Successful one-lung ventilation in a patient with aberrant tracheal bronchus

IMPLICATIONS: We report a 47-yr-old patient who underwent surgery for esophageal cancer. Because of the isolated ventilation of the right upper lobe after occlusion of the right mainstem bronchus, bronchoscopic re-confirmation exposed an aberrant tracheal bronchus. A Fogarty tube was introduced to block the tracheal bronchus and provide one-lung ventilation.     

Thoracoscopic surgery using a new bronchial blocker

We report use of a new bronchial blocker through a single-lumen endotracheal tube to achieve one-lung ventilation to perform thoracoscopic operation in patients in whom placement of the double-lumen tube failed and difficult intubation is predicted. The bronchial blocker tube was placed into the aimed bronchus under the bronchoscopic vision and the cuff of the blocker was inflated to achieve one-lung ventilation. In all of the 4 patients, the bronchial blocker could be inserted and placed safely, quickly, and exactly under the fiberoptic flexible bronchoscopic vision to perform thoracoscopic operation without any complications. The new bronchial blocker tube through the indwelling endotracheal tube may have advantages in situations where placement of double-lumen endotracheal tubes is technically impossible or inappropriate. The use of the new bronchial blocker tube will, however, require careful evaluation in larger series.     

One-lung ventilation using a new original connector: with a bronchial blocker and a single lumen tracheal tube

We experienced 22 consecutive anaesthetic managements requiring one-lung ventilation for thoracotomy. We used our original connector, which enabled us to insert a bronchial blocker cut from Univent tube and fibreoptic bronchoscope into the single lumen tracheal tube without air leakage and instability. The bronchial blocker was easily introduced into the mainstem bronchus of the non-dependent lung. The pulmonary alveoli were well collapsed through air-vent inside the bronchial blocker, and we could offer good surgical field. When one-lung ventilation was finished during surgery, we removed the bronchial blocker with connector, and could insert a larger fibreoptic bronchoscope and a suction catheter into the single lumen tracheal tube. We could detach or exchange the bronchial blocker, when they are not functioning well. This method was excellent in the airway management for usual thoracotomy.     

Difficulty in one-lung ventilation reveals tracheobronchial anomaly

A 57-year-old man with carcinoma of the esophagus was scheduled for a subtotal esophagectomy. We used a bronchial blocker tube to perform one-lung ventilation (OLV). But the OLV was not feasible because of a tracheobronchial anomaly of the right superior lobe bronchus. We replaced the bronchial blocker tube with a standard double lumen tube, and the OLV thus became complete. When we cannot perform a complete OLV with a bronchial blocker tube, we should consider the possibility of a tracheobronchial anomaly. When one is found in the right superior lobe bronchus, we should use a standard double lumen tube to perform the OLV.     

Three-dimensional CT image analysis of a tracheal bronchus in a patient undergoing cardiac surgery with one-lung ventilation

The incidence of a tracheal bronchus—that is, a congenitally abnormal bronchus originating from the trachea or main bronchi–is 0.1%–2%. Serious hypoxia and atelectasis can develop in such patients with intubation and one-lung ventilation. We experienced a remarkable decrease in peripheral oxygen saturation () and a rise in airway pressure during placement of a double-lumen endobronchial tube in a patient with patent ductus arteriosus and tracheal bronchus. Substitution of the double-lumen tube with a bronchial blocker tube provided secure isolation of the lung intraoperatively. A type I tracheal bronchus and segmental tracheal stenosis were identified on postoperative three-dimensional (3D) computed tomographic (CT) images. Preoperative examination of chest X-rays, CT images, and preoperative tracheal 3D images should preempt such complications and assist in securing safe and optimal one-lung ventilation.     

Difficulty in placement of a left-sided double-lumen tube due to aberrant tracheobronchial anatomy

A rare case of a tracheal bronchus coexisting with a left-shifted carina and an acute angle of left main bronchus is presented. A 66 year old man with a history of colon cancer was scheduled for right thoracoscopic pericardial window due to recurrent pericardial effusion. After induction of anesthesia, the trachea was intubated using a 39-French, left-sided double lumen tube (DLT); the DLT was positioned with fiberoptic bronchoscopic guidance. Significantly high airway pressure was noticed as we initiated one-lung ventilation after the patient was positioned in the left lateral decubitus position. While repositioning the DLT, we found an aberrant tracheal bronchus. Although multiple attempts were made to adjust the DLT so as to achieve lung isolation, we could not place the DLT in the appropriate position due to abnormal and distorted anatomy. Lung isolation was unsuccessful; both lungs were carefully ventilated with small tidal volumes.     

Single lung ventilation in children using a new paediatric bronchial blocker

As video-assisted thoracoscopic surgery has become more common in paediatric patients, the use of single lung ventilation in children has also increased. Single lung ventilation in young children is performed by either advancing a tracheal tube into the mainstem bronchus opposite the side of surgery or by positioning a bronchial blocker into the mainstem bronchus on the operative side. Techniques for placing a variety of bronchial blockers outside the tracheal tube have been described. We describe a technique for placement of a new bronchial blocker through an indwelling tracheal tube using a multiport adaptor and a fibreoptic bronchoscope.     

Accidental fracture of the tip of the Coopdech bronchial blocker during insertion for one lung ventilation

Purpose

The distal tip of a Coopdech bronchial blocker has a preformed angulation to aid placement in the desired bronchus. We report two cases wherein this design may have resulted in distal tip fracture due to entanglement at the level of the Murphy’s eye of the endotracheal tube or at the carina.

Clinical features

A 49-yr-old female had a Coopdech bronchial blocker inserted into her right main bronchus for video-assisted thoracoscopic (VAT) lung biopsy. Resistance was encountered on its insertion, followed by confirmation of its position by fibreoptic bronchoscopy. As lung isolation was inadequate, bronchoscopy was repeated during surgery. This showed fracture of the blocker tip that required patient repositioning and insertion of another blocker. In a second incident, a bronchial blocker was inserted into the right main bronchus of a 19-yr-old male for VAT bullectomy. This procedure was performed under continuous fibreoptic guidance. Nevertheless, it was difficult to pass the blocker tip beyond the Murphy’s eye of the endotracheal tube, as repeated attempts resulted in its entanglement and fracture. Another blocker was inserted by maneuvering the tip beyond the Murphy’s eye.

Conclusion

The preformed tip of the Coopdech bronchial blocker can be damaged at the Murphy’s eye of the endotracheal tube or at the carina. This can result in tip fracture, especially during insertion into the right main bronchus. Maneuvering the tip away from the Murphy’s eye can circumvent this problem. Continuous bronchoscopic guidance should be used as recommended by the manufacturer.     

Imaging aid for thoracic surgery: multidetector-row computed tomography evaluation of the tracheobronchial structure and bronchial tube selection for one-lung anesthesia

Objective  The tracheobronchial structures were evaluated by multidetector-row computed tomography (MDCT), which provided imaging information for one-lung anesthesia during thoracic surgery. Methods  The subjects consisted of 100 patients. Three-dimensional (3D) images of the tracheobronchial structures and the bronchial tubes were created. Results  Individual differences were found in the tracheobronchial structures in 100 patients. The length and the diameter of the right main bronchus were measured with 3D images and were not related to the patient’s physical appearance, such as body height. Problematic intubation cases included a short right main bronchus <10 mm, an anomaly of the right bronchus, and tracheal stenosis. Conclusion  The 3D images demonstrated problematic areas of the tracheobronchial structure and helped the anesthesiologists select the most appropriate bronchial tube suitable for the tracheobronchial structure variations. Therefore, this technique is considered to contribute to safer performance of one-lung anesthesia. Presented at the 60th Annual Scientific Meeting of the Japanese Association for Thoracic Surgery.     

Airway obstruction during one-lung ventilation using a bronchial blocker and a tracheostomy tube

We describe our experience with a 60-year-old man who had severe airway obstruction during one-lung ventilation with the tracheostomy tube using a bronchial blocker. The blocker, deriving from Univent tube, was passed through the tracheostomy tube and placed in the right main bronchus. We checked that the blocker was in appropriate place with a bronchofiberscope and obtained good one-lung ventilation with the patient in the left lateral position. However, just after the start of operation, when the skin was incised, sever hypoxia and resultant bradycardia and hypotension occurred, probably because of not only malposition of blocker but also atelectasis in the upper lobe of the dependent lung by secretion.     

Bougienage and balloon dilation using a conventional tracheal tube for tracheobronchial stenosis before stent placement

In order to achieve urgent restoration of the airways in tracheobronchial stenosis and to make stent placement simpler and safer, we developed a method that allows combined bougienage and balloon dilation via the use of a conventional tracheal tube. Fifteen patients with tracheobronchial stenosis underwent bougienage and balloon dilation using a tracheal tube with a cuff attached, inserted via a tracheostomy, before stent placement. The conventional tracheal tube was inserted via a tracheostomy, the cuff was expanded at the stenotic site, and the tube was fixed to the tracheostomy and left in place for a few days until sufficient dilation was achieved. This procedure was conducted on the trachea in 10 patients, the left main bronchus in three patients, and the right main bronchus in two patients. In all patients, the procedure immediately relieved the obstructive symptoms and dilated the stenosis sufficiently. Thereafter, Dumon stents were inserted in 10 patients, dynamic stents in four patients, and an expandable metallic stent in one patient. The stents were introduced easily with no other dilation procedure after a mean of 5 days from the start of the procedure. For tracheobronchial stenosis, bougienage and balloon dilation using a tracheal tube with an integral cuff via a tracheostomy is a simple and safe method for achieving both urgent relief of airway stenosis and dilation before stent placement. Received: 20 May 1999/Accepted: 17 December 1999/Online publication: 25 April 2000     

Computed tomography-based tracheobronchial image reconstruction allows selection of the individually appropriate double-lumen tube size.

OBJECTIVES: To determine whether individualized selection of double-lumen tubes or alternatives based on three-dimensional reconstruction of the tracheobronchial image from routine preoperative computed tomography (CT) scans leads to clinically appropriate choices. DESIGN: Prospective observational study; comparison to historic controls. SETTING: Anesthesia and radiology facilities of a university medical center. PARTICIPANTS: Forty-nine patients undergoing thoracic surgery requiring one-lung ventilation. INTERVENTIONS: Three-dimensional image reconstruction of individual tracheobronchial anatomy was performed from routine preoperative spiral CT scans as well as from scans of five left-sided and four right-sided double-lumen tubes. Results of image-based tube size selection were compared with literature recommendations. Prospectively, individualized tube selection was performed by superimposition of printed transparencies of tubes over the tracheobronchial system and was validated using bronchoscopic and clinical criteria (n = 24). MEASUREMENTS AND MAIN RESULTS: Three-dimensional reconstruction visualized individual anatomy with good accuracy and resolution. Correlations between patient morphology and tracheobronchial dimensions were weak (height versus mainstem bronchial diameters: r < 0.50). In 11 of 48 patients (23%). CT-fitted double-lumen tube sizes would have differed from a conventional height-based and gender-based selection. Individual, prospective, CT-based double-lumen tube selection was associated with (1) good fit and positioning confirmed by fiberoptic bronchoscopy, (2) adequate bronchial cuff seal volumes, (3) complete lung separation, and (4) oxygenation and ventilation parameters during one-lung ventilation similar to those with conventional size selection. In one patient, three-dimensional CT study allowed noninvasive evaluation of a tracheal stenosis precluding double-lumen tube placement. CONCLUSION: Individualized selection of double-lumen tube size using CT-based reconstructions of tracheobronchial anatomy leads to clinically appropriate choices. Risks resulting from variations in tracheobronchial morphology are recognized in advance.     

Sequential silastic and expandable metal stenting for tracheobronchial strictures.

The risks and limitations of surgical resection and reconstruction for tracheobronchial strictures demand consideration of other therapeutic options that can alleviate the distressing symptoms of tracheobronchial obstruction. One alternative is to stent the obstructive lesion until surgical advances allow primary reconstruction or replacement of the critically diseased airway or until an ideal endoprosthesis is found. The latter requires uniformity in the distribution of expansile force, conformability and stability within the tracheobronchial tree, and ease of placement. Here we report our experience with the placement of expandable metal stents (Wall-stent) used in conjunction with our Silastic (Dow Corning) endobronchial stents in 5 patients with recurrent tracheal or bronchial strictures. The major site of obstruction was the trachea in 1 patient and a main bronchus or both bronchi in 4 patients. Three patients had a benign bronchial stricture (anastomotic stricture in 2, idiopathic polychondritis in 1), and 2 patients had an obstructive airway neoplasm. Placement of the stents was performed under rigid bronchoscopic guidance. We had no complications from our technique of stenting. There has been no evidence of restenosis or occlusion within the stented segment of airway. The complementary use of expandable metal and Silastic endobronchial stents provided symptomatic and functional improvement in our patients during follow-up ranging from 5 to 24 months.     

Right bronchial intubation using a left-sided double-lumen tube in a patient with situs inversus

A 74-year-old man was scheduled for resection of a pulmonary tumor in the left upper lobe. He had asymptomatic complete situs inversus, and therefore his left lung had three lobes whereas his right lung had two. Since the tumor had been growing through the left upper bronchus into the left main bronchus, it seemed that the use of a bronchial blocker in the left bronchus should be avoided. A 37-Fr left-sided double-lumen tube was rotated in the opposite direction (clockwise) and advanced easily into the right (anatomically left) main bronchus under fiberoptic guidance. One lung ventilation during the operation was performed successfully and there was no postoperative airway complication. Several ways of achieving one lung ventilation in patients with situs inversus are discussed in this report. The use of a bronchial blocker should be considered first-choice, but sometimes its use is inappropriate as in this case. Commercially available double-lumen tubes are not intended for use in cases of situs inversus. If a double-lumen tube is desired, intentional right bronchial insertion of a left-sided double-lumen tube seems to be an easy and reliable option.     

Selective right bronchial intubation using tracheal tubes under fibroscopic guidance]

We have evaluated the technique of right bronchial intubation for selective right pulmonary ventilation using one lumen tracheal tubes as an alternative to double lumen tubes. We studied 20 patients ASA II-III with a relatively preserved pulmonary function who were programmed for left thoracotomy. We used Shiley nr. 9 or Mallinckrodt nr. 11 tubes. After endotracheal intubation the tube was blindly advanced to the main right bronchus. The position of the tube was assessed by auscultation and it was verified and modified, if necessary, by fibroscopic visualization. The tube was advanced in such a way that Murphy's hole of the endotracheal tube remained in front of the exit of the right superior lobar bronchus. In three patients (15%) blinded placement of the tube was appropriate and in 4 patients (20%) fibroscopic replacement of the tube was required. In the remaining 13 patients (65%) placement of the tracheal tube was considered incorrect: tube rotation in 7 cases, upper placement of the Murphy's hole with respect to the origin of the superior lobar bronchus in 4 cases, and excessive distal placement of Murphy's hole with respect to the superior lobar bronchus in 2 patients. Complications related with the incorrect position of the tube were: leaking of gas into the left bronchium in 5 patients (25%), displacement of the tracheal tube into the main left bronchus requiring withdrawal of the tube to the trachea in one case (5%), hypoxemia (saturation of O2 lower than 90%) in spite of ventilation with FiO2 = 1 in two patients, moderate hypercapnia in three cases, and atelectasis of the right superior lobe during the postoperative phase in three patients (15%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Failure to provide adequate one-lung ventilation with a conventional endotracheal tube using a transbronchial approach: a case report

PURPOSE: To report a case where failure to provide adequate one-lung ventilation during transbronchial intubation resulted in a potentially fatal mishap. CLINICAL FEATURES: A 61-yr-old male was scheduled for right lung lobectomy. Induction of general anesthesia was smooth, and subsequent resection of the right middle lobe was uneventful. Difficult ventilation with high airway pressure and poor right lung re-expansion prompted repositioning of the double-lumen tube after the resection. The removal of the right middle bronchial clamp and associated right mainstem manipulation caused flooding of blood into the double-lumen tube. Mindful of the risk of fatal desaturation, the surgeon immediately opened the right mainstem bronchus and cleared the airway. Confirmation of a displaced double-lumen tube prompted the surgeon to insert an endotracheal tube (internal diameter 5.5 mm) from the opened right mainstem bronchus to the left main bronchus to maintain oxygenation. Although bronchoscopic examination confirmed proper location of the reinserted tube, oxygen saturation was not sufficiently (60%) improved. Another 5.5-mm endotracheal tube was inserted, with its tip inside the right upper bronchiole, for further ventilatory support. Finally, a rise in SpO2 to around 95% allowed completion of surgery. CONCLUSIONS: Displacement of the double-lumen endobronchial tube and flooding with clotted blood will result in potentially fatal ventilation difficulties. Repositioning and cleaning of the tube must be prompt to reduce the risk of hypoxemia. Where emergency single-lung ventilation is required, we suggest the utilization of a modified single-lumen endotracheal tube with a shortened cuff-tip length to ensure an adequate margin of safety for mainstem bronchus intubation.     

Case report: pulmonary soiling after one-lung ventilation with a bronchial blocker

PURPOSE: To report a case of pulmonary soiling of the dependent and of the non-dependent remaining lung when a Univent tube was used to achieve one-lung ventilation (OLV). CLINICAL FEATURES: A 61-yr-old, 158-cm, 61-kg woman was scheduled for the resection of a lung cancer in the left lower lobe. An internal diameter 7.0-mm Univent tube was inserted under direct laryngoscopy and positioned via fibreoptic bronchoscopy. Prior to termination of OLV, there was no discharge through the blocker's lumen, aspirated just before deflating the cuff. As soon as the cuff was deflated, however, abundant blood-tinged secretions were aspirated. At the end of the operation, the chest radiograph showed haziness in the right upper lobe and in the remaining left upper lobe. The ineffective removal of secretions through the lumen of the blocker may be one of its main disadvantages. The bronchial blocker is always placed in the non-dependent bronchus for OLV, which may increase the probability of contaminating the dependent lung. Before deflating the blocker, we recommend the steep Trendelenburg position and the presence of a fibreoptic bronchoscope with a suction port at the tracheal carina to prevent overflow of secretions and soiling of the dependent lung. CONCLUSION: Whenever a bronchial blocker is used for OLV, we should be cautious about the possibility that secretions accumulated distal to the blocker may contaminate the dependent or the non-dependent remaining lung.     

Clinical experience using percutaneous cardiopulmonary support system for stent replacement

Three cases of tracheal or mein bronchus stenoses were treated using percutaneous cardiopulmonary support system (PCPS). Case 1 was a 63-year-old male admitted for dyspnea due to stenotic trachea with primary lung cancer invasion. YAG-laser operation and Dynamic stent was inserted to the trachea using PCPS. Case 2 was a 74-year-old male admitted for dyspnea due to stenotic right mein bronchus with primary lung cancer invasion. Dumon Y stent was inserted to the right mein bronchus using PCPS. Case 3 was 57-year-old male admitted for dyspnea due to stenotic trachea and occluded left mein bronchus with ischemic change after primary esophageal cancer operation. Dynamic stent was inserted to the trachea and left mein bronchus using PCPS. Tracheal and mein bronchus stenoses the trachea of all was dilated after placement of stent. These three cases had no complications during or after these treatment. These results indicated that using PCPS was a very useful, powerful and satisfactory method in the treatment of tracheal or mein bronchus stenoses during the lack of lung ventilation.     

A coaxial technique for facilitating one-lung ventilation

A tube for bronchial intubation is described. A long (48 cm), small bore (5.0 mm internal diameter), cuffed, bronchial plastic tube is inserted coaxially within a large bore tracheal tube (10.0 mm) used for ventilation. The inner tube is designed primarily as a blocker to be inserted with a fibreoptic or optical bronchoscope, but can be effected blindly with a stylet. Several methods of inserting the inner tube and ensuring correct placement were used in 10 males undergoing thoracic surgery. If the bronchial cuff is inflated the tube can be used either as a blocker or as a conduit for suction and conventional and differential ventilatory techniques. Early clinical experience suggests that the technique is an alternative method of facilitating one-lung ventilation.     

Tracheobronchial injury

We studied 6 cases of tracheobronchial injury due to the blunt chest truma in our department. All patients were male of 19 to 60 years of age. Injured sites were main bronchus in 2, tracheobronchial portion in 2, cervical trachea and main bronchus in 1, cervical trachea in 1. In a case of cervical tracheal injury and 2 cases of tracheobronchial injury, emergent operation was performed on the day of accident. Other cases with the main bronchial injury underwent conservative treatment at first, but subsequent bronchoplasty was necessary for them due to the bronchial stenosis. After the surgery for 2 cases of tracheobronchial injury, mechanical ventilation with double lumen tube was continued to reduce the airway pressure for the anastomotic sites. In conclusion, early surgical treatment is recommended for the airway injury and the respiratory management using double lumen tube after surgery may be helpful in preventing trouble at the anastomosis.