSB was 29.4 (4.6) mm. The inter-observer agreement was substantial with both methods (Kim's method: intraclass correlation coefficient [ICC] = 0.84; carina-to-carina method: ICC = 0.95). Both measures were closely related (ICC = 0.93; P < 0.001). The RULB presented a wide range angulation [mean (SD), 0.1 (9.5)°; range, -28.6 to 21.2].

These anatomic observations provide a better understanding of the variable anatomy of the right bronchial tree and may guide thoracic anesthesiologists in the choice of the best lung isolation device for their patients.