When should I rotate a double‑lumen endotracheal tube during insertion, and how many degrees should I rotate it for left‑ versus right‑sided tubes?

Rotation of Double-Lumen Tube During Insertion

Rotate the double-lumen tube 90 degrees counterclockwise (for left-sided tubes) immediately after the bronchial cuff passes through the vocal cords, then advance until resistance is met. 1

Timing and Technique of Rotation

When to Rotate

• Perform the 90-degree counterclockwise rotation as soon as the bronchial cuff clears the vocal cords, before advancing the tube further into the bronchus 1
• One study specifically used 110 degrees of counterclockwise rotation with successful placement in 60% of cases when the stylet was retained throughout the procedure 1

Stylet Management During Rotation

• Keep the stylet in place during the entire intubation procedure, including the rotation, as this significantly improves correct initial placement (60% vs 17% success rate) 1
• Removing the stylet after passing the vocal cords but before rotation increases the risk of right mainstem intubation (7 out of 30 cases placed incorrectly in the right bronchus) 1
• Retaining the stylet does not increase tracheobronchial mucosal injury compared to early removal 1

Advancement After Rotation

Depth of Insertion

• After rotation, advance the tube until gentle resistance is encountered 2, 3, 1
• The tube should be inserted deeply enough that the bronchial cuff is at least 1 cm inside the left mainstem bronchus 4

Common Pitfall: Over-advancement

• Left-sided double-lumen tubes placed in the right main bronchus occur in approximately 4.2% of cases, with increased likelihood in shorter patients, women, and when using smaller tube sizes 5, 6
• Clinical confirmation by auscultation alone has poor sensitivity and specificity, with up to 39.5% of tubes malpositioned when checked subsequently with bronchoscopy 6

Mandatory Confirmation Steps

Fiberoptic Bronchoscopy Requirements

• Fiberoptic bronchoscopy is mandatory to confirm correct tube placement, even when clinical confirmation suggests proper positioning 7
• Deep neuromuscular blockade confirmed by peripheral nerve stimulator must be established before bronchoscopy 7

Two-Position Verification

• Verify tube position in both supine and lateral positions, as tubes move predominantly upward with lateral positioning (mean movement 0.92 cm in both tracheal and bronchial directions) 4
• Inflating the endobronchial cuff before lateral positioning does not prevent tube movement 4
• Final positioning should always be verified in the lateral position after the patient is positioned for surgery 5, 4

Bronchoscopic Confirmation Technique

• Visualize that the carina is located at the same level with the middle 5 mm between the proximal margin of the endobronchial balloon and the circumferential black mark 2
• Confirm the distal end of the bronchial lumen is above the left upper and lower lobe bifurcation 5
• Inflate the bronchial cuff under direct bronchoscopic vision 7

Right-Sided Tubes (Different Rotation)

• Right-sided tubes require mandatory endoscopic confirmation to ensure ventilation of the right upper lobe 7
• Left-sided tubes are preferred for most thoracic procedures 7