Thoracic cases frequently require repeated airway instrumentation: double-lumen tube (DLT) placement, bronchoscopy, and suctioning. Many patients have coexisting pulmonary disease, airway pathology, or recent airway surgery, and some may have fragile suture lines or bullous disease (as in COPD), increasing the risk of barotrauma. Each airway manipulation should be deliberate, gentle, and anatomically informed.

DLT placement often requires gentle rotation of the lubricated ETT into the bronchial lumen, usually a two-person technique as a trainee. Videolaryngoscopes can make DLT placement more challenging due to their steep angle. When using a videolaryngoscope, you may have to retract the hyperangulated blade slightly to improve your angle of approach. It is my experience that in the majority of patients, a Mac 3 blade provides a smoother, more forgiving path for DLT entry.

Never force a tube past resistance; doing so risks trauma to the vocal cords, supraglottic tissue, or anterior tracheal wall. Your goal is safe ventilation, not successful DLT placement at any cost. If placement fails, alternatives exist and should be considered early.

Every device you introduce into the airway or esophagus—DLT, gastric tubes, temperature probes—is your responsibility. At all times, be aware of what’s in the airway and ensure clear communication with the surgical team about the presence or removal of these devices.

Thoracic cases offer hands-on experience with bronchoscopy, so take advantage of it. Study bronchoscopic anatomy beforehand, especially the carina, mainstem bronchi, and lobar takeoffs. Online simulators like those from the University of Toronto are excellent for visual learning.

Bronchoscopy demands a gentle and deliberate technique. Avoid repeatedly bumping the airway wall or overusing suction, especially in inflamed or friable airways. Suction should be targeted and brief, and you should resist the urge to disturb any tissue that looks abnormal. Your role is to inspect and clear the airway only.

Most thoracic procedures require lateral decubitus positioning, which should be done in partnership with the surgical team. If it’s your first time positioning a patient laterally, wait for your attending. Ensure that all lines and the airway are secure, that the neck is maintained in neutral alignment, and that the axillary roll is positioned correctly under the upper thorax, not the axilla, to prevent brachial plexus injury.

This is a critical time to recheck your DLT positioning, confirm with bronchoscopy that the bronchial cuff is properly placed, and verify correct lumen isolation before initiating OLV.