Feasibility Of Video Laryngoscope-guided Double-lumen Tube Tracheal Intubation In The Left Lateral Position:a Non-inferiority Trial

Objective:To evaluate the intubation time and success rate of the first-attempt double-lumen endobronchial tube(DLT)intubation guided by video Laryngoscope in the left position,and to explore its potential clinical benefits and safety.For Non-intubated video-assisted thoracoscopic surgery(NIVATS)anesthesia,if necessary,the feasibility of direct conversion from lateral laryngeal mask ventilation to DLT ventilation,lateral position DLT intubation for routine clinical practice to provide further basis.Methods:The trial is a prospective,single-center,randomized,non-inferiority trial.It is carried out in the teaching third-class and first-class hospital.From July 2022 to September 2022,patients who underwent elective right video-assisted thoracoscopic surgery in China-Japan Union Hospital of Jilin University,aged from 18 to 75 years old.They were randomly divided into the lateral position group(group L)and supine position group(group S),with 47 cases in each group.The patients in group L were placed in the left recumbent position when awake,followed by routine general anesthesia and DLT intubation;In group S,general anesthesia and DLT intubation were performed in the supine position,and the operating room staff placed in the lateral position.The patient’s age,sex,Body Mass Index(BMI),American Society of Anesthesiologists(ASA)grade,Mallampati grade and catheter type were evaluated and recorded before operation.The main outcomes were the intubation time and the first-attempt intubation success rate.The secondary outcomes were Cormack-Lehane(CL)grade,preoperative DLT adjustment times,patient’s operation posture preparation time,the number of medical staff involved in posture placement and the number of assistant intubation.The safety indicators were intubation-related adverse events and complications,including carina injury,tracheal wall injury,oral injury,tooth injury,intubated misplacement,hypoxia and intubation failure.Results:A total of 94 patients was included in this trial,without withdrawal or exclusion.There was no significant difference in baseline data between the two groups in terms of age,sex composition,BMI,ASA grade,Mallampati grade and DLT type.For main outcomes,DLT intubation was successful once between the two groups,and the difference was 0(97.5%Confidence interval(CI):-7.56,7.56)%.The intubation time of group L was 6.49(97.5%CI:3.26,9.41)seconds longer than that of group S.Both results were within the corresponding non-inferiority threshold δ,and intubation in the lateral position was not inferior to the supine position.In terms of secondary outcomes,there was no significant difference in CL grade between the two groups(P=0.789).Compared with supine position,intubation in lateral position used,fiberoptic bronchoscope(FOB)to adjust DLT more less(P<0.001),and intubation in lateral position could reduce the number of medical staff placed in posture(P<0.001)and shorten the preparation time of operation position(P<0.001).The DLT was misplaced into the right main bronchus in 7 patients in the lateral position group,but not in the supine position group(P>0.05).There was no significant difference in other safety outcomes(P>0.05).Conclusion:We observed that DLT intubation in the left position guided by video Laryngoscope was non-inferior to the supine position in terms of operational feasibility.It can effectively reduce the number of DLT adjusted by FOB,the number of medical staff placed on posture,and shorten the preparation time of surgical posture,but DLT intubation in the left position is easy to mislead the DLT into the right main bronchus,and there is no significant difference in other safety indexes.Therefore,the technique of DLT intubation in lateral recumbent position still needs to be improved to reduce the rate of intubated misplacement.