Factors associated with selective fiberoptic bronchoscopy use after left double-lumen tube placement

Fiberoptic bronchoscopy (FOB) is considered the gold standard for confirming correct placement of left-sided double-lumen tubes (LDLTs) during thoracic anesthesia. However, routine FOB use is not always feasible in high-volume centers, and selective strategies are frequently adopted. This study aimed to identify factors associated with the need for selective intraoperative FOB following conventional LDLT placement in a high-volume thoracic anesthesia practice where FOB is not routinely used. This retrospective observational study was conducted in a high-volume tertiary thoracic surgery center over a 3.5-year period (July 2017 to January 2021). Adult patients undergoing elective thoracic surgery with LDLT placement were reviewed. FOB was not used routinely and was performed only when clinical findings suggested possible tube malposition. Patients were categorized according to intraoperative FOB requirement. Controls were randomly selected in a 1:2 ratio. Demographic, clinical, surgical, and operator-related variables were evaluated. Binary logistic regression was used to identify independent predictors of FOB requirement. Among 2155 eligible patients, FOB was required in 152 (7.05%); 136 patients with complete data were analyzed. Compared with controls (n = 272), patients requiring FOB more frequently had higher body weight, higher body mass index, smaller LDLT size, and procedures performed by less experienced anesthesiologists. In multivariable analysis, anesthesiologist experience remained the only independent predictor of FOB requirement: procedures performed by anesthesiologists with < 1 year (OR 6.77; 95% CI 3.66–12.52; p < 0.001) and 1–5 years of experience (OR 2.57; 95% CI 1.43–4.60; p = 0.001) were associated with increased FOB use. The most common indications for FOB were pressure and/or volume incompatibility and unexpected desaturation, with malposition most frequently corrected via the tracheal lumen. In thoracic anesthesia practices where routine FOB is not available, a selective, experience-guided FOB strategy appears appropriate. Anesthesiologist experience is the primary determinant of intraoperative FOB requirement following LDLT placement, whereas patient- and procedure-related factors do not independently predict the need for bronchoscopy. A lower threshold for FOB use should be considered when LDLT placement is performed by less experienced anesthesiologists.