03 °“√»÷°…“‡ª√`¬∫‡∑`¬∫

°“√»÷°…“‡ª√’¬∫‡∑’¬∫§«“¡ ”‡√Á®„π°“√„ à∑àÕÀ≈Õ¥§Õ™π‘¥
Õß√Ÿ¢â“ߴ⓬¥â«¬«‘∏’°“√„ à·°π≈«¥μ≈Õ¥°“√„ à∑àÕÀ≈Õ¥§Õ
°—∫«‘∏’ª°μ‘
‚™μ‘ π‘ Ÿß æ.∫.,*
¬Õ¥¬‘Ëß ªí≠® «— ¥‘Ï«ß»å æ.∫.,*
πÿ™π“√∂ ∫ÿ≠®÷ߡߧ≈ æ.∫.,*
æ—¥™“ ™—™«√—μπå æ.∫.*
Abstract : Comparison of Success Rate in of Left Double-Lumen Tube Placement between Stylet Retained in
DLT for Entire Intubating Procedure and Conventional Technique
Nisoong C, M.D., FRCAT,* Punjasawadwong Y, M.D., FRCAT,* M.Med.Sc (Clinical Epidemiology),*
Bunchungmongkol N, M.D., FRCAT,* Chatchawarat P, M.D.*
*Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200.
for 90o counterclockwise and advanced until resistance
was encountered. The position of the DLT was confirmed by fiberoptic bronchoscopy. After surgery, the
complications such as ruptured of tracheobronchial
tree and pulmonary artery were observed. Results :
The success rate of the placement of left-DLT to LMS
in S-group was higher than C-group (97% vs 74%,
p = 0.02). The success rate of the placement of DLT to
correct position in S-group and C-group were 20% and
13%, respectively (p = 0.73). No severe complication
was observed in both groups. Conclusion : Retaining
the stylet in the left-DLT for the entire intubating
procedure showed higher success rate of placement
to left mainstem bronchus than conventional technique
without severe complications.
Background : The double-lumen tube (DLT) is
the mainstay instrument of one-lung ventilation (OLV).
Poor positioning of a DLT could affect oxygenation
during OLV. Objective : To compare the success rate in
the placement of left Rüsch-Endobronchial tube to
left mainstem bronchus (LMS) in thoracic surgery
between stylet retained in the DLT for the entire intubating procedure and conventional technique. Design :
Randomized controlled trial. Materials and Methods :
60 ASA physical status I-III patients scheduled for
elective surgical procedures requiring left-sided endobronchial intubations were included in this study.
Patients were randomly assigned into two groups. In
S-group (n = 30), the stylet was retained for the entire
intubating procedure and in C-group (n = 30), the
stylet was removed once the bronchial cuff passed
through vocal cord. In both groups, the DLT was turned
Keywords : Left double-lumen tube, retained stylet, left
mainstem bronchus
*¿“§«‘ ™ “«‘ — ≠ ≠’ «‘ ∑ ¬“ §≥–·æ∑¬»“ μ√å ¡À“«‘ ∑ ¬“≈— ¬ ‡™’ ¬ ß„À¡à
®.‡™’¬ß„À¡à 50200
Thai J Anesthesiology 2007 ; 33(3) : 161-8.
161
∫∑π”
°“√„À⬓√–ß—∫§«“¡√Ÿâ ÷° ”À√—∫°“√ºà“μ—¥∑√«ßÕ°
‡™àπ °“√ºà“μ—¥¡–‡√Áߪե‚¥¬°“√μ—¥ªÕ¥ÕÕ°∫“ß à«π °“√
ºà“μ—¥‡Õ“ªÕ¥ÕÕ°∑—Èߢâ“ß °“√ºà“μ—¥∑√«ßÕ°¥â«¬«‘∏’ àÕß°≈âÕß
°“√ºà “ μ— ¥ ÀπÕß„π‡¬◊Ë Õ Àÿâ ¡ ªÕ¥ √«¡∂÷ ß °“√ºà “ μ— ¥ ¡–‡√Á ß
À≈Õ¥Õ“À“√ ¡’§«“¡®”‡ªìπ∑’Ë®–μâÕß„™â‡∑§π‘§°“√¥¡¬“ ≈∫
”À√—∫°“√ºà“μ—¥∑√«ßÕ° ‚¥¬°“√™à«¬À“¬„®¥â«¬«‘∏·’ ¬°ªÕ¥
(one-lung ventilation, OLV) ‡æ◊ËÕ„Àâ»—≈¬·æ∑¬å∑”°“√ºà“μ—¥
‰¥â –¥«°¢÷πÈ
∑àÕÀ≈Õ¥§Õ™π‘¥ Õß√Ÿ (double-lumen tube, DLT)
®÷ ß ¡’ ∫ ∑∫“∑ ”À√— ∫ °“√™à « ¬À“¬„®¥â « ¬ OLV ‚¥¬π‘¬¡„™â
DLT ¢â“ߴ⓬ ∂⓺ŸâªÉ«¬‰¡à¡’¢âÕÀâ“¡‡π◊ËÕß®“°¡’ Margin of
1
safety ¡“°°«à “ ·μà ‡ π◊Ë Õ ß®“° DLT ¡’ ¢ 𓥄À≠à ° «à “ ∑à Õ
À≈Õ¥§Õ™π‘¥√Ÿ‡¥’¬« (Single lumen tube) §◊Õ ¡’‡ âπºà“»Ÿπ¬å°≈“ß¿“¬πÕ°¡“°°«à“ ·≈–¡’§«“¡¬“«¡“°°«à“ √«¡∑—Èß
¬—ß¡’ à«π‚§âß∑’˧ßμ—«¡“°°«à“ (fixed shape)2 ®÷ß∑”„Àâ°“√„ à
È “√„ à
DLT ¡’§«“¡¬“°°«à“∑àÕÀ≈Õ¥§Õ™π‘¥√Ÿ‡¥’¬« πÕ°®“°π’°
DLT ¢â“ߴ⓬μâÕß„À≥âμ”·Àπàß∑’ˇÀ¡“– ¡‡æ◊ËÕ„Àâ “¡“√∂∑”
OLV ‰¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ·≈–≈¥¿“«–·∑√°´âÕπ®“°°“√
™à«¬À“¬„®¥â«¬ OLV ‡™àπ ÕÕ°´‘‡®π„π°√–· ‡≈◊Õ¥μË” §“√å∫Õπ‰¥ÕÕ°‰´§å„π°√–· ‡≈◊Õ¥ Ÿß ªÕ¥·ø∫ √«¡∂÷߉¡à “¡“√∂
∑”°“√™à«¬À“¬„®¥â«¬ OLV ‰¥â ”‡√Á® ∑”„À⇪ìπÕÿª √√§
”À√—∫°“√ºà“μ—¥ ´÷Ëß à«π„À≠à¡’ “‡Àμÿ¡“®“°μ”·ÀπàߢÕß
3
DLT ‰¡à‡À¡“– ¡ ¥—ßπ—Èπ°“√„ à DLT ¢â“ߴ⓬„Àâ ”‡√Á®®÷ß¡’
§«“¡®”‡ªìπ ”À√—∫°“√∑”°“√™à«¬À“¬„®¥â«¬ OLV
„πÕ¥’μ„™â«‘∏’°“√øí߇ ’¬ß≈¡ºà“πªÕ¥ ‡æ◊ËÕ¬◊π¬—π
μ”·ÀπàߢÕß DLT ·μà¡’°“√»÷°…“æ∫«à“ °“√øíߪե‡æ’¬ß
Õ¬à“߇¥’¬«‰¡àπà“‡™◊ËÕ∂◊Õ4-7 ®÷߉¥â¡’°“√π”°≈âÕß àÕßÀ≈Õ¥≈¡
™π‘¥„¬·°â«π”· ß (fiberoptic bronchoscope, FOB) ¡“„™â
‡æ◊ËÕ¬◊π¬—πμ”·Àπàß∑’ˇÀ¡“– ¡4-6,8-9 ·≈–æ∫«à“À≈—ß®“°„™â
FOB ‡æ◊ËÕμ√«® Õ∫μ”·Àπàß„π°“√„ à DLTs ¢â“ߴ⓬™π‘¥
æ’«’´’ æ∫«à“„ à‰¥â„πμ”·Àπàß∑’ˉ¡à‡À¡“– ¡∂÷ß 48-78% ‚¥¬
æ∫«à“ μ”·Àπàß„π°“√„ à DLT ¢â“ߴ⓬∑’ˉ¡à‡À¡“– ¡¡’ 3
·∫∫§◊Õ „ à‡¢â“À≈Õ¥≈¡¢â“ߢ«“ (Incorrect bronchus) „ à
‡¢â“À≈Õ¥≈¡´â“¬ (Correct bronchus) ·μàμ◊ÈπÀ√◊Õ≈÷°‡°‘π‰ª10
‚¥¬æ∫°“√„ à‡¢â“À≈Õ¥≈¡¢«“¥â«¬«‘∏’ª°μ‘ (Conventional
6
technique) √âÕ¬≈– 20 ´÷ßË Õ“®‡°‘¥®“°≈—°…≥–∑“ß°“¬«‘¿“§
∑’Ë·μ°μà“ß°—π¢ÕßÀ≈Õ¥≈¡´â“¬·≈–¢«“11 §◊Õ °“√∑’ËÀ≈Õ¥≈¡
¢«“∑”¡ÿ¡°—∫·π«°÷Ëß°≈“ߢÕß∑àÕÀ≈Õ¥§ÕπâÕ¬°«à“À≈Õ¥≈¡
162
«‘ —≠≠’ “√
´â“¬ §◊Õ 25 Õß»“·≈– 45 Õß»“μ“¡≈”¥—∫ √à«¡°—∫¢π“¥¢Õß
À≈Õ¥≈¡¢«“„À≠à°«à“À≈Õ¥≈¡´â“¬§◊Õ 16 ¡¡. ·≈– 13 ¡¡.
μ“¡≈”¥—∫ ®÷ß∑”„Àâ¡’‚Õ°“ „ à DLT ¢â“ߴ⓬‡¢â“À≈Õ¥≈¡
¢«“‰¥â
·°π≈«¥∑’Ë„ à¡“„π Bronchial lumen ¢Õß DLT
™à«¬∑”„Àâ√Ÿª√à“ß√«¡∂÷ߧ«“¡‚§âßμ—«¢Õß DLT §ß√Ÿª ´÷Ëß„π
§”·π–π”®“°‚√ßß“π∑’˺≈‘μ DLT ™π‘¥π’È„Àâ¥÷ß·°π≈«¥ÕÕ°
∂⓪≈“¬¢Õß DLT ºà“π‡ âπ‡ ’¬ß ‚¥¬„Àâ‡Àμÿº≈μ“¡∑ƒ…Æ’«à“
®–≈¥°“√∫“¥‡®Á∫¢Õ߇¬◊ËÕ∫ÿÀ≈Õ¥§Õ·≈–À≈Õ¥≈¡ ·μà°Á¬—ß
‰¡à¡’°“√√“¬ß“π∑’Ë π—∫ πÿπ·π«§‘¥π’È √«¡∂÷ß®“°°“√»÷°…“
¢Õß Leiberman D. ·≈–§≥–12 æ∫«à“°“√„ à DLT ™π‘¥æ’«’´’
¢â“ߴ⓬ ‚¥¬«‘∏’°“√„ à·°π≈«¥μ≈Õ¥°“√„ à∑àÕÀ≈Õ¥§Õ‡æ‘Ë¡
§«“¡ ”‡√Á®„π°“√„ à DLT „À⇢â“À≈Õ¥≈¡´â“¬‡¡◊ËÕ‡ª√’¬∫
‡∑’¬∫°—∫«‘∏’ª°μ‘ ‚¥¬∑’ˉ¡à‰¥â‡æ‘Ë¡¿“«–·∑√°´âÕπ®“°°“√„ à
DLT ¥â«¬«‘∏’π’È ·μà°“√»÷°…“„π‡√◊ËÕß°“√„ à DLT ¥â«¬«‘∏’π’È¡’
‡æ’¬ß°“√»÷°…“‡¥’¬«‡∑à“π—Èπ ·≈–»÷°…“„πª√–™“°√ª√–‡∑»
·§π“¥“ ‚¥¬¬—߉¡à¡’°“√»÷°…“„πª√–™“°√‰∑¬ §≥–ºŸâ«‘®—¬®÷ß
μâÕß°“√»÷°…“„π§π‰∑¬«à“°“√„ à·°π≈«¥μ≈Õ¥°“√„ à DLT
¢â“ߴ⓬™à«¬‡æ‘Ë¡§«“¡ ”‡√Á®„π°“√„ à DLT „À⇢â“À≈Õ¥≈¡
´â“¬¡“°°«à“°“√„ à¥â«¬«‘∏’ª°μ‘À√◊Õ‰¡à
«—μ∂ÿª√– ߧåß“π«‘®—¬
1. ‡æ◊ËÕ‡ª√’¬∫‡∑’¬∫§«“¡ ”‡√Á®„π°“√„ à DLT ¢â“ß
´â“¬„À⇢â“À≈Õ¥≈¡´â“¬„πºŸâªÉ«¬∑’ˇ¢â“√—∫°“√ºà“μ—¥∑√«ßÕ°
√–À«à“ß«‘∏’°“√„ à·°π≈«¥μ≈Õ¥°“√„ à∑àÕÀ≈Õ¥§Õ°—∫«‘∏’ª°μ‘
2. ‡æ◊Ë Õ ‡ª√’ ¬ ∫‡∑’ ¬ ∫§«“¡ ”‡√Á ® „π°“√„ à DLT
¢â“ߴ⓬„À≥âμ”·Àπàß∑’ˇÀ¡“– ¡„πºŸâªÉ«¬∑’ˇ¢â“√—∫°“√ºà“μ—¥
∑√«ßÕ°√–À«à“ß«‘∏’°“√„ à·°π≈«¥μ≈Õ¥°“√„ à∑àÕÀ≈Õ¥§Õ
°—∫«‘∏’ª°μ‘
3. ‡æ◊Ë Õ ‡ª√’ ¬ ∫‡∑’ ¬ ∫¿“«–·∑√°´â Õ π®“°°“√„ à
DLT ¢â“ߴ⓬„πºŸâªÉ«¬∑’ˇ¢â“√—∫°“√ºà“μ—¥∑√«ßÕ°√–À«à“ß«‘∏’
°“√„ à·°π≈«¥μ≈Õ¥°“√„ à∑àÕÀ≈Õ¥§Õ°—∫«‘∏’ª°μ‘
«‘∏’°“√»÷°…“
°“√»÷°…“§√—Èßπ’ȉ¥âºà“π°“√æ‘®“√≥“·≈–‰¥â√—∫§«“¡
‡ÀÁπ™Õ∫®“°§≥–°√√¡°“√®√‘¬∏√√¡°“√«‘®—¬„π¡πÿ…¬å¢Õß
·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à ·≈–‰¥â√—∫§«“¡¬‘π¬Õ¡
®“°ºŸâªÉ«¬„π°“√‡¢â“√à«¡«‘®—¬‚¥¬≈ß™◊ËÕ„π„∫Õπÿ≠“μ„Àâ∑”°“√
»÷°…“ ‚¥¬‰¥â∑”°“√»÷°…“·∫∫ Randomized controlled trial
ªï∑’Ë 33 ©∫—∫∑’Ë 3 °√°Æ“§¡-°—𬓬π 2550
„πºŸªâ «É ¬∑’¡Ë “√—∫°“√ºà“μ—¥∑√«ßÕ°™π‘¥‰¡à‡√àߥà«π ¢Õß‚√ß欓∫“≈¡À“√“™π§√ ‡™’¬ß„À¡à ®”π«π 60 §π ´÷Ëß¡’§ÿ≥ ¡∫—μ‘
μ“¡ Inclusion ·≈– Exclusion criteria ¥—ßμàÕ‰ªπ’È
Inclusion criteria
1. ASA class I-III
2. ‡¢â “ √— ∫ °“√ºà “ μ— ¥ ∑√«ßÕ°™π‘ ¥ ‰¡à ‡ √à ß ¥à « π ∑’Ë
®”‡ªìπμâÕß„ à DLT ¢â“ߴ⓬
Exclusion criteria
1. ºŸâªÉ«¬∑’Ë¡’¢âÕÀâ“¡„π°“√„ à DLT ¢â“ߴ⓬13 ‡™àπ
¡’√Õ¬‚√§„π∫√‘‡«≥∑’Ë DLT ºà“π, ¡’°“√μ’∫·§∫¢ÕßÀ≈Õ¥§Õ
(Tracheal stenosis) À√◊Õ∑àÕÀ≈Õ¥≈¡¢â“ߴ⓬ (Left main
bronchus stenosis) ·≈–≈—°…≥–√Ÿª√à“ߢÕß∫√‘‡«≥À≈Õ¥§Õ∑’Ë
·¬°‡ªìπÀ≈Õ¥≈¡¢â“ߴ⓬·≈–¢â“ߢ«“∑’˺‘¥ª°μ‘ (distorted
carinal architecture)
í À“„π°“√„ à∑Õà ™à«¬À“¬„®
â «É ¬∑’§Ë “¥«à“®–¡’ª≠
2. ºŸª
≈”∫“° ‰¥â·°à ºŸâªÉ«¬∑’Ë¡’ª√–«—μ‘ºà“μ—¥∫√‘‡«≥§Õ ¡’ª√–«—μ‘
‰¥â√∫— √—ß ’√°— …“∫√‘‡«≥§Õ√à«¡°—∫¡’ª√–«—μ°‘ “√„ à∑Õà ™à«¬À“¬„®
¬“° ·≈–°√–¥Ÿ° —πÀ≈—ß à«π§Õ‰¥â√—∫∫“¥‡®Á∫ μ√«®√à“ß°“¬
æ∫«à“ Mallampati classification III-IV13, Inter-incisor gap
< 3 ´¡. Thyromental distance < 6 ´¡. ·≈–¡’°“√®”°—¥
¢Õß°“√°â¡·≈–·Àßπ¢âÕμàÕ atlanto-occipital
ºŸâªÉ«¬∑—ÈßÀ¡¥ 60 §π ∂Ÿ°·∫àßÕÕ°‡ªìπ 2 °≈ÿà¡ Ê ≈–
30 §π ‚¥¬°“√ ÿà¡·≈–„™â sealed envelope ”À√—∫ allocation concealment ‚¥¬ C-group ‡ªìπ°≈ÿࡧ«∫§ÿ¡ ‰¥â√—∫
°“√„ à DLT ¢â“ߴ⓬¥â«¬«‘∏’ª°μ‘ §◊Õ °“√„ à DLT ‚¥¬
¥÷ß·°π≈«¥ÕÕ°‡¡◊ËÕ bronchial cuff ¢Õß DLT ºà“π‡ âπ‡ ’¬ß
·≈â « À≈— ß ®“°π—È π À¡ÿ π DLT ∑«π‡¢Á¡π“Ãî°“ 90o ·≈â«¥—π
14
DLT ‡¢â“‰ª®π√Ÿâ ÷°«à“¡’·√ßμâ“π ·≈â«®÷ßÀ¬ÿ¥ à«π S-group
‡ªìπ°≈ÿà¡»÷°…“‰¥â√—∫°“√„ à DLT ¢â“ߴ⓬‡À¡◊Õπ«‘∏’ª°μ‘ ·μà
®–¥÷ß·°π≈«¥ÕÕ°°ÁμàÕ‡¡◊ËÕ„ à DLT ‡ √Á®
ºŸªâ «É ¬‰¥â√∫— ÕÕ°´‘‡®π 100% ºà“πÀπâ“°“°π“π 3-5
π“∑’ ®“°π—Èππ” ≈∫¥â«¬ Thiopentone 3-5 mg/kg ∫√‘À“√
¬“∑“ßÀ≈Õ¥‡≈◊Õ¥¥” À≈—ß®“°π—Èπ„À⬓À¬àÕπ°≈â“¡‡π◊ÈÕ°≈ÿà¡
nondepolarizing §◊Õ Vecuronium 0.1-0.2 mg/kg ∫√‘À“√
¬“∑“ßÀ≈Õ¥‡≈◊Õ¥¥” „™â‡«≈“ª√–¡“≥ 3 π“∑’ „π°“√™à«¬
À“¬„®ºà“πÀπâ“°“°·≈–Õ“®„™âÕÿª°√≥凪î¥∑“߇¥‘πÀ“¬„®∑“ß
ª“°À“°¡’ § «“¡®”‡ªì π À≈— ß ®“°π—È π „ à DLT ‚¥¬·æ∑¬å
ª√–®”∫â“πªï∑’Ë 2 À√◊Õ 3 À√◊ÕÕ“®“√¬å·æ∑¬å ‚¥¬‡≈◊Õ°¢π“¥
(French number) μ“¡«‘∏’¢Õß Hannallah15 μ“¡ Appendix
Vol. 33, No. 3, July-September 2007
1 À≈—ß®“°„ à DLT ·≈â« «‘ —≠≠’·æ∑¬å∑’Ë¡’§«“¡™”π“≠„π
°“√„™â FOB ´÷Ë߉¡à∑√“∫«à“ºŸâªÉ«¬Õ¬Ÿà„π°≈ÿà¡„¥„™â FOB μ√«®
Õ∫μ”·ÀπàߢÕß DLT «à“Õ¬Ÿ„à πμ”·Àπàß∂Ÿ°μâÕß·≈–‡À¡“– ¡
À√◊Õ‰¡à ‚¥¬°“√ àÕß FOB ºà“π‡¢â“‰ª„π tracheal lumen ®π
‡ÀÁπ carina ∂ⓇÀÁπ bronchial lumen ‡¢â“‰ª„πÀ≈Õ¥≈¡´â“¬
·≈–‡ÀÁπ à«π∫π ÿ¥¢Õß bronchial cuff ´÷ßË ¡’ ø’ “Ñ Õ¬Ÿ„à πÀ≈Õ¥≈¡
´â“¬·≈–Õ¬Ÿà∫√‘‡«≥„μâμàÕ carina ‡≈Á°πâÕ¬ (just below carina)
∂◊Õ«à“μ”·Àπàß∂Ÿ°μâÕß À√◊Õ∂â“¡Õ߉¡à‡ÀÁπ bronchial cuff
· ¥ß«à“‡¢â“‰ª„πÀ≈Õ¥≈¡´â“¬≈÷°‡°‘π‰ª ·≈–∂â“¡Õ߇ÀÁπ
bronchial cuff Õ¬Ÿà∫π carina ∂◊Õ«à“μ◊Èπ‡°‘π‰ª
„π™à«ß‡«≈“√–À«à“ߺà“μ—¥¡’°“√‡ΩÑ“μ‘¥μ“¡≈—°…≥–
∑“ߧ≈‘π‘°¢ÕߺŸâªÉ«¬«à“¡’¿“«–·∑√°´âÕπ∑’Ë√ÿπ·√ß®“°°“√„ à
DLT §◊Õ ¡’°“√©’°¢“¥¢ÕßÀ≈Õ¥§ÕÀ√◊ÕÀ≈Õ¥≈¡ À√◊Õ¡’°“√
©’°¢“¥¢ÕßÀ≈Õ¥‡≈◊Õ¥ Palmonary À√◊Õ‰¡à
√–À«à“ß°“√„ à DLT ºŸâªÉ«¬∑ÿ°§π‰¥â√—∫°“√‡ΩÑ“√–«—ß
√–¥—∫§«“¡Õ‘Ë¡μ—«¢ÕßÕÕ°´‘‡®π„π‡≈◊Õ¥·¥ß¥â«¬ Pulse oximeter „ÀâÕ¬Ÿà„π™à«ß 94-100% §«“¡¥—π‚≈À‘μ·≈–Õ—μ√“°“√
‡μâπ¢ÕßÀ—«„®‰¡à„Àâ‡æ‘Ë¡¢÷ÈπÀ√◊Õ≈¥≈ß¡“°°«à“ 20% ®“°√–¥—∫
ª°μ‘¢ÕߺŸâªÉ«¬ ·≈–§≈◊Ëπ‰øøÑ“À—«„®„ÀâÕ¬Ÿà„π‡°≥±åª°μ‘
∑”°“√∫—π∑÷°¢âÕ¡Ÿ≈∑—Ë«‰ª¢ÕߺŸâªÉ«¬ μ”·ÀπàߢÕß
DLT ∑’Ë„ à„π§√—Èß·√° ‚¥¬·∫à߇ªìπ„ à‰¥âμ”·Àπà߇À¡“– ¡
À√◊Õ„ à‡¢â“À≈Õ¥≈¡¢â“ߢ«“ ‡¢â“À≈Õ¥≈¡¢â“ߴ⓬·μàμ◊ÈπÀ√◊Õ
≈÷°‡°‘π‰ª À√◊Õ„ à‡¢â“À≈Õ¥Õ“À“√ ®”π«π§√—Èß„π°“√„ à DLT
®π ”‡√Á® ºŸâ„ à DLT „π§√—Èß·√° √–¬–‡«≈“∑’Ë„™â„π°“√„ à DLT
®π ”‡√Á® (μ—Èß·μà‡√‘Ë¡„ à Laryngoscope ®π∂÷ß„ à DLT ‡¢â“
À≈Õ¥≈¡´â“¬‰¥âμ”·Àπà߇À¡“– ¡‚¥¬°“√¬◊π¬—π®“° FOB)
·≈–¿“«–·∑√°´âÕπ∑’Ë√ÿπ·√ß®“°°“√„ à DLT
¢π“¥μ—«Õ¬à“ß
§”π«≥¢π“¥μ— « Õ¬à “ ß®“°Õ— μ √“¢Õß°“√„ à DLT
¢â“ߴ⓬‡¢â“À≈Õ¥≈¡¢«“ ®“°°“√»÷°…“∑’ˇ§¬¡’¡“°àÕπ4 ´÷Ëß
æ∫√âÕ¬≈– 20 °”Àπ¥ α = 0.05 ·≈– β = 0.2 ·≈–°”Àπ¥
«à“°“√„ à·°π≈«¥μ≈Õ¥°“√„ à DLT “¡“√∂≈¥Õ—μ√“¢Õß
°“√„ à‡¢â“À≈Õ¥≈¡¢«“√âÕ¬≈– 50 „™â‚ª√·°√¡ STATA „π
°“√§”π«≥À“¢π“¥μ—«Õ¬à“߉¥â 30 §πμàÕ°≈ÿà¡
°“√«‘‡§√“–Àå∑“ß ∂‘μ‘
«‘‡§√“–ÀåÀ“§«“¡·μ°μà“ߢÕß§à“‡©≈’ˬ¢ÕߢâÕ¡Ÿ≈
æ◊Èπ∞“πºŸâªÉ«¬√–À«à“ß°≈ÿà¡ ª√–°Õ∫¥â«¬ Õ“¬ÿ πÈ”Àπ—° à«π
Thai Journal of Anesthesiology
163
Ÿß ·≈–√–¬–‡«≈“∑’Ë„™â„π°“√„ à DLT ®π ”‡√Á® ¥â«¬ t-test
for independent group «‘‡§√“–ÀåÀ“§«“¡·μ°μà“ߢÕߢâÕ¡Ÿ≈
æ◊Èπ∞“πÕ◊Ëπ Ê √–À«à“ß°≈ÿà¡ ª√–°Õ∫¥â«¬ ‡æ», ASA physical
status, Mallampati classification, laryngoscopic view
¢â“ߴ⓬ ·≈–ª√–‡¿∑¢ÕߺŸâ„ à DLT ¥â«¬
Chi-squre ·≈– Fisher’s exact test À“§«“¡·μ°μà“ߢÕß
§«“¡ ”‡√Á ® ¢Õß°“√„ à DLT ¢â “ ß´â “ ¬‡¢â “ À≈Õ¥≈¡´â “ ¬
√–À«à“ß°≈ÿࡥ⫬ Fisher’s exact test
«‘‡§√“–Àå‚¥¬„™â‚ª√·°√¡ SPSS version 13.0 ‚¥¬
p < 0.05 ∂◊Õ«à“¡’§«“¡·μ°μà“ß°—πÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘
¢π“¥¢Õß
DLT
º≈°“√»÷°…“
ºŸâªÉ«¬∑’Ë∑”°“√»÷°…“∑—ÈßÀ¡¥¡’ 60 §π ∑—Èß Õß°≈ÿà¡
‰¡à¡’§«“¡·μ°μà“ß°—πÕ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘„π¥â“πÕ“¬ÿ
‡æ» πÈ”Àπ—° à«π Ÿß ASA physical status ™π‘¥°“√ºà“μ—¥
Mallampati classification ¥—ß· ¥ß„πμ“√“ß∑’Ë 1 ¢π“¥¢Õß
DLT √–¥—∫ª√– ∫°“√≥å¢ÕߺŸâ„ à DLT laryngoscopic view
®”π«π§√—Èß·≈–√–¬–‡«≈“∑’Ë„ à DLT ®π ”‡√Á® ¥—ß· ¥ß‰«â
μ“¡μ“√“ß∑’Ë 2 §«“¡ ”‡√Á®¢Õß°“√„ à DLT §”π«≥®“°
√âÕ¬≈–¢ÕߺŸâªÉ«¬∑’Ë “¡“√∂„ à DLT ‡¢â“À≈Õ¥≈¡´â“¬ ”‡√Á®
„π§√—Èß·√°æ∫«à“ S-group ¡’§«“¡ ”‡√Á®¡“°°«à“ C-group
Õ¬à“ß¡’π—¬ ”§—≠∑“ß ∂‘μ‘ (97% vs 74%, p = 0.026) ¥—ß
· ¥ß‰«âμ“¡μ“√“ß∑’Ë 3 ·μàæ∫«à“°“√„ à DLT „À≥âμ”·Àπàß
∑’ˇÀ¡“– ¡°—π√–À«à“ß S-group °—∫ C-group §◊Õ (20% vs
13%, p = 0.733) ¥—ß· ¥ß‰«âμ“¡μ“√“ß∑’Ë 4
°“√»÷°…“§√—ßÈ π’‰È ¡àæ∫¿“«–§«“¡Õ‘¡Ë μ—«¢ÕßÕÕ°´‘‡®π
„π°√–· ‡≈◊Õ¥μË”°«à“ 90% „π√–À«à“ß°“√„ à DLT ·≈–°“√
„™â FOB ¬◊π¬—πμ”·ÀπàߢÕß DLT „π√–À«à“ß°“√™à«¬À“¬„®
¥â«¬ OLV ‚¥¬„™â√–¥—∫§«“¡‡¢â¡¢âπ¢ÕßÕÕ°´‘‡®π√–À«à“ß
60-100% æ∫«à“§«“¡Õ‘Ë¡μ—«¢ÕßÕÕ°´‘‡®πμË”°«à“ 90% „π
C-group ®”π«π 1 √“¬ ®÷ߙ૬À“¬„®¥â«¬ªÕ¥∑—Èß Õߢâ“ß
√–¥—∫§«“¡Õ‘Ë¡μ—«¢ÕßÕÕ°´‘‡®π‡æ‘Ë¡¢÷Èπ‡ªìπ 100% ·≈–‰¥âπ”
FOB ¬◊π¬—πμ”·ÀπàߢÕß DLT ´È” æ∫«à“‰¡à¡’°“√‡ª≈’ˬπ
·ª≈ß ®÷߉¥â„™â continuous positive airway pressure (CPAP)
„πªÕ¥∑’Ë∂Ÿ°¬ÿ∫·ø∫ ∑”„Àâ “¡“√∂™à«¬À“¬„®¥â«¬ OLV ‰¥â
‚¥¬‰¡à¡’¿“«–ÕÕ°´‘‡®π„π°√–· ‡≈◊Õ¥μË” ·≈–‰¡à√∫°«π°“√
ºà“μ—¥ „π°“√»÷°…“§√—Èßπ’ȉ¡àæ∫ºŸâªÉ«¬∑’Ë¡’¿“«–·∑√°´âÕπ∑’Ë
√ÿπ·√ß®“°°“√„ à DLT
Table 1 Patient’s data
S-group (n = 30)
C-group (n = 30)
p-value
49.1 ± 16.8
47.7 ± 14.9
0.333
13 (43%)
12 (40%)
1.000
Weight (kg)
56.4 ± 10.7
52.6 ± 8.5
1.534
Height (cm)
163.2 ± 8.6
160.5 ± 8.5
1.222
Patient’s data
Age (year)
Sex
Male
0.210
ASA physical status
1
17 (56%)
11 (37%)
2
10 (33%)
17 (56%)
3
3 (9%)
2 (7%)
1.000
Mallampati Classification
164
1
10 (33%)
11 (37%)
2
20 (67%)
19 (63%)
«‘ —≠≠’ “√
ªï∑’Ë 33 ©∫—∫∑’Ë 3 °√°Æ“§¡-°—𬓬π 2550
Table 2 Data about DLT intubation
S-group (n = 30)
Data
C-group (n = 30)
p-value
0.510
¢π“¥ DLT
Fr35
10 (33%)
12 (40%)
Fr37
9 (30%)
8 (27%)
Fr39
11 (37%)
10 (33%)
19/9/2 (63%/30%/7%)
15/11/4 (50%/37%/13%)
ºŸâ„ à DLT (R2/R3/Staff)
0.170
1.670
Laryngoscopic view
grade 1
24 (80%)
21 (70%)
grade 2
6 (20%)
9 (30%)
0.080
Number of intubation (§√—Èß)
1-2
30 (100%)
26 (86%)
3-4
0 (0%)
4 (14%)
190.8 ± 88.1
207.4 ± 88.7
0.460
S-group (n = 30)
C-group (n = 30)
P-value
29 (97%)
22 (74%)
0.026
1 (3%)
8 (26%)
Duration of intubation (seconds)
Table 3 Success rate DLT
Position of left-DLT
Correct bronchus (LMS)*
Incorrect bronchus (RMS) or esophagus
Table 4 Position of left-DLT in Left mainstem Bronchus (%)
S-group (n = 29)
C-group (n = 22)
P-value
Proper position
6 (20%)
4 (13%)
0.733
Out too far
3 (10%)
2 (7%)
20 (67%)
16 (54%)
Left mainstem bronchus
In too far
«‘®“√≥å
°“√„ à DLT „À≥âμ”·Àπàß∑’ˇÀ¡“– ¡‡æ◊ËÕ°“√™à«¬
À“¬„®¥â«¬ OLV ¡’§«“¡ ”§—≠„Àâ°“√√–ß—∫§«“¡√Ÿâ ÷° ”À√—∫
°“√ºà“μ—¥∑√«ßÕ° ‡π◊ËÕß®“°æ∫«à“ “‡Àμÿ∑’Ë∑”„À⇰‘¥¿“«–
ÕÕ°´‘‡®π„π°√–· ‡≈◊Õ¥μË”√–À«à“ߙ૬À“¬„®¥â«¬ OLV §◊Õ
Vol. 33, No. 3, July-September 2007
μ”·ÀπàߢÕß DLT ‰¡à‡À¡“– ¡ ´÷Ëßæ∫∫àÕ¬°«à“ “‡Àμÿ®“°
‚√§ªÕ¥‡¥‘¡¢ÕߺŸâªÉ«¬16
°“√»÷°…“§√—Èßπ’Èæ∫«à“ §«“¡ ”‡√Á®¢Õß°“√„ à DLT
™π‘¥ left Rüsch-Endobronchial tube ‡¢â“À≈Õ¥≈¡´â“¬¥â«¬
«‘∏’°“√„ à·°π≈«¥μ≈Õ¥°“√„ à∑àÕÀ≈Õ¥§Õ Ÿß°«à“«‘∏’ª°μ‘ ´÷Ëß
Thai Journal of Anesthesiology
165
‡À¡◊Õπ°—∫°“√»÷°…“¢Õß Leiberman D. ·≈–§≥–12 ∑’Ë„™â
DLT ™π‘¥ left BronchoCathTM Endobronchial tube ‚¥¬
§«“¡ ”‡√Á®∑’‡Ë æ‘¡Ë ¢÷πÈ Õ“®‡°‘¥®“°°“√∑’·Ë °π≈«¥∑”„À⧫“¡‚§âß
¢Õß DLT §ß√ŸªÕ¬Ÿà¢≥–„ ஓ°À≈Õ¥§Õ‡¢â“ ŸàÀ≈Õ¥≈¡´â“¬
®÷ß∑”„Àâ “¡“√∂„ àÀ≈Õ¥≈¡´â“¬‰¥â ”‡√Á®¡“°¢÷Èπ
„π°“√»÷°…“§√—Èßπ’È æ∫§«“¡≈⡇À≈«„π°“√„ à DLT
¥â«¬«‘∏ª’ °μ‘√Õâ ¬≈– 26 „°≈⇧’¬ß°—∫°“√»÷°…“¢Õß Leiberman
12
D. ·≈–§≥– ∑’Ëæ∫°“√„ à‡¢â“À≈Õ¥≈¡¢â“ߢ«“√âÕ¬≈– 23
¥â«¬«‘∏’ª°μ‘ ´÷Ëß„°≈⇧’¬ß°—∫∑’Ë Smith ·≈–§≥–4 ‰¥â√“¬ß“π‰«â
§◊Õ√âÕ¬≈– 20 §«“¡≈⡇À≈«¥—ß°≈à“«Õ“®‡°‘¥®“°°“√¥÷ß·°π
≈«¥ÕÕ°¢≥–∑’Ë Bronchial cuff ºà“π‡ âπ‡ ’¬ß°àÕπ∑’Ë®–¥—π
DLT ‡¢â“À≈Õ¥≈¡ ´÷ËßÕ“®‡°‘¥°“√∫‘¥‡∫’Ȭ«¢Õß DLT ·≈–∑”
„Àâ Bronchial angle ‡ ’¬‰ª DLT ®÷߇¢â“ ŸàÀ≈Õ¥≈¡¢«“·∑π
πÕ°®“°π’È DLT Õ“®‡§≈◊ËÕπÀ≈ÿ¥ÕÕ°¡“Õ¬Ÿà„πÀ≈Õ¥Õ“À“√‰¥â
®“°°“√¥÷ß·°π≈«¥∑’Ë¡’§«“¡·¢ÁßÕÕ° ‚¥¬‡©æ“–∂â“¡’°“√„ à
DLT ∑’Ë≈÷°‰¡àæÕÀ√◊Õ„ à “√À≈àÕ≈◊Ëπ∑’Ë·°π≈«¥πâÕ¬‡°‘π‰ª ∑”
„Àâ¥÷ß·°π≈«¥ÕÕ°‰¥â¬“°
·¡â«“à °“√„ à·°π≈«¥μ≈Õ¥°“√„ à∑Õà À≈Õ¥§Õ®–™à«¬
‡æ‘¡Ë §«“¡ ”‡√Á®„π°“√„ à DLT ¢â“ߴ⓬‡¢â“ ŸÀà ≈Õ¥≈¡´â“¬¡“°
°«à“¢â“ߢ«“ ·μà°Áæ∫°“√„ à DLT „À≥âμ”·Àπàß∑’ˇÀ¡“– ¡
πâÕ¬„π∑—Èß Õß°≈ÿà¡ ´÷ËßÕ“®‡°‘¥®“°§«“¡™”π“≠¢ÕߺŸâ„ à ‡π◊ËÕß
®“°∑—Èß Õß°≈ÿà¡„ à‚¥¬·æ∑¬åª√–®”∫â“πªï∑’Ë 2 ·≈–ªï∑’Ë 3 ‡ªìπ
à«π„À≠à
¥—ßπ—Èπ°“√„ à·°π≈«¥‰«âμ≈Õ¥¢≥–„ à DLT ®÷ߙ૬
„Àâ„ à‡¢â“À≈Õ¥≈¡∂Ÿ°¢â“ß ·μàÕ“®‰¡à™à«¬„Àâ„ à‰¥âμ”·Àπàߧ«“¡
≈÷°∑’ˇÀ¡“– ¡ ¥—ßπ—Èπ°“√„™â FOB ‡æ◊ËÕ¬◊π¬—πμ”·ÀπàߢÕß
DLT ®÷߬—ß¡’§«“¡®”‡ªìπÕ¬Ÿà Õ¬à“߉√°Áμ“¡°“√„ à·°π≈«¥
μ≈Õ¥°“√„ à∑àÕÀ≈Õ¥§ÕÕ“®∑”„À⇰‘¥°“√∫“¥‡®Á∫¢Õ߇¬◊ËÕ∫ÿ
À≈Õ¥§Õ·≈–À≈Õ¥≈¡ ‰ª®π∂÷ß¿“«–·∑√°´âÕπ∑’Ë√ÿπ·√ߧ◊Õ
°“√©’°¢“¥¢Õß∑àÕÀ≈Õ¥≈¡·≈–À≈Õ¥‡≈◊Õ¥ pulmonary ‚¥¬
¡’√“¬ß“π«à“ °“√©’°¢“¥¢Õß∑àÕÀ≈Õ¥≈¡ —¡æ—π∏å°—∫§«“¡¥—π
¿“¬„π bronchial cuff17-21 „π°“√»÷°…“§√—Èßπ’ȉ¡à‰¥â„™â FOB
àÕߥŸ°“√∫“¥‡®Á∫¢Õ߇¬◊ËÕ∫ÿÀ≈Õ¥§Õ·≈–À≈Õ¥≈¡À≈—߇ √Á®
ºà“μ—¥ ·μஓ°°“√μ‘¥μ“¡ºŸâªÉ«¬‰¡àæ∫°“√∫“¥‡®Á∫®π‡°‘¥°“√
©’°¢“¥¢Õß∑àÕÀ≈Õ¥≈¡ ·≈–®“°°“√»÷°…“¢Õß Leiberman D.
·≈–§≥–12 æ∫«à“°“√∫“¥‡®Á∫¢Õ߇¬◊ÕË ∫ÿÀ≈Õ¥≈¡·≈–À≈Õ¥§Õ
∑’Ëæ∫§◊Õ °“√¡’®ÿ¥‡≈◊Õ¥ÕÕ°À√◊Õ∫«¡·¥ß ∫√‘‡«≥ Bronchial
17-21
‚¥¬„π
cuff ‡∑à“π—Èπ ´÷Ëß Õ¥§≈âÕß°—∫∑’ˇ§¬√“¬ß“π‰«â
°≈ÿ¡à ∑’„Ë à¥«â ¬«‘∏„’ à·°π≈«¥μ≈Õ¥°“√„ à∑Õà À≈Õ¥§Õ·≈–«‘∏ª’ °μ‘
166
«‘ —≠≠’ “√
‰¡à·μ°μà“ß°—πÕ¬à“ß¡’π¬— ”§—≠∑“ß ∂‘μ‘ ·≈–‰¡àæ∫°“√©’°¢“¥
¢Õ߇¬◊ËÕ∫ÿÀ≈Õ¥§Õ·≈–°“√©’°¢“¥¢ÕßÀ≈Õ¥≈¡
√ÿª
°“√„ à·°π≈«¥μ≈Õ¥°“√„ à∑àÕÀ≈Õ¥§Õ‡æ‘Ë¡§«“¡
”‡√Á®„π°“√„ à DLT ¢â“ߴ⓬‡¢â“À≈Õ¥≈¡´â“¬¡“°°«à“°“√
„ à¥â«¬«‘∏’ª°μ‘ ·μà‰¡à¡’º≈μàÕμ”·Àπàß∑’ˇÀ¡“– ¡¢Õß∑àÕ„π
À≈Õ¥≈¡·≈–‰¡àæ∫¿“«–·∑√°´âÕπ∑’Ë√ÿπ·√ß
°‘μμ‘°√√¡ª√–°“»
ß“π«‘®—¬π’ȉ¥â√—∫∑ÿπ π—∫ πÿπ®“°§≥–·æ∑¬»“ μ√å
¡À“«‘ ∑ ¬“≈— ¬ ‡™’ ¬ ß„À¡à ·≈–¢Õ¢Õ∫§ÿ ≥ ∫ÿ § ≈“°√¿“§«‘ ™ “
«‘ —≠≠’«‘∑¬“ §≥–·æ∑¬»“ μ√å ¡À“«‘∑¬“≈—¬‡™’¬ß„À¡à ∑’Ë„Àâ
§«“¡√à«¡¡◊Õ§√—Èßπ’ȇªìπÕ¬à“ߥ’
‡Õ° “√Õâ“ßÕ‘ß
1. Benumof JL, Partridge BL, Salvatierra C, Keating J. Margin
of safety in positioning modern double-lumen endotracheal
tube. Anesthesiology 1987 ; 67 : 729-38.
2. Shulman GB. Connelly NR. Double lumen tube placement
with Bullard laryngoscope. Can J Anaesth 1999 ; 46 :
232-4.
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tubes for thoracic anesthesia : a prospective study. Anesthesiology 1998 ; 88 : 346-50.
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impressions and bronchoscopic findings. Br J Anaesth
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5. Ehrenwerth J. Pro : Proper positioning of a double-lumen
endobronchial tube can only be accomplished with endoscopy. J Cardiothorac Anesth 1988 ; 2 : 101-4.
6. Alliaume B, Coddens J, Deloof T. Reliability of auscultation in positioning of double-lumen endobronchial tubes.
Can J Anaesth 1992 ; 39 : 687-90.
7. Lewis JW, Serwin JP, Gabriel FS, Bastanfar M, Jacoben G.
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in a variety of noncardiac thoracic surgical procedures. J
Cardiothorac Vasc Anesth 1992 ; 6 : 705-10.
8. Slinger PD. Fiberoptic bronchoscopic positioning of double-lumen tubes. J Cardiothorac Anesth 1989 ; 3 : 486-96.
9. Benumof JL. The positioning of a double-lumen endobronchial tube should be routinely determined by fiberoptic bronchoscopy. J Cardiothorac Vasc Anesth 1993 ; 7 : 513-4.
ªï∑’Ë 33 ©∫—∫∑’Ë 3 °√°Æ“§¡-°—𬓬π 2550
16. Inoue S, Nishimine N, Kitaguchi K, Furuva H, Taniguchi
S. Double lumen tube location predicts tube malposition
and hypoxemia during one lung ventilation. Br J Anaesth
2004 ; 92 : 195-201.
17. Wagner DL, Gammage GW, Wong ML. Tracheal rupture
following the insertion of a disposable double-lumen endotracheal tube. Anesthesiology 1985 ; 63 : 698-700.
18. Burton NA, Fall SM, Lyons T, Graeber GM. Rupture of
the left main-stem bronchus with a polyvinylchloride double-lumen tube. Chest 1983 ; 83 : 928-9.
19. Foster JM, Lau OJ, Alimo EB. Ruptured bronchus following endobronchial intubation. A case report. Br J Anaesth
1983 ; 55 ; 687-8.
20. Heiser M, Steinberg JJ, MacVaugh H 3rd, Klineberg PL.
Bronchial Rupture, a complication of use of the Robertshaw
double-lumen tube. Anesthesiology 1979 ; 51 : 88.
21. Guernelli N, Bragaglia RB, Briccoli A, Mastrorilli M,
Vecchi R. Tracheobronchial ruptures due to cuffed Carlens
tube. Ann Thorac Surg 1979 ; 28 : 66-7.
10. Brodsky JB. Con : proper positioning of a double-lumen
endobronchial tube can only be accomplished with the use
of endoscopy. J Cardiothorac Anesth 1988 ; 2 : 105-9.
11. »‘√‘≈—°…≥å ÿ¢ ¡ªÕß. °“√„À⬓√–ß—∫§«“¡√Ÿâ ÷° ”À√—∫°“√ºà“μ—¥
∑√«ßÕ°. Õ—ß°“∫ ª√“°“√√—μπå, «√¿“ ÿ«√√≥®‘π¥“, ∫√√≥“∏‘°“√.
μ”√“«‘ —≠≠’«‘∑¬“. æ‘¡æå§√—Èß∑’Ë 3. °√ÿ߇∑æœ : ”π—°æ‘¡æå°√ÿ߇∑æ
‡«™°“√ 2548 ; 234-64.
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Appendix 1 Selection of Left Rüsch-Endobronchial tube
Height (cm)
Female
Male
< 165 cm.
35 Fr.
37 Fr.
165-179 cm
37 Fr.
39 Fr.
> 179 cm
39 Fr.
41 Fr.
Vol. 33, No. 3, July-September 2007
Thai Journal of Anesthesiology
167
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