Comparison of the effects of video double-lumen endotracheal tubes and conventional double-lumen endotracheal tubes on peripheral oxygen saturation during one-lung ventilation in patients undergoing thoracoscopic surgery: a prospective randomized controlled trial

Comparison of the effects of video double-lumen endotracheal tubes and conventional double-lumen endotracheal tubes on peripheral oxygen saturation during one-lung ventilation in patients undergoing thoracoscopic surgery: a prospective randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of the effects of video double-lumen endotracheal tubes and conventional double-lumen endotracheal tubes on peripheral oxygen saturation during one-lung ventilation in patients undergoing thoracoscopic surgery: a prospective randomized controlled trial Si Long, Yuhang Li, Xiaoyang Zheng, Fang Ye, Jiayan Li, Yu Yu, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7012275/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Compared to the conventional double-lumen endotracheal tube (c-DLT), the video double-lumen endotracheal tube (v-DLT) demonstrates a shorter intubation time and the capability of observing and adjusting malposition at any time. Our objective was to compare the incidence of hypoxemia during one-lung ventilation (OLV) and perioperative complications between the two tube types. Methods 100 patients undergoing video-assisted thoracic surgery (VATS) were randomized to receive either a v-DLT or a c-DLT. Low tidal volume ventilation was used during OLV. The primary outcome was the incidence of hypoxemia (defined as SpO 2 <90%) during OLV. To prevent its occurrence, a predefined protocol was activated if SpO 2 dropped below 95%. Sequential interventions included DLT repositioning, increasing FiO₂, adjusting ventilator settings, applying 5 cmH₂O PEEP to the ventilated lung, applying 5 cmH₂O CPAP to the operative lung, or resuming two-lung ventilation. Results The incidence of hypoxemia during OLV in the v-DLT group was significantly lower than that in the c-DLT group (6.3% vs. 27.7%, p = 0.006). No statistically significant difference was observed in postoperative complications between two groups ( p = 0.732). The v-DLT demonstrated greater convenience ( p <0.001), shorter intubation time ( p < 0.001), easier intubation ( p < 0.001), higher intubation success rate ( p < 0.001), lower workload ( p < 0.001), higher work efficiency ( p < 0.001), and could enhance user satisfaction among anesthesiologists ( p < 0.001). Conclusions The v-DLT can significantly reduce the incidence of hypoxemia during OLV compared with the c-DLT. Simultaneously, it reduced the workload of anesthesiologists and enhanced their overall satisfaction levels. Trial registration: Chictr.org.cn ChiCTR2100046484. Registered on 16 May 2021. Video double-lumen endotracheal tube conventional double-lumen endotracheal tube thoracoscopic surgery one-lung ventilation hypoxemia Figures Figure 1 Introduction Video-assisted thoracic surgery (VATS) is a widely employed surgical procedures for the identification and therapy of chest issues 1 . Successful VATS requires effective mechanical lung separation to facilitate OLV. While several techniques exist, including double-lumen endotracheal tube (DLT), single-lumen tubes with bronchial blocker (BB), and even laryngeal mask airway combined with a BB, the DLT remains the gold standard for OLV during VATS. 2 A critical challenge during OLV is hypoxemia, a severe complication with reported incidences ranging from 1–30%, and severe hypoxemia occurring in 10–30% of patients. 3 – 7 Hypoxemia arises from factors such as ventilation-perfusion mismatch, decreased oxygen reserves, impaired ventilation, and the Bohr effect. 8 Importantly, DLT malpositioning is a major contributor, implicated in up to 83% of hypoxemia cases during OLV. 9 Techniques to mitigate hypoxemia include repositioning the isolation device, increasing FiO 2 , ventilator adjustments, applying PEEP to the ventilated lung, applying CPAP to the non-ventilated lung, and two-lung ventilation. 10 – 14 This intervention cascade is not benign; it often necessitates interrupting the surgical procedure, increasing operative time and complexity. Furthermore, interventions like high FiO₂ or inappropriate ventilator settings carry risks, including ventilator-induced lung injury (VILI). 15 Persistent or severe hypoxemia can lead to serious sequelae such as cerebral desaturation, organ dysfunction, and cardiac arrest, significantly increasing perioperative risk, healthcare costs, and medico-legal liability. 16 , 17 Therefore, preventing hypoxemia, particularly that caused by device malposition, is vastly preferable to treating it. This underscores the critical importance of identifying the isolation device most effective at minimizing malposition and thereby reducing the incidence of hypoxemia. Ensuring optimal DLT positioning is therefore paramount. The video double-lumen endotracheal tube (v-DLT), equipped with a distal camera within the tracheal lumen, offers continuous, real-time visualization of tube position. This technology enables immediate intraoperative adjustment, significantly reducing intubation time and the need for fiberoptic bronchoscopy (FOB) for initial placement and position confirmation compared to conventional DLTs (c-DLTs). 18 – 21 Based on the established link between malposition and hypoxemia, the burdensome nature of hypoxemia treatment, and the v-DLT's capability for real-time position monitoring, we hypothesized that the v-DLT would significantly reduce the incidence of hypoxemia during OLV in patients undergoing VATS compared to the c-DLT. Methods Study design This study was a randomized, prospective, single-blind, single-center clinical trial. The trial was approved by the Clinical Trial Review Board of the First Affiliated Hospital, Sun Yat-sen University in Guangzhou, China (Document number 2020 − 418, date: October 2020). The study was registered at the China Clinical Trial Registration Center (ChiCTR2100046484, Wenqi Huang, Date: May 2021). The clinical trial was registered prior to patient enrollment, written informed consent was obtained from each participating patient. The work had been reported in line with Consolidated Standards of Reporting Trials (CONSORT) Guidelines. 22 Participants Patients with American Society of Anesthesiologists (ASA) physical status I–III and Mallampati airway assessment score I–II, scheduled for elective thoracic surgery under thoracoscopy, were enrolled in this study. Exclusion criteria comprised individuals under 18 years old, those with moderate-to-severe lung ventilation or gas exchange dysfunction (forced expiratory volume in the 1s < 60% of the expected value for ventilation dysfunction; diffusion of carbon monoxide in the lung < 60% of the expected value for gas exchange dysfunction), a history of thoracic surgery, chronic lung disease, systemic infection or suspected tuberculosis within the past month, impaired liver and kidney function (Child-Pugh grade B and C for liver function; endogenous creatinine clearance rate ≤ 50mL min − 1 , blood creatinine > 178µmol L − 1 , or blood urea nitrogen > 9mmol L − 1 for renal function), severe cardiovascular and cerebrovascular diseases (including high risk of hypertension, untreated coronary heart disease, valvular heart disease, previous history of myocardial infarction, cerebral infarction, cerebral thrombosis, or cerebral hemorrhage), inability to cooperate with the research due to language comprehension disorder or mental illness, and use of other trial drugs or participation in other clinical trials within 3 months prior to enrollment. Randomisation The complete protocol had been published. 23 A total of 100 patients undergoing VATS and meeting the inclusion criteria were randomly assigned into two groups: Group v-DLT (using the v-DLT) and Group conventional-DLT (using the c-DLT), in a 1:1 ratio. The primary investigator obtained informed consent from the participants, and the secondary investigator was responsible for random number allocation and participant grouping. Participants were assigned numerical identifiers from 1 to 100 according to their enrollment sequence. Random numbers, generated using SPSS (version 22.0), determined the random allocation of participants to either the v-DLT group or the c-DLT group. The patient and the principal anesthesiologist remained unaware of the group assignment before the surgical procedure. Because blinding was not feasible during the surgical procedure, researchers unaware of the participants' group assignment conducted post-operative assessments the day after the operation. Procedures Preoperatively, patients underwent assessment documenting demographics (sex, age), anthropometrics (height, weight, BMI), chest CT, ECG, and pulmonary function. The primary investigator (PI) determined ASA and Mallampati grades. Informed consent was obtained. DLT size was selected based on the PI’s clinical judgment and chest CT findings, guided by Chow’s method 24 : tracheal internal diameter measured on CT dictates size selection: ≥19 mm: 39 Fr; ≥15 mm: 37 Fr; ≥13 mm: 35 Fr. Patient entered the operating room, routine monitoring, electrocardiogram, non-invasive arterial blood pressure, blood oxygen saturation, and Narcotrend monitoring, was conducted. Dexmedetomidine (0.5-1.0ug kg − 1 ) was intravenously administered for sedation before anesthesia induction. General anesthesia was induced with propofol (2-3mg kg − 1 ), cisatracurium (2mg kg − 1 ), and sufentanil (0.3-0.5ug kg − 1 ). Anesthesia maintenance involved sevoflurane (0%-1%), and continuous infusion of propofol (4-12mg kg h − 1 ), remifentanil (TCI 3-6ng ml − 1 ), and intermittent injection of cisatracurium (0.05mg kg − 1 ) and sufentanil (5-10ug dose − 1 ). The depth of anesthesia was controlled to a Narcotrend level of D2–E0. Vital signs were recorded during the perioperative period. Patients in the c-DLT group were intubated with conventional double-lumen tubes (left/right selected per surgical requirements), with correct position routinely confirmed by fiberoptic bronchoscopy (FOB). Correct position required: 1) FOB via the tracheal lumen visualizing the main carina and bronchial cuff edge within the target bronchus, and 2) FOB via the bronchial lumen visualizing ipsilateral lobar bronchial openings (left upper/lower lobes for left c-DLT; right middle/lower lobes and upper lobe orifice for right c-DLT). Conversely, the v-DLT group underwent intubation using the video-enabled tube (left/right per surgery), achieving target position using its integrated camera or FOB (same criteria). FOB was not routine in this group, reserved only for positioning right-sided tubes or when camera-guided localization failed. For each patient, investigators recorded two metrics: (1) intubation time, measured with a stopwatch from laryngoscope blade insertion into the mouth until confirmed correct DLT positioning (as defined in the Methods section), and (2) frequency of fiberoptic bronchoscopy (FOB) use (during intubation, lateral positioning and OLV). Concurrently, the performing anesthesiologist completed a post-intubation assessment using a standardized questionnaire to evaluate seven domains of DLT experience: (1) convenience of use, (2) intubation time reduction, (3) ease of intubation, (4) perceived success rate, (5) workload reduction, (6) work efficiency improvement, and (7) overall satisfaction. Each domain was rated using a 3-point ordinal scale: Yes, Partially, or No). After securing the DLT, mechanical ventilation of double lungs was initiated using a volume-controlled mode. Tidal volume for bilateral lung ventilation was set at 5–10 ml kg − 1 , FiO 2 was maintained at 50%, and ventilation frequency was adjusted to maintain end-tidal CO 2 (ETCO 2 ) levels between 35–45 mmHg. Vital signs and ventilation parameters were recorded 5 minutes post-intubation. OLV was initiated prior to pleural opening, with a tidal volume set at 5–8 ml kg − 1 , FiO 2 maintained at 50%, and ventilation frequency adjusted to maintain ETCO 2 between 35–45 mmHg. Surgeons assessed the quality of lung collapse using the following scoring system: 1 = collapse, 2 = partial collapse, 3 = complete lung collapse. During OLV, if SpO 2 dropped below 95%, the following interventions were performed sequentially to improve oxygenation: (1) Repositioning the DLT and suctioning of trachea secretions; (2) Increasing FiO 2 to 80%-100%; (3) Adjusting ventilation parameters (tidal volume and frequency); (4) Applying PEEP of 5cmH 2 O to the dependent ventilated lung; (5) Administering intermittent resuscitation or CPAP of 5cmH 2 O to the unventilated lung; (6) Converting to two-lung ventilation (TLV). The number of intraoperative interventions triggered by SpO 2 < 95% were recorded. The number of malposition (occurring during lateral positioning, and during OLV) was recorded. Vital signs and ventilatory parameters during TLV, OLV, and each intervention were documented. Hemodynamic stability was maintained throughout the procedure. Sevoflurane was discontinued 15 minutes before surgery, followed by discontinuation of propofol and remifentanil postoperatively. Following the surgery, patients were transferred to the post-anesthesia care unit for postoperative extubation and analgesia. Patients were followed up to assess their recovery and to monitor for any complications. This included evaluating symptoms such as cough (None, Occasional, Moderate), sore throat (None, During swallowing, Constant), hoarseness (None, Noticed by the patient, Noticed by the patient and study member), and hypoxemia. Outcomes The primary outcomes of the trial were the incidence of hypoxemia (SpO 2 <90%) during OLV in the two groups. Secondary outcomes included the number of interventions triggered by SpO 2 < 95% during OLV, postoperative complications (hypoxemia, cough, hoarseness and sore throat occurring 24 hours after surgery), workload and satisfaction scores of the anesthesiologists in two groups. Statistical analysis The primary outcome measure was the prevalence of hypoxemia in the study population. Previous studies have reported an estimated occurrence of hypoxemia of around 30% in patients using c-DLT. 9 Based on the results of our preliminary experiment, the occurrence of hypoxemia in v-DLT was approximately 8%, with a significance level of 5% and a power of 80%. Using the PASS (version 11.0) program, a total of 46 patients were determined to be required for each group. To account for a potential dropout rate of up to 10%, a minimum of 50 participants per group was deemed necessary, resulting in a total sample size of 100 patients for the study. Normally distributed variables were presented as mean (standard deviation SD), and analyzed using a t -test. Non-normally distributed variables were presented as median and quartile values, and analyzed using the Mann-Whitney U test. Categorical variables were presented as sample size and percentage, and analyzed using the χ2 test or Fisher’s exact test, as appropriate. Fisher's exact test is applicable for detecting indicators when the sample size is less than 40 or the theoretical frequency less than 5 accounted for more than 20%. Statistical analyses were conducted using SPSS (version 22.0). All tests were two-tailed, and p values less than 0.05 were considered statistically significant. Results 100 patients were recruited from August 2021 to August 2022, with 50 in each group. Two patients were excluded from the v-DLT group: one underwent a second surgery for postoperative bleeding, and the other was unable to fit the tube, necessitating replacement with a conventional-DLT. Three patients were excluded from the c-DLT group: two did not undergo the planned surgery, and one was sent to the ICU after surgery (Fig. 1 ). Baseline demographics and clinical characteristics were shown in Table 1 . Table 1 Demographic and clinical characteristics of patients. Data are presented as mean (SD), number (percentage) or median (IQT [range]). BMI, Body Mass Index; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; VATS, Video-assisted thoracic surgery; DLT, double-lumen endotracheal tube; ASA, American Society of Anesthesiologists; OLV, one-lung ventilation. Variables c-DLT (n = 47) v-DLT (n = 48) Age (year) 54.2 (12.6) 56.3 (11.3) Sex, Male/female 21/26 20/28 Height (cm) 161.9 (7.2) 163.4 (7.6) Weight (kg) 61.6 (12.1) 61.5 (9.5) BMI 23.4 (3.5) 23.0 (2.6) FEV1 (% predicted) 106.0 (12.7) 104.7 (14.7) FVC (% predicted) 105.4 (11.6) 102.3 (15.2) Smoking history, yes/no 8/39 7/41 VATS side, Right/left 30/17 28/22 DLT side, right/left 8/39 11/37 OLV duration (min) 96 (73.5-127.5) 90 (66–123) Surgery duration (min) 105 (77.5-144.25) 100 (80–135) Surgical procedure Lobectomy 20 (42.6%) 28 (58.3%) Segmentectomy 13 (27.6%) 5 (10.4%) Wedge 8 (17.0%) 7 (14.6%) Other 6 (12.8%) 8 (16.7%) For the primary outcome, the v-DLT group demonstrated a significantly lower incidence of hypoxemia compared to c-DLT (6.3% [3/48] vs. 27.3% [13/47], p = 0.006) during OLV. Secondary outcomes revealed: (a) Intraoperatively, v-DLT showed a non-significant reduction in DLT malpositioning (Table 2 ) but significantly reduced FOB utilization ( p < 0.001) and fewer hypoxemia-triggered interventions (SpO₂<95%: 35.4% vs. 66.0% required ≥ 1 intervention, p = 0.006; intervention steps differed significantly per Table 2 ); (b) Intubation efficiency improved with video-assisted DLT (time: 85.5s vs. 280s, p < 0.001), though lung collapse completion did not reach significance (Table 2 ). Anesthesiologists rated v-DLT superior in convenience (81.3% vs. 23.4%), workload reduction (87.5% vs. 4.3%), and satisfaction (81.3% vs. 8.5%) (all p < 0.001; full survey: Table 3 ). Postoperatively, no differences emerged in complications (hypoxemia/coughing/hoarseness/sore throat), or hospital stay (Table 4 ). Table 2 One-lung ventilation effects and interventions. Data are presented as number (percentage), or median (IQT [range]). * p <0.001 by Mann-Whitney U test. # p <0.001 by Fisher’s exact test. † p = 0.006 for the hypoxemia rate by Fisher’s exact test. § p = 0.004 for the SPO 2 <95% rate by Fisher’s exact test. ¶ p = 0.006 for the intervention by Fisher’s exact test. FOB, fiberoptic bronchoscopy; OLV, one-lung ventilation; PEEP, positive end-expiratory pressure; CPAP, continuous positive airway pressure; TLV, two-lung ventilation; OLV, one-lung ventilation. Investigation contents c-DLT (n = 47) v-DLT (n = 48) p Value Number of patients with hypoxemia (%) † 13 (27.7) 3 (6.3) 0.006 Number of patients with SpO 2 <95% (%) § 31 (66.0) 17 (35.4) 0.004 Number of patients of intervention, No. (%) ¶ 0.006 no intervention 16 (34.0) 31 (64.6) First intervention (Repositioning or suctioning of trachea secretions), No. (%) 31 (66.0) 17 (35.4) Second intervention (Increasing FiO 2 or Adjusting ventilation parameters), No. (%) 18 (38.3) 4 (8.3) Third intervention (5cmH 2 O PEEP for ventilated lung), No. (%) 9 (19.1) 2 (4.2) Fourth intervention (5cmH 2 O CPAP for surgery lung or TLV), No. (%) 4 (8.5) 1 (2.1) Malposition during lateral positioning, No. (%) 18 (42.5) 12 (25) 0.190 Malposition during OLV, No. (%) 10 (21.3) 5 (10.4) 0.170 Time for intubation in correct position (s) * 280 (125–360) 85.5 (36-202.5) <0.001 Quality of lung collapse, No. (%) 0.224 1 1 (2.1) 0 (0.0) 2 10 (21.3) 6 (12.5) 3 36 (76.6) 42 (87.5) FOB, No. (%) # During intubation 47 (100.0) 11 (22.9) <0.001 Lateral positioning 47 (100.0) 11 (22.9) <0.001 OLV 31 (66.0) 5 (10.4) <0.001 Table 3 Anesthesiologist workload and satisfaction survey scores. Data are presented as number (percentage). * p <0.001 by Fisher’s exact test. DLT, double-lumen endotracheal tube. Investigation contents c-DLT (n = 47) v-DLT (n = 48) p Value * Was it more convenient to use this DLT <0.001 yes 11 (23.4%) 39 (81.3%) partially 15 (31.9%) 7 (14.6%) no 21 (44.7%) 2 (4.2%) Was the time of intubation with this DLT shortened <0.001 yes 6 (12.8%) 40 (83.3%) partially 15 (31.9%) 5 (10.4%) no 26 (55.3%) 3 (6.3%) Was it easier to intubate with this DLT <0.001 yes 13 (27.7%) 38 (79.2%) partially 26 (55.3%) 3 (6.3%) no 8 (17.0%) 7 (14.6%) Was the success rate of intubation higher with this DLT <0.001 yes 4 (8.5%) 37 (77.1%) partially 21 (44.7%) 6 (12.5%) no 22 (46.8%) 5 (10.4%) Could this DLT reduce workload <0.001 yes 2 (4.3%) 42 (87.5%) partially 5 (10.6%) 6 (12.5%) no 40 (85.1%) 0 (0.0%) Could this DLT improve work efficiency <0.001 yes 2 (4.3%) 43 (89.6%) partially 3 (6.4%) 5 (10.4%) no 42 (89.4%) 0 (0.0%) Were you satisfied with this DLT <0.001 yes 4 (8.5%) 39 (81.3%) partially 21 (44.7%) 8 (16.7%) no 22 (46.8%) 1 (2.1%) Table 4 Postoperative complications. Data are presented as number (percentage), or median (IQT [range]). Postoperative complications c-DLT (n = 47) v-DLT (n = 48) p Value Postoperative complications, No. (%) 17 (36.2%) 19 (39.6%) 0.732 Hypoxemia 0 0 / Coughing 0.802 None 36 (76.6%) 39 (81.3%) Occasional 10 (21.3%) 8 (16.7%) Moderate 1 (2.1%) 1 (2.1.%) Hoarseness 0.509 None 43 (91.5%) 41 (85.4%) Noticed by the patient 4 (8.5%) 5 (10.4%) Noticed by the patient and study member 0 2 (4.2%) Sore throat 0.673 None 41 (87.2%) 39 (81.3%) During swallowing 6 (12.8%) 8 (16.7%) Constant 0 1 (2.1%) Hospital stays (day) 7 (6-9.75) 8 (6–12) 0.179 Discussion In this randomized clinical trial of patients undergoing VATS, the v-DLT significantly reduced the incidence of hypoxemia (SpO₂ <90%) during OLV compared to the c-DLT. Crucially, it also reduced the occurrence of SpO₂ desaturation below 95%, thereby decreasing the need for sequential rescue interventions. Furthermore, v-DLT improved anesthesiologist satisfaction and reduced workload during OLV management. The primary finding—reduced hypoxemia with v-DLT—is likely attributable to its unique design enabling proactive prevention of malposition-related ventilation problems. Hypoxemia remains a significant concern during VATS with the OLV. 8 We propose that v-DLT diminishes the occurrence of hypoxemia during OLV through two mechanisms. Firstly, continuous real-time position monitoring: The v-DLT provides continuous visualization of tube position within the airways. Malposition is a major contributor to hypoxemia during OLV. 8 , 9 With c-DLT, detecting and correcting malposition requires time-consuming FOB 25 , delaying intervention while hypoxemia develops. The v-DLT allows immediate visualization, enabling anesthesiologists to anticipate and correct potential dislodgement before significant desaturation occurs. This is reflected in our findings of fewer desaturation events requiring intervention. Although our study did not show a statistically significant difference in recorded malposition events (potentially due to limited sampling points and sample size), the ability to visualize continuously likely prevented malpositions from progressing to hypoxemia more effectively than the reactive approach needed with c-DLT. Secondly, reduced need for FOB, minimizing ventilation disruption: positioning the FOB through the ventilation side rubber opening, which is located above the Y-shaped connector's branches of the DLT, could potentially disrupt ventilation on that side. Furthermore, multiple factors, such as surgical procedures, gravitational shifts in the mediastinum, and abdominal compression, can disrupt the connection between the DLT and the patient's tracheobronchial architecture, necessitating frequent perioperative FOB application for correct tube positioning. v-DLT has been shown to reduce the need for FOB during the initial placement and verification of DLT during OLV 18 , 21 , 26 , 27 , suggesting a decrease in ventilation issues associated with ventilator disconnection. In the present study, a notable disparity was observed in the utilization of FOB between the two patient groups. The results are comparable with previous studies 18 , 27 . In this study, hypoxemia was defined as SpO 2 <95% 28 . Using this definition, our incidence in the c-DLT group (27.7%) aligns with prior reports (22–25%) 6 . Since SpO 2 may not decline until PaO 2 drops below 70 mm Hg 29 , hypoxemia is alternatively defined as a reduction in SpO 2 to less than 95% when measured by pulse oximetry. Applying this criteria, two earlier investigations documented hypoxemia rates of 38% 7 and 3% 4 , respectively, which differ from the incidence observed in this study. This variation can be attributed to the use of a FiO 2 greater than 50% in both two-lung ventilation and OLV in the two earlier studies. Given that a high FiO 2 is now considered as a risk factor for pulmonary complications and myocardial injury, a recent study has suggested the implementation of continuous FiO 2 titration during OLV, rather than maintaining a high FiO 2 level 30 . Studies have shown that using a protective ventilation strategy (pressure-controlled ventilation, tidal volume of 5 ml/kg, FiO 2 0.5, PEEP 5 cmH 2 O) significantly reduces the incidence of postoperative acute lung injury (ALI) (4% vs. 22%) compared to a traditional ventilation strategy (volume-controlled ventilation, tidal volume of 10 ml/kg, FiO 2 1.0) 31 . Additionally, researchers have found that when the FiO 2 threshold exceeds 80%, the AUC is associated with postoperative pulmonary complications. However, when considering the independent effects of exposure time and FiO2, the results do not support limiting oxygen concentration to reduce postoperative pulmonary complications 32 . The optimal minimum oxygen concentration during OLV still requires further research. Regarding secondary outcomes, we found no statistically significant differences between the two groups regarding the occurrence of postoperative pulmonary complications, including postoperative hypoxemia, coughing, hoarseness and sore throat. Furthermore, our study did not reveal any substantial disparities in postoperative pain intensity, as assessed by VAS score between the study groups during the initial 3 days. This can be attributed to the absence of statistically significant differences in factors such as tube size, insertion side, ventilation strategies, tube insertion procedure, OLV duration, or surgery duration between the v-DLT group and the c-DLT group. Nevertheless, the study conducted by Massot et al . 26 reported instances of overheating and melting of the distal port of v-DLT, attributable to overheating of the built-in LED camera. Furthermore, in a study performed by Dean et al. 33 , the v-DLT 37F tube exhibited an exterior diameter 36% larger than the conventional Mallinckrodt 37Fr DLT, measuring 15 mm compared to 11 mm, due to the profile of the build-in LED camera, suggesting a potential risk of airway trauma during tube placement. To address these concerns adequately, further studies involving a diverse patient population and an extended exposure period should be conducted to identify potential complications associated with the use of v-DLT. The insertion of a DLT is typically performed by anesthesiologists with specialized training in cardiothoracic anesthesia, as it necessitates expertise in FOB 25 . Even though anesthesiologists who frequently utilize the DLT have undergone the requisite training, they may still face an elevated workload and experience reduced satisfaction with regard to DLT installation and maintenance. A genuine concern exists regarding the safety and well-being of both these anesthesiologists and the patients under their care. To date, there has been a dearth of comprehensive evaluations among anesthesiologists to ascertain whether the use of v-DLT may enhance procedure satisfaction and alleviate the clinical workload associated with DLT procedures. In the present study, through the utilization of a survey questionnaire administered to anesthesiologists who frequently employ DLT, we suggest that v-DLT offers enhanced convenience, a simplified intubation process, reduced workload, improved job efficiency, and greater user satisfaction when compared to c- DLT. This study has several limitations that should be acknowledged. Firstly, the enrollment was confined to a single hospital, meaning that the results primarily pertain to the therapeutic practices of this particular institution, potentially limiting their generalizability to a wider context. Secondly, in the present study, we employed SpO 2 to detect hypoxemia, a noninvasive and sensitive technique that accurately measures a patient's peripheral oxygen saturation and closely correlates with arterial oxygen saturation (SaO 2 ). However, it's important to note that we did not include measurements of arterial oxygen tension (PaO 2 ) in this study. Oxygen Reserve Index (ORI), a recently adopted technique for continuously analyzing PaO 2 values within a range of 100–200 mmHg, warrants careful consideration in future research on OLV. Thirdly, the operators were aware of whether they were using a v-DLT or a conventional-DLT during the intubation and OLV process. Although the operators were unaware of the experimental purpose and primary outcomes indicators, bias may still exist in their operations. In addition, our current investigation did not furnish data concerning patients at a heightened risk of hypoxemia. Specifically, patients with ASA grade > III, Mallampati grade > II, or those afflicted with severe heart or pulmonary conditions were deliberately excluded from our study. In conclusion, the utilization of v-DLT led to a reduced occurrence of hypoxemia during OLV in patients undergoing VATS when compared to the c- DLT. This benefit stems primarily from its capacity for continuous position visualization, enabling proactive correction of malposition, and its reduction in FOB requirements, minimizing ventilation disruption. Additionally, the v-DLT reduced the requirement for FOB and shortened intubation time. Anesthesiologists have expressed high satisfaction with the v-DLT, and believe it can significantly reduce their workload. Declarations Ethics approval and consent to participate The trial was approved by the Clinical Trial Review Board of the First Affiliated Hospital, Sun Yat-sen University in Guangzhou, China (Document number 2020-418, date: October 2020). The study was registered prior to patient enrollment at the China Clinical Trial Registration Center (ChiCTR2100046484, Wenqi Huang, Date: May 2021). Informed consent to participate was obtained from all of the participants in the study. The study adhered to the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding Funding was provided by the Guang Dong Basic and Applied Basic Research Foundation (No. 2020A1515110681 to RH). None of funding bodies had any influence on the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Authors' contributions Study conception: RH, SL, ZXW, WQH, JYG Study performance: RH, SL, YHL, XYZ, ZXW Data collection: SL, YHL, XYZ, FY, JYL, YY Data analysis and interpretation: RH, SL, ZXW, JYG, WQH Manuscript preparation: RH, SL, XYZ, ZXW Approval of the final version of the manuscript: RH, SL, ZXW, WQH Acknowledgements The authors thank Professor Jing Gu from the School of Public Health, Sun Yat-sen University for his invaluable assistance in the statistical analysis of the research data. Her expertise and guidance played a pivotal role in ensuring the accuracy and reliability of the findings. Authors' information 1 Department of Anaesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China. References Howington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. 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Performance comparison of right- and left-sided double-lumen tubes among infrequent users. J Cardiothorac Vasc Anesth. 2010;24(4):598–601. Sagiroglu G, Baysal A, Karamustafaoglu YA. The use of oxygen reserve index in one-lung ventilation and its impact on peripheral oxygen saturation, perfusion index and, pleth variability index. BMC Anesthesiol. 2021;21(1):319. Campos JH, Feider A. Hypoxia During One-Lung Ventilation-A Review and Update. J Cardiothorac Vasc Anesth. 2018;32(5):2330–8. Inoue S, Nishimine N, Kitaguchi K, Furuya H, Taniguchi S. Double lumen tube location predicts tube malposition and hypoxaemia during one lung ventilation. Br J Anaesth. 2004;92(2):195–201. Şentürk M, Slinger P, Cohen E. Intraoperative mechanical ventilation strategies for one-lung ventilation. Best Pract Res Clin Anaesthesiol. 2015;29(3):357–69. Unzueta C, Tusman G, Suarez-Sipmann F, Bohm S, Moral V. Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial. Br J Anaesth. 2012;108(3):517–24. Cinnella G, Grasso S, Natale C, Sollitto F, Cacciapaglia M, Angiolillo M, Pavone G, Mirabella L, Dambrosio M. Physiological effects of a lung-recruiting strategy applied during one-lung ventilation. Acta Anaesthesiol Scand. 2008;52(6):766–75. Ferrando C, Mugarra A, Gutierrez A, Carbonell JA, Garcia M, Soro M, Tusman G, Belda FJ. Setting individualized positive end-expiratory pressure level with a positive end-expiratory pressure decrement trial after a recruitment maneuver improves oxygenation and lung mechanics during one-lung ventilation. Anesth Analg. 2014;118(3):657–65. Benumof JL. One-lung ventilation: which lung should be PEEPed? Anesthesiology. 1982;56(3):161–3. Horncastle E, Lumb AB. Hyperoxia in anaesthesia and intensive care. BJA Educ. 2019;19(6):176–82. Suehiro K, Okutai R. Cerebral desaturation during single-lung ventilation is negatively correlated with preoperative respiratory functions. J Cardiothorac Vasc Anesth. 2011;25(1):127–30. Li XM, Li F, Liu ZK, Shao MT. Investigation of one-lung ventilation postoperative cognitive dysfunction and regional cerebral oxygen saturation relations. J Zhejiang Univ Sci B. 2015;16(12):1042–8. Heir JS, Guo SL, Purugganan R, Jackson TA, Sekhon AK, Mirza K, Lasala J, Feng L, Cata JP. A Randomized Controlled Study of the Use of Video Double-Lumen Endobronchial Tubes Versus Double-Lumen Endobronchial Tubes in Thoracic Surgery. J Cardiothorac Vasc Anesth. 2018;32(1):267–74. Levy-Faber D, Malyanker Y, Nir RR, Best LA, Barak M. Comparison of Video double-lumen tube with a conventional double-lumen tube in adult patients undergoing video-assisted thoracoscopic surgery. Anaesthesia. 2015;70(11):1259–63. Koopman EM, Barak M, Weber E, Valk MJ, de Schepper RT, Bouwman RA, Huitink JM. Evaluation of a new double-lumen endobronchial tube with an integrated camera (Video-DL()): a prospective multicentre observational study. Anaesthesia. 2015;70(8):962–8. Rapchuk IL, Kunju S, Smith IJ, Faulke DJ. A six-month evaluation of the Video™ video double-lumen endotracheal tube after introduction into thoracic anaesthetic practice at a single institution. Anaesth Intensive Care. 2017;45(2):189–95. Bennett JA. The Consolidated Standards of Reporting Trials (CONSORT): Guidelines for reporting randomized trials. Nurs Res. 2005;54(2):128–32. Long S, Li Y, Guo J, Hu R. Effect of the Video double-lumen tube on the incidence of hypoxaemia during one-lung ventilation in patients undergoing thoracoscopic surgery: a study protocol for a prospective randomised controlled trial. BMJ Open. 2023;13(4):e068071. Chow MY, Liam BL, Thng CH, Chong BK. Predicting the size of a double-lumen endobronchial tube using computed tomographic scan measurements of the left main bronchus diameter. Anesth Analg. 1999;88(2):302–5. Klein U, Karzai W, Bloos F, Wohlfarth M, Gottschall R, Fritz H, Gugel M, Seifert A. Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia: a prospective study. Anesthesiology. 1998;88(2):346–50. Massot J, Dumand-Nizard V, Fischler M, Le Guen M. Evaluation of the Double-Lumen Tube Video-DL (DLT-ETView): A Prospective Single-Center Study. J Cardiothorac Vasc Anesth. 2015;29(6):1544–9. Onifade A, Lemon-Riggs D, Smith A, Pak T, Pruszynski J, Reznik S, Moon TS. Comparing the rate of fiberoptic bronchoscopy use with a video double lumen tube versus a conventional double lumen tube-a randomized controlled trial. J Thorac Dis. 2020;12(11):6533–41. Durkin C, Romano K, Egan S, Lohser J. Hypoxemia During One-Lung Ventilation: Does It Really Matter? Curr Anesthesiol Rep. 2021;11(4):414–20. Hsia CC. Respiratory function of hemoglobin. N Engl J Med. 1998;338(4):239–47. Yang M, Kim JA, Ahn HJ, Choi YS, Park M, Jeong H, Kim K, Lee NY. Continuous Titration of Inspired Oxygen Using Oxygen Reserve Index to Decrease Oxygen Exposure During One-Lung Ventilation: A Randomized Controlled Trial. Anesth Analg. 2022;135(1):91–9. Yang M, Ahn HJ, Kim K, Kim JA, Yi CA, Kim MJ, Kim HJ. Does a Protective Ventilation Strategy Reduce the Risk of Pulmonary Complications After Lung Cancer Surgery? Chest. 2011;139(3):530–7. Douville NJ, Smolkin ME, Naik BI, Mathis MR, Colquhoun DA, Kheterpal S, Collins SR, Martin LW, Popescu WM, Pace NL, Blank RS, Aziz M, Blasberg JD, Chang AC, Freundlich RE, O’Reilly-Shah V, Schonberger RB. Association between inspired oxygen fraction and development of postoperative pulmonary complications in thoracic surgery: a multicentre retrospective cohort study. Br J Anaesth. 2024;133(5):1073–84. C D. The Video-DL double-lumen tube with integrated camera. Eur J Anaesthesiol 2016;33(4):299–300. Additional Declarations No competing interests reported. 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c-DLT. conventional double-lumen endotracheal tube.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7012275/v1/0cf0533a3d13af0f3fbb2938.png"},{"id":91318862,"identity":"d155cf93-d8f1-4138-84c0-1c8d73b190dd","added_by":"auto","created_at":"2025-09-15 08:47:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":977613,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7012275/v1/057d3763-5722-46ea-b227-b80d5fb10097.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of the effects of video double-lumen endotracheal tubes and conventional double-lumen endotracheal tubes on peripheral oxygen saturation during one-lung ventilation in patients undergoing thoracoscopic surgery: a prospective randomized controlled trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eVideo-assisted thoracic surgery (VATS) is a widely employed surgical procedures for the identification and therapy of chest issues \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Successful VATS requires effective mechanical lung separation to facilitate OLV. While several techniques exist, including double-lumen endotracheal tube (DLT), single-lumen tubes with bronchial blocker (BB), and even laryngeal mask airway combined with a BB, the DLT remains the gold standard for OLV during VATS.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eA critical challenge during OLV is hypoxemia, a severe complication with reported incidences ranging from 1\u0026ndash;30%, and severe hypoxemia occurring in 10\u0026ndash;30% of patients.\u003csup\u003e\u003cspan additionalcitationids=\"CR4 CR5 CR6\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Hypoxemia arises from factors such as ventilation-perfusion mismatch, decreased oxygen reserves, impaired ventilation, and the Bohr effect.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Importantly, DLT malpositioning is a major contributor, implicated in up to 83% of hypoxemia cases during OLV.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Techniques to mitigate hypoxemia include repositioning the isolation device, increasing FiO\u003csub\u003e2\u003c/sub\u003e, ventilator adjustments, applying PEEP to the ventilated lung, applying CPAP to the non-ventilated lung, and two-lung ventilation.\u003csup\u003e\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e This intervention cascade is not benign; it often necessitates interrupting the surgical procedure, increasing operative time and complexity. Furthermore, interventions like high FiO₂ or inappropriate ventilator settings carry risks, including ventilator-induced lung injury (VILI).\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Persistent or severe hypoxemia can lead to serious sequelae such as cerebral desaturation, organ dysfunction, and cardiac arrest, significantly increasing perioperative risk, healthcare costs, and medico-legal liability.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eTherefore, preventing hypoxemia, particularly that caused by device malposition, is vastly preferable to treating it. This underscores the critical importance of identifying the isolation device most effective at minimizing malposition and thereby reducing the incidence of hypoxemia. Ensuring optimal DLT positioning is therefore paramount. The video double-lumen endotracheal tube (v-DLT), equipped with a distal camera within the tracheal lumen, offers continuous, real-time visualization of tube position. This technology enables immediate intraoperative adjustment, significantly reducing intubation time and the need for fiberoptic bronchoscopy (FOB) for initial placement and position confirmation compared to conventional DLTs (c-DLTs).\u003csup\u003e\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eBased on the established link between malposition and hypoxemia, the burdensome nature of hypoxemia treatment, and the v-DLT's capability for real-time position monitoring, we hypothesized that the v-DLT would significantly reduce the incidence of hypoxemia during OLV in patients undergoing VATS compared to the c-DLT.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy design\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study was a randomized, prospective, single-blind, single-center clinical trial. The trial was approved by the Clinical Trial Review Board of the First Affiliated Hospital, Sun Yat-sen University in Guangzhou, China (Document number 2020\u0026thinsp;\u0026minus;\u0026thinsp;418, date: October 2020). The study was registered at the China Clinical Trial Registration Center (ChiCTR2100046484, Wenqi Huang, Date: May 2021). The clinical trial was registered prior to patient enrollment, written informed consent was obtained from each participating patient. The work had been reported in line with Consolidated Standards of Reporting Trials (CONSORT) Guidelines. \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eParticipants\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatients with American Society of Anesthesiologists (ASA) physical status I\u0026ndash;III and Mallampati airway assessment score I\u0026ndash;II, scheduled for elective thoracic surgery under thoracoscopy, were enrolled in this study. Exclusion criteria comprised individuals under 18 years old, those with moderate-to-severe lung ventilation or gas exchange dysfunction (forced expiratory volume in the 1s\u0026thinsp;\u0026lt;\u0026thinsp;60% of the expected value for ventilation dysfunction; diffusion of carbon monoxide in the lung\u0026thinsp;\u0026lt;\u0026thinsp;60% of the expected value for gas exchange dysfunction), a history of thoracic surgery, chronic lung disease, systemic infection or suspected tuberculosis within the past month, impaired liver and kidney function (Child-Pugh grade B and C for liver function; endogenous creatinine clearance rate\u0026thinsp;\u0026le;\u0026thinsp;50mL min\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e, blood creatinine\u0026thinsp;\u0026gt;\u0026thinsp;178\u0026micro;mol L\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e, or blood urea nitrogen\u0026thinsp;\u0026gt;\u0026thinsp;9mmol L\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e for renal function), severe cardiovascular and cerebrovascular diseases (including high risk of hypertension, untreated coronary heart disease, valvular heart disease, previous history of myocardial infarction, cerebral infarction, cerebral thrombosis, or cerebral hemorrhage), inability to cooperate with the research due to language comprehension disorder or mental illness, and use of other trial drugs or participation in other clinical trials within 3 months prior to enrollment.\u003c/p\u003e\u003cp\u003e\u003cb\u003eRandomisation\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe complete protocol had been published.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e A total of 100 patients undergoing VATS and meeting the inclusion criteria were randomly assigned into two groups: Group v-DLT (using the v-DLT) and Group conventional-DLT (using the c-DLT), in a 1:1 ratio. The primary investigator obtained informed consent from the participants, and the secondary investigator was responsible for random number allocation and participant grouping. Participants were assigned numerical identifiers from 1 to 100 according to their enrollment sequence. Random numbers, generated using SPSS (version 22.0), determined the random allocation of participants to either the v-DLT group or the c-DLT group. The patient and the principal anesthesiologist remained unaware of the group assignment before the surgical procedure. Because blinding was not feasible during the surgical procedure, researchers unaware of the participants' group assignment conducted post-operative assessments the day after the operation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eProcedures\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePreoperatively, patients underwent assessment documenting demographics (sex, age), anthropometrics (height, weight, BMI), chest CT, ECG, and pulmonary function. The primary investigator (PI) determined ASA and Mallampati grades. Informed consent was obtained. DLT size was selected based on the PI\u0026rsquo;s clinical judgment and chest CT findings, guided by Chow\u0026rsquo;s method\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e: tracheal internal diameter measured on CT dictates size selection: \u0026ge;19 mm: 39 Fr; \u0026ge;15 mm: 37 Fr; \u0026ge;13 mm: 35 Fr.\u003c/p\u003e\u003cp\u003ePatient entered the operating room, routine monitoring, electrocardiogram, non-invasive arterial blood pressure, blood oxygen saturation, and Narcotrend monitoring, was conducted. Dexmedetomidine (0.5-1.0ug kg\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e) was intravenously administered for sedation before anesthesia induction. General anesthesia was induced with propofol (2-3mg kg\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e), cisatracurium (2mg kg\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e), and sufentanil (0.3-0.5ug kg\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e). Anesthesia maintenance involved sevoflurane (0%-1%), and continuous infusion of propofol (4-12mg kg h\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e), remifentanil (TCI 3-6ng ml\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e), and intermittent injection of cisatracurium (0.05mg kg\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e) and sufentanil (5-10ug dose\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e). The depth of anesthesia was controlled to a Narcotrend level of D2\u0026ndash;E0. Vital signs were recorded during the perioperative period.\u003c/p\u003e\u003cp\u003ePatients in the c-DLT group were intubated with conventional double-lumen tubes (left/right selected per surgical requirements), with correct position routinely confirmed by fiberoptic bronchoscopy (FOB). Correct position required: 1) FOB via the \u003cem\u003etracheal lumen\u003c/em\u003e visualizing the main carina and bronchial cuff edge within the target bronchus, and 2) FOB via the \u003cem\u003ebronchial lumen\u003c/em\u003e visualizing ipsilateral lobar bronchial openings (left upper/lower lobes for left c-DLT; right middle/lower lobes and upper lobe orifice for right c-DLT). Conversely, the v-DLT group underwent intubation using the video-enabled tube (left/right per surgery), achieving target position using its integrated camera or FOB (same criteria). FOB was not routine in this group, reserved only for positioning \u003cem\u003eright-sided\u003c/em\u003e tubes or when camera-guided localization failed.\u003c/p\u003e\u003cp\u003eFor each patient, investigators recorded two metrics: (1) intubation time, measured with a stopwatch from laryngoscope blade insertion into the mouth until confirmed correct DLT positioning (as defined in the Methods section), and (2) frequency of fiberoptic bronchoscopy (FOB) use (during intubation, lateral positioning and OLV). Concurrently, the performing anesthesiologist completed a post-intubation assessment using a standardized questionnaire to evaluate seven domains of DLT experience: (1) convenience of use, (2) intubation time reduction, (3) ease of intubation, (4) perceived success rate, (5) workload reduction, (6) work efficiency improvement, and (7) overall satisfaction. Each domain was rated using a 3-point ordinal scale: Yes, Partially, or No).\u003c/p\u003e\u003cp\u003eAfter securing the DLT, mechanical ventilation of double lungs was initiated using a volume-controlled mode. Tidal volume for bilateral lung ventilation was set at 5\u0026ndash;10 ml kg\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e, FiO\u003csub\u003e2\u003c/sub\u003e was maintained at 50%, and ventilation frequency was adjusted to maintain end-tidal CO\u003csub\u003e2\u003c/sub\u003e (ETCO\u003csub\u003e2\u003c/sub\u003e) levels between 35\u0026ndash;45 mmHg. Vital signs and ventilation parameters were recorded 5 minutes post-intubation. OLV was initiated prior to pleural opening, with a tidal volume set at 5\u0026ndash;8 ml kg\u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e, FiO\u003csub\u003e2\u003c/sub\u003e maintained at 50%, and ventilation frequency adjusted to maintain ETCO\u003csub\u003e2\u003c/sub\u003e between 35\u0026ndash;45 mmHg. Surgeons assessed the quality of lung collapse using the following scoring system: 1\u0026thinsp;=\u0026thinsp;collapse, 2\u0026thinsp;=\u0026thinsp;partial collapse, 3\u0026thinsp;=\u0026thinsp;complete lung collapse. During OLV, if SpO\u003csub\u003e2\u003c/sub\u003e dropped below 95%, the following interventions were performed sequentially to improve oxygenation: (1) Repositioning the DLT and suctioning of trachea secretions; (2) Increasing FiO\u003csub\u003e2\u003c/sub\u003e to 80%-100%; (3) Adjusting ventilation parameters (tidal volume and frequency); (4) Applying PEEP of 5cmH\u003csub\u003e2\u003c/sub\u003eO to the dependent ventilated lung; (5) Administering intermittent resuscitation or CPAP of 5cmH\u003csub\u003e2\u003c/sub\u003eO to the unventilated lung; (6) Converting to two-lung ventilation (TLV). The number of intraoperative interventions triggered by SpO\u003csub\u003e2\u003c/sub\u003e\u0026thinsp;\u0026lt;\u0026thinsp;95% were recorded. The number of malposition (occurring during lateral positioning, and during OLV) was recorded. Vital signs and ventilatory parameters during TLV, OLV, and each intervention were documented. Hemodynamic stability was maintained throughout the procedure. Sevoflurane was discontinued 15 minutes before surgery, followed by discontinuation of propofol and remifentanil postoperatively.\u003c/p\u003e\u003cp\u003eFollowing the surgery, patients were transferred to the post-anesthesia care unit for postoperative extubation and analgesia. Patients were followed up to assess their recovery and to monitor for any complications. This included evaluating symptoms such as cough (None, Occasional, Moderate), sore throat (None, During swallowing, Constant), hoarseness (None, Noticed by the patient, Noticed by the patient and study member), and hypoxemia.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOutcomes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe primary outcomes of the trial were the incidence of hypoxemia (SpO\u003csub\u003e2\u003c/sub\u003e\u0026lt;90%) during OLV in the two groups. Secondary outcomes included the number of interventions triggered by SpO\u003csub\u003e2\u003c/sub\u003e\u0026thinsp;\u0026lt;\u0026thinsp;95% during OLV, postoperative complications (hypoxemia, cough, hoarseness and sore throat occurring 24 hours after surgery), workload and satisfaction scores of the anesthesiologists in two groups.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eThe primary outcome measure was the prevalence of hypoxemia in the study population. Previous studies have reported an estimated occurrence of hypoxemia of around 30% in patients using c-DLT.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Based on the results of our preliminary experiment, the occurrence of hypoxemia in v-DLT was approximately 8%, with a significance level of 5% and a power of 80%. Using the PASS (version 11.0) program, a total of 46 patients were determined to be required for each group. To account for a potential dropout rate of up to 10%, a minimum of 50 participants per group was deemed necessary, resulting in a total sample size of 100 patients for the study.\u003c/p\u003e\u003cp\u003eNormally distributed variables were presented as mean (standard deviation SD), and analyzed using a \u003cem\u003et\u003c/em\u003e-test. Non-normally distributed variables were presented as median and quartile values, and analyzed using the Mann-Whitney U test. Categorical variables were presented as sample size and percentage, and analyzed using the χ2 test or Fisher\u0026rsquo;s exact test, as appropriate. Fisher's exact test is applicable for detecting indicators when the sample size is less than 40 or the theoretical frequency less than 5 accounted for more than 20%. Statistical analyses were conducted using SPSS (version 22.0). All tests were two-tailed, and \u003cem\u003ep\u003c/em\u003e values less than 0.05 were considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e100 patients were recruited from August 2021 to August 2022, with 50 in each group. Two patients were excluded from the v-DLT group: one underwent a second surgery for postoperative bleeding, and the other was unable to fit the tube, necessitating replacement with a conventional-DLT. Three patients were excluded from the c-DLT group: two did not undergo the planned surgery, and one was sent to the ICU after surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Baseline demographics and clinical characteristics were shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eDemographic and clinical characteristics of patients.\u003c/b\u003e Data are presented as mean (SD), number (percentage) or median (IQT [range]). BMI, Body Mass Index; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; VATS, Video-assisted thoracic surgery; DLT, double-lumen endotracheal tube; ASA, American Society of Anesthesiologists; OLV, one-lung ventilation.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ec-DLT (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ev-DLT (n\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54.2 (12.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56.3 (11.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex, Male/female\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21/26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20/28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e161.9 (7.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e163.4 (7.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61.6 (12.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61.5 (9.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.4 (3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.0 (2.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFEV1 (% predicted)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e106.0 (12.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e104.7 (14.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFVC (% predicted)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e105.4 (11.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e102.3 (15.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking history, yes/no\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8/39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7/41\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVATS side, Right/left\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30/17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28/22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDLT side, right/left\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8/39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11/37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOLV duration (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e96 (73.5-127.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90 (66\u0026ndash;123)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgery duration (min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e105 (77.5-144.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100 (80\u0026ndash;135)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurgical procedure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLobectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (42.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (58.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSegmentectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (27.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (10.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWedge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (17.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (14.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (12.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (16.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFor the primary outcome, the v-DLT group demonstrated a significantly lower incidence of hypoxemia compared to c-DLT (6.3% [3/48] vs. 27.3% [13/47], p\u0026thinsp;=\u0026thinsp;0.006) during OLV. Secondary outcomes revealed: (a) Intraoperatively, v-DLT showed a non-significant reduction in DLT malpositioning (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) but significantly reduced FOB utilization ( p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and fewer hypoxemia-triggered interventions (SpO₂\u0026lt;95%: 35.4% vs. 66.0% required\u0026thinsp;\u0026ge;\u0026thinsp;1 intervention, p\u0026thinsp;=\u0026thinsp;0.006; intervention steps differed significantly per Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e); (b) Intubation efficiency improved with video-assisted DLT (time: 85.5s vs. 280s, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), though lung collapse completion did not reach significance (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Anesthesiologists rated v-DLT superior in convenience (81.3% vs. 23.4%), workload reduction (87.5% vs. 4.3%), and satisfaction (81.3% vs. 8.5%) (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; full survey: Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Postoperatively, no differences emerged in complications (hypoxemia/coughing/hoarseness/sore throat), or hospital stay (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eOne-lung ventilation effects and interventions.\u003c/b\u003e Data are presented as number (percentage), or median (IQT [range]). * \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001 by Mann-Whitney U test. # \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001 by Fisher\u0026rsquo;s exact test. \u0026dagger; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006 for the hypoxemia rate by Fisher\u0026rsquo;s exact test. \u0026sect; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004 for the SPO\u003csub\u003e2\u003c/sub\u003e \u0026lt;95% rate by Fisher\u0026rsquo;s exact test. \u0026para; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006 for the intervention by Fisher\u0026rsquo;s exact test. FOB, fiberoptic bronchoscopy; OLV, one-lung ventilation; PEEP, positive end-expiratory pressure; CPAP, continuous positive airway pressure; TLV, two-lung ventilation; OLV, one-lung ventilation.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInvestigation contents\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ec-DLT (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ev-DLT (n\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of patients with hypoxemia (%) \u0026dagger;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (27.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (6.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of patients with SpO\u003csub\u003e2\u003c/sub\u003e \u0026lt;95% (%) \u0026sect;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31 (66.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (35.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of patients of intervention, No. (%) \u0026para;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eno intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16 (34.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31 (64.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFirst intervention (Repositioning or suctioning of trachea secretions), No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31 (66.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (35.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecond intervention (Increasing FiO\u003csub\u003e2\u003c/sub\u003e or Adjusting ventilation parameters), No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (38.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (8.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThird intervention\u003c/p\u003e\u003cp\u003e(5cmH\u003csub\u003e2\u003c/sub\u003eO PEEP for ventilated lung), No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (19.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFourth intervention (5cmH\u003csub\u003e2\u003c/sub\u003eO CPAP for surgery lung or TLV), No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (8.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMalposition during lateral positioning, No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (42.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.190\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMalposition during OLV, No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (21.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (10.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.170\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTime for intubation in correct position (s) *\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e280 (125\u0026ndash;360)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85.5 (36-202.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuality of lung collapse, No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.224\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (21.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (12.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 (76.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (87.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFOB, No. (%) #\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuring intubation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47 (100.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (22.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLateral positioning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47 (100.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (22.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOLV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e31 (66.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (10.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003eAnesthesiologist workload and satisfaction survey scores.\u003c/b\u003e Data are presented as number (percentage). * \u003cem\u003ep\u003c/em\u003e\u0026lt;0.001 by Fisher\u0026rsquo;s exact test. DLT, double-lumen endotracheal tube.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInvestigation contents\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ec-DLT (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ev-DLT (n\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep Value *\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eWas it more convenient to use this DLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11 (23.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e39 (81.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epartially\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15 (31.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7 (14.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e21 (44.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2 (4.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eWas the time of intubation with this DLT shortened\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (12.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40 (83.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epartially\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15 (31.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5 (10.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e26 (55.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3 (6.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eWas it easier to intubate with this DLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13 (27.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38 (79.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epartially\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e26 (55.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3 (6.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8 (17.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7 (14.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eWas the success rate of intubation higher with this DLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (8.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37 (77.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epartially\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e21 (44.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6 (12.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22 (46.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5 (10.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCould this DLT reduce workload\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (4.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42 (87.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epartially\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5 (10.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6 (12.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40 (85.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCould this DLT improve work efficiency\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2 (4.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e43 (89.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epartially\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3 (6.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5 (10.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e42 (89.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eWere you satisfied with this DLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eyes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (8.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e39 (81.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003epartially\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e21 (44.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8 (16.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eno\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22 (46.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1 (2.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cb\u003ePostoperative complications.\u003c/b\u003e Data are presented as number (percentage), or median (IQT [range]).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative complications\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ec-DLT (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ev-DLT (n\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative complications, No. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (36.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (39.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.732\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypoxemia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCoughing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.802\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 (76.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (81.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOccasional\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (21.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (16.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.1.%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHoarseness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.509\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43 (91.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41 (85.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNoticed by the patient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (8.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (10.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNoticed by the patient and study member\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (4.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSore throat\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.673\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41 (87.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (81.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuring swallowing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (12.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (16.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConstant\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (2.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital stays (day)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (6-9.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (6\u0026ndash;12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.179\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this randomized clinical trial of patients undergoing VATS, the v-DLT significantly reduced the incidence of hypoxemia (SpO₂ \u0026lt;90%) during OLV compared to the c-DLT. Crucially, it also reduced the occurrence of SpO₂ desaturation below 95%, thereby decreasing the need for sequential rescue interventions. Furthermore, v-DLT improved anesthesiologist satisfaction and reduced workload during OLV management.\u003c/p\u003e\u003cp\u003eThe primary finding\u0026mdash;reduced hypoxemia with v-DLT\u0026mdash;is likely attributable to its unique design enabling proactive prevention of malposition-related ventilation problems. Hypoxemia remains a significant concern during VATS with the OLV.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e We propose that v-DLT diminishes the occurrence of hypoxemia during OLV through two mechanisms. Firstly, continuous real-time position monitoring: The v-DLT provides continuous visualization of tube position within the airways. Malposition is a major contributor to hypoxemia during OLV. \u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e With c-DLT, detecting and correcting malposition requires time-consuming FOB \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e, delaying intervention while hypoxemia develops. The v-DLT allows immediate visualization, enabling anesthesiologists to anticipate and correct potential dislodgement before significant desaturation occurs. This is reflected in our findings of fewer desaturation events requiring intervention. Although our study did not show a statistically significant difference in recorded malposition events (potentially due to limited sampling points and sample size), the ability to visualize continuously likely prevented malpositions from progressing to hypoxemia more effectively than the reactive approach needed with c-DLT. Secondly, reduced need for FOB, minimizing ventilation disruption: positioning the FOB through the ventilation side rubber opening, which is located above the Y-shaped connector's branches of the DLT, could potentially disrupt ventilation on that side. Furthermore, multiple factors, such as surgical procedures, gravitational shifts in the mediastinum, and abdominal compression, can disrupt the connection between the DLT and the patient's tracheobronchial architecture, necessitating frequent perioperative FOB application for correct tube positioning. v-DLT has been shown to reduce the need for FOB during the initial placement and verification of DLT during OLV\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e, suggesting a decrease in ventilation issues associated with ventilator disconnection. In the present study, a notable disparity was observed in the utilization of FOB between the two patient groups. The results are comparable with previous studies\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn this study, hypoxemia was defined as SpO\u003csub\u003e2\u003c/sub\u003e\u0026lt;95% \u003csup\u003e28\u003c/sup\u003e. Using this definition, our incidence in the c-DLT group (27.7%) aligns with prior reports (22\u0026ndash;25%) \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Since SpO\u003csub\u003e2\u003c/sub\u003e may not decline until PaO\u003csub\u003e2\u003c/sub\u003e drops below 70 mm Hg \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e, hypoxemia is alternatively defined as a reduction in SpO\u003csub\u003e2\u003c/sub\u003e to less than 95% when measured by pulse oximetry. Applying this criteria, two earlier investigations documented hypoxemia rates of 38% \u003csup\u003e7\u003c/sup\u003e and 3% \u003csup\u003e4\u003c/sup\u003e, respectively, which differ from the incidence observed in this study. This variation can be attributed to the use of a FiO\u003csub\u003e2\u003c/sub\u003e greater than 50% in both two-lung ventilation and OLV in the two earlier studies. Given that a high FiO\u003csub\u003e2\u003c/sub\u003e is now considered as a risk factor for pulmonary complications and myocardial injury, a recent study has suggested the implementation of continuous FiO\u003csub\u003e2\u003c/sub\u003e titration during OLV, rather than maintaining a high FiO\u003csub\u003e2\u003c/sub\u003e level \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Studies have shown that using a protective ventilation strategy (pressure-controlled ventilation, tidal volume of 5 ml/kg, FiO\u003csub\u003e2\u003c/sub\u003e 0.5, PEEP 5 cmH\u003csub\u003e2\u003c/sub\u003eO) significantly reduces the incidence of postoperative acute lung injury (ALI) (4% vs. 22%) compared to a traditional ventilation strategy (volume-controlled ventilation, tidal volume of 10 ml/kg, FiO\u003csub\u003e2\u003c/sub\u003e 1.0) \u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. Additionally, researchers have found that when the FiO\u003csub\u003e2\u003c/sub\u003e threshold exceeds 80%, the AUC is associated with postoperative pulmonary complications. However, when considering the independent effects of exposure time and FiO2, the results do not support limiting oxygen concentration to reduce postoperative pulmonary complications \u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. The optimal minimum oxygen concentration during OLV still requires further research.\u003c/p\u003e\u003cp\u003eRegarding secondary outcomes, we found no statistically significant differences between the two groups regarding the occurrence of postoperative pulmonary complications, including postoperative hypoxemia, coughing, hoarseness and sore throat. Furthermore, our study did not reveal any substantial disparities in postoperative pain intensity, as assessed by VAS score between the study groups during the initial 3 days. This can be attributed to the absence of statistically significant differences in factors such as tube size, insertion side, ventilation strategies, tube insertion procedure, OLV duration, or surgery duration between the v-DLT group and the c-DLT group. Nevertheless, the study conducted by Massot \u003cem\u003eet al\u003c/em\u003e. \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e reported instances of overheating and melting of the distal port of v-DLT, attributable to overheating of the built-in LED camera. Furthermore, in a study performed by Dean \u003cem\u003eet al.\u003c/em\u003e \u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e, the v-DLT 37F tube exhibited an exterior diameter 36% larger than the conventional Mallinckrodt 37Fr DLT, measuring 15 mm compared to 11 mm, due to the profile of the build-in LED camera, suggesting a potential risk of airway trauma during tube placement. To address these concerns adequately, further studies involving a diverse patient population and an extended exposure period should be conducted to identify potential complications associated with the use of v-DLT.\u003c/p\u003e\u003cp\u003eThe insertion of a DLT is typically performed by anesthesiologists with specialized training in cardiothoracic anesthesia, as it necessitates expertise in FOB \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Even though anesthesiologists who frequently utilize the DLT have undergone the requisite training, they may still face an elevated workload and experience reduced satisfaction with regard to DLT installation and maintenance. A genuine concern exists regarding the safety and well-being of both these anesthesiologists and the patients under their care. To date, there has been a dearth of comprehensive evaluations among anesthesiologists to ascertain whether the use of v-DLT may enhance procedure satisfaction and alleviate the clinical workload associated with DLT procedures. In the present study, through the utilization of a survey questionnaire administered to anesthesiologists who frequently employ DLT, we suggest that v-DLT offers enhanced convenience, a simplified intubation process, reduced workload, improved job efficiency, and greater user satisfaction when compared to c- DLT.\u003c/p\u003e\u003cp\u003eThis study has several limitations that should be acknowledged. Firstly, the enrollment was confined to a single hospital, meaning that the results primarily pertain to the therapeutic practices of this particular institution, potentially limiting their generalizability to a wider context. Secondly, in the present study, we employed SpO\u003csub\u003e2\u003c/sub\u003e to detect hypoxemia, a noninvasive and sensitive technique that accurately measures a patient's peripheral oxygen saturation and closely correlates with arterial oxygen saturation (SaO\u003csub\u003e2\u003c/sub\u003e). However, it's important to note that we did not include measurements of arterial oxygen tension (PaO\u003csub\u003e2\u003c/sub\u003e) in this study. Oxygen Reserve Index (ORI), a recently adopted technique for continuously analyzing PaO\u003csub\u003e2\u003c/sub\u003e values within a range of 100\u0026ndash;200 mmHg, warrants careful consideration in future research on OLV. Thirdly, the operators were aware of whether they were using a v-DLT or a conventional-DLT during the intubation and OLV process. Although the operators were unaware of the experimental purpose and primary outcomes indicators, bias may still exist in their operations. In addition, our current investigation did not furnish data concerning patients at a heightened risk of hypoxemia. Specifically, patients with ASA grade\u0026thinsp;\u0026gt;\u0026thinsp;III, Mallampati grade\u0026thinsp;\u0026gt;\u0026thinsp;II, or those afflicted with severe heart or pulmonary conditions were deliberately excluded from our study.\u003c/p\u003e\u003cp\u003eIn conclusion, the utilization of v-DLT led to a reduced occurrence of hypoxemia during OLV in patients undergoing VATS when compared to the c- DLT. This benefit stems primarily from its capacity for continuous position visualization, enabling proactive correction of malposition, and its reduction in FOB requirements, minimizing ventilation disruption. Additionally, the v-DLT reduced the requirement for FOB and shortened intubation time. Anesthesiologists have expressed high satisfaction with the v-DLT, and believe it can significantly reduce their workload.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe trial was approved by the Clinical Trial Review Board of the First Affiliated Hospital, Sun Yat-sen University in Guangzhou, China (Document number 2020-418, date: October 2020). The study was registered prior to patient enrollment at the China Clinical Trial Registration Center (ChiCTR2100046484, Wenqi Huang, Date: May 2021). Informed consent to participate was obtained from all of the participants in the study. The study adhered to the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding was provided by the Guang Dong Basic and Applied Basic Research Foundation (No. 2020A1515110681 to RH).\u0026nbsp;None of funding bodies had any influence on the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy conception: RH, SL, ZXW, WQH, JYG\u003c/p\u003e\n\u003cp\u003eStudy performance: RH, SL, YHL, XYZ, ZXW\u003c/p\u003e\n\u003cp\u003eData collection: SL, YHL, XYZ, FY, JYL, YY\u003c/p\u003e\n\u003cp\u003eData analysis and interpretation: RH, SL, ZXW, JYG, WQH\u003c/p\u003e\n\u003cp\u003eManuscript preparation: RH, SL, XYZ, ZXW\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApproval of the final version of the manuscript: RH, SL, ZXW, WQH\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank Professor Jing Gu from the School of Public Health, Sun Yat-sen University for his invaluable assistance in the statistical analysis of the research data. Her expertise and guidance played a pivotal role in ensuring the accuracy and reliability of the findings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eDepartment of Anaesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHowington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):eS278\u0026ndash;313.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNarayanaswamy M, McRae K, Slinger P, Dugas G, Kanellakos GW, Roscoe A, Lacroix M. 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Evaluation of a new double-lumen endobronchial tube with an integrated camera (Video-DL()): a prospective multicentre observational study. Anaesthesia. 2015;70(8):962\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRapchuk IL, Kunju S, Smith IJ, Faulke DJ. A six-month evaluation of the Video\u0026trade; video double-lumen endotracheal tube after introduction into thoracic anaesthetic practice at a single institution. Anaesth Intensive Care. 2017;45(2):189\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBennett JA. The Consolidated Standards of Reporting Trials (CONSORT): Guidelines for reporting randomized trials. Nurs Res. 2005;54(2):128\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLong S, Li Y, Guo J, Hu R. Effect of the Video double-lumen tube on the incidence of hypoxaemia during one-lung ventilation in patients undergoing thoracoscopic surgery: a study protocol for a prospective randomised controlled trial. BMJ Open. 2023;13(4):e068071.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChow MY, Liam BL, Thng CH, Chong BK. Predicting the size of a double-lumen endobronchial tube using computed tomographic scan measurements of the left main bronchus diameter. Anesth Analg. 1999;88(2):302\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKlein U, Karzai W, Bloos F, Wohlfarth M, Gottschall R, Fritz H, Gugel M, Seifert A. Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia: a prospective study. Anesthesiology. 1998;88(2):346\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMassot J, Dumand-Nizard V, Fischler M, Le Guen M. 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Continuous Titration of Inspired Oxygen Using Oxygen Reserve Index to Decrease Oxygen Exposure During One-Lung Ventilation: A Randomized Controlled Trial. Anesth Analg. 2022;135(1):91\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang M, Ahn HJ, Kim K, Kim JA, Yi CA, Kim MJ, Kim HJ. Does a Protective Ventilation Strategy Reduce the Risk of Pulmonary Complications After Lung Cancer Surgery? Chest. 2011;139(3):530\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDouville NJ, Smolkin ME, Naik BI, Mathis MR, Colquhoun DA, Kheterpal S, Collins SR, Martin LW, Popescu WM, Pace NL, Blank RS, Aziz M, Blasberg JD, Chang AC, Freundlich RE, O\u0026rsquo;Reilly-Shah V, Schonberger RB. Association between inspired oxygen fraction and development of postoperative pulmonary complications in thoracic surgery: a multicentre retrospective cohort study. Br J Anaesth. 2024;133(5):1073\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eC D. The Video-DL double-lumen tube with integrated camera. Eur J Anaesthesiol 2016;33(4):299\u0026ndash;300.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Video double-lumen endotracheal tube, conventional double-lumen endotracheal tube, thoracoscopic surgery, one-lung ventilation, hypoxemia","lastPublishedDoi":"10.21203/rs.3.rs-7012275/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7012275/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eCompared to the conventional double-lumen endotracheal tube (c-DLT), the video double-lumen endotracheal tube (v-DLT) demonstrates a shorter intubation time and the capability of observing and adjusting malposition at any time. Our objective was to compare the incidence of hypoxemia during one-lung ventilation (OLV) and perioperative complications between the two tube types.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e100 patients undergoing video-assisted thoracic surgery (VATS) were randomized to receive either a v-DLT or a c-DLT. Low tidal volume ventilation was used during OLV. The primary outcome was the incidence of hypoxemia (defined as SpO\u003csub\u003e2\u003c/sub\u003e\u0026lt;90%) during OLV. To prevent its occurrence, a predefined protocol was activated if SpO\u003csub\u003e2\u003c/sub\u003e dropped below 95%. Sequential interventions included DLT repositioning, increasing FiO₂, adjusting ventilator settings, applying 5 cmH₂O PEEP to the ventilated lung, applying 5 cmH₂O CPAP to the operative lung, or resuming two-lung ventilation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe incidence of hypoxemia during OLV in the v-DLT group was significantly lower than that in the c-DLT group (6.3% vs. 27.7%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006). No statistically significant difference was observed in postoperative complications between two groups (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.732). The v-DLT demonstrated greater convenience (\u003cem\u003ep\u003c/em\u003e \u0026lt;0.001), shorter intubation time (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), easier intubation (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), higher intubation success rate (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), lower workload (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), higher work efficiency (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001), and could enhance user satisfaction among anesthesiologists (\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe v-DLT can significantly reduce the incidence of hypoxemia during OLV compared with the c-DLT. Simultaneously, it reduced the workload of anesthesiologists and enhanced their overall satisfaction levels.\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e\u003cp\u003eChictr.org.cn ChiCTR2100046484. Registered on 16 May 2021.\u003c/p\u003e","manuscriptTitle":"Comparison of the effects of video double-lumen endotracheal tubes and conventional double-lumen endotracheal tubes on peripheral oxygen saturation during one-lung ventilation in patients undergoing thoracoscopic surgery: a prospective randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-07 10:50:11","doi":"10.21203/rs.3.rs-7012275/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c6b54576-201d-4e1f-87dc-198373e8aabe","owner":[],"postedDate":"August 7th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-15T08:39:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-07 10:50:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7012275","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7012275","identity":"rs-7012275","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}