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We would like to report a complication with a double-lumen tube (DLT) and a Frova Intubating Introducer (FII) (Cook Medical, Europe) used for tracheal intubation in a female undergoing thoracoscopy.

When attempting to site a left-sided 39-F DLT (Covidien-Mallinckrodt, Ireland) over a 14-FG FII, advancement of the DLT met resistance. The 39-FG DLT was withdrawn and a left-sided 37-FG DLT sited instead using the same method. During retraction of a bronchoscope (Olympus LF-GP, Olympus, Japan) used to check the tube’s position, a blue foreign body was noticed in the trachea (Fig. 3). Attempts to remove this with suction catheters and biopsy forceps inserted through the DLT failed. The DLT was exchanged for an 8.5-mm single-lumen tracheal tube (Covidien-Mallinckrodt, Ireland). The blue object, subsequently confirmed as a sheared distal fragment of the FII, was removed using a bronchoscope and biopsy forceps. The patient recovered uneventfully.

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Figure 3.  Bronchoscopic view of a blue object, subsequently confirmed as a sheared fragment of distal Frova Intubating Introducer.

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An identical report was published in 2006 [1]. These events were reported to the manufacturers, who explained that there is a sharp ridge on the internal surface of many DLTs, close to the Y-piece, that can cause distal FII shearing. Cook Medical have previously notified the manufacturers of DLTs, and amended the FII’s instructions for use in 2005 to state “this device is not intended for use with double lumen endobronchial tubes”, advice that appears to have been omitted from the currently published instructions for use [2] in which the possible risk of FII shearing is not mentioned. Furthermore, current instructions state that “the 14F intubating introducer is designed for placement of an endotracheal tube with an internal diameter of 6 mm or larger”, whereas even a 41-FG DLT has a bronchial and tracheal internal diameter of only 5.4 mm [3].

It is debatable whether changes to instruction leaflets can prevent complications during DLT insertion, because clinicians tend not to re-read the instructions before each insertion. Although anaesthetists are responsible for the safe use of equipment, we suggest that manufacturers have a duty to disseminate information when they change the instructions for use of their equipment, and note that there are initiatives to this end in Scotland [4].

We think it likely that similar complications have occurred but not been published, and so are potentially looking at the (sheared) tip of an iceberg. We would be interested to learn whether others have encountered a similar problem.

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