Anesth Analg 2005;101:1554-1555
© 2005 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000180834.13549.E4
GENERAL ARTICLES
Hypoxemia During One-Lung Ventilation: Jet Ventilation of the Middle and Lower Lobes During Right Upper Lobe Sleeve Resection
Ju-Mei Ng, FANZCA
Department of Anaesthesia & Surgical Intensive Care, Singapore General Hospital, Singapore
Address correspondence and reprint requests to J. M. Ng, FANZCA, Department of Anesthesia & Surgical Intensive Care, Singapore General Hospital, Outram Road, Singapore 169608, Republic of Singapore. Address electronic mail to gannjm{at}sgh.com.sg.
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Abstract
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A 64-yr-old man underwent right thoracotomy and upper lobectomy for lung carcinoma. Hypoxemia on one-lung ventilation was being managed with continuous positive airway pressure to the nondependent lung when a sleeve resection had to be performed. As this positive airway pressure would no longer be maintained with the bronchus open, an alternate method of oxygenation was necessary. This report describes the successful use of jet ventilation via an airway exchange catheter placed in the bronchus intermedius through the tracheal lumen of a left-sided double-lumen endobronchial tube. Oxygenation was maintained and surgical access was good during the 15-min resection.
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Introduction
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Predicting which patients will desaturate during one-lung ventilation (OLV) is difficult (1). Different methods of improving arterial oxygenation on OLV include intermittent inflation of the collapsed lung with oxygen (2), administration of IV almitrine (3) nitric oxide (4) or both (5), lung recruitment (6), and application of continuous positive airway pressure (CPAP) to the nondependent lung (7,8). This case report describes the use of CPAP to the right lung, which was converted to high-frequency jet ventilation (HFJV) of the middle and lower lobes during unexpected right upper lobe sleeve resection.
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Case Report
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A 64-yr old man with lung carcinoma presented for right upper lobectomy. He had a 40 pack-year smoking history and single vessel coronary artery disease. Preoperative arterial blood gases (Fio2, 0.21) showed a Pao2 of 91 mm Hg and Paco2 of 39 mm Hg. His forced expiratory volume in 1 s was 1.43 L and forced vital capacity was 2.58 L. An epidural catheter was placed at T5-6 level under local anesthesia, and induction of anesthesia was uneventful. His trachea was intubated with a left-sided 39F double-lumen tube (DLT). Correct position and depth of the DLT in the left main bronchus was verified fiberoptically in both supine and left lateral decubitus positions. The patient received a 6 mL epidural bolus of 0.25% bupivacaine followed by an infusion of 0.2% ropivacaine + fentanyl 2 µg/mL at 6 mL/h. Anesthesia was maintained with desflurane (end-tidal concentration 5.0%–6.0%) in 100% oxygen and atracurium at 20 mg/h. A muscle-sparing thoracotomy incision was made over the right fifth intercostal space.
Ten minutes into OLV, oxygen saturation (Sao2) decreased from 97%–98% on two-lung ventilation to 84%–85%. He was ventilated with tidal volume 8 mL/kg and respiratory rate of 12 breaths/min, and peak airway pressures were 28 cm H2O. Urgent bronchoscopy showed good positioning of the DLT and there was good air entry in the dependent lung with no adventitious sounds on auscultation. Positive end-expiratory pressure of 5 cm H2O was applied to the dependent lung with no improvement. Increasing the positive end-expiratory pressure to 7.5 cm H2O worsened the Sao2. With 5 cm H2O of dependent lung positive end-expiratory pressure and 5 cm H2O of nondependent lung CPAP, Sao2 improved to 95%–96%. CPAP was decreased to 2 cm H2O and Sao2 remained at 94%–95%. Operative conditions were satisfactory. Unfortunately, to attain tumor-free margins, a sleeve resection was necessary, and CPAP was no longer feasible. Discontinuation of CPAP resulted in desaturation within 5 min. An 11F 83-cm airway exchange catheter (C-CAE-11.0–83-DLT; Cook Inc, Bloomington, IN) was placed in the bronchus intermedius. As the catheter and fiberoptic bronchoscope were too large to be passed concurrently through the tracheal lumen of the DLT, the bronchoscope was first passed until its tip was at the distal bronchus intermedius. The marking at the proximal tracheal lumen was noted. With the bronchoscope withdrawn, the catheter was then inserted to this same distance through the tracheal lumen (Fig. 1). This allowed for HFJV of the middle and lower lobes with the bronchus open. The Monsoon Universal Jet Ventilator (v2.1e; Innovmedics Pte Ltd., Singapore) with a respiratory rate of 150 breaths/min, inspiratory time 30%, and driving pressure of 1 mbar was used. Sao2 immediately improved to 98%–99% and surgical exposure was adequate. Inflation of the middle and lower lobes was observed. HFJV was continued for 15 min until bronchial closure. CPAP with 2 cm H2O was then resumed until clamping of the supplying pulmonary artery and improvement in the Sao2.
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Figure 1. The airway exchange catheter in the bronchus intermedius. RUL = right upper lobe; RML = right middle lobe; RLL = right lower lobe.
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Discussion
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Although this patient had pathology in his nonventilated lung and an obstructive pattern on preoperative pulmonary function tests, he developed hypoxemia on OLV. His hypoxemia was corrected with application of CPAP to the nondependent lung. Unfortunately, a sleeve resection had to be performed and an alternate means of treating hypoxemia had to be formulated, as CPAP could no longer be maintained with the open bronchus exposed to atmospheric pressure. HFJV provides satisfactory oxygenation and good surgical access during OLV for thoracotomy (9–11), where it has been delivered via a DLT (9), a small uncuffed endobronchial tube (10), and the lumen of the bronchial blocker of a Univent tube (11). In this patient, selective HFJV to the right middle and lower lobes would be comparable to selective lobar collapse of the right upper lobe (12). This not only maintained oxygenation but also provided optimal surgical access by collapsing the right upper lobe. It was achieved, without manipulation of the patient’s DLT, by passing a catheter of adequate length such that its tip would lie well within the bronchus intermedius and beyond the surgical incision in the right main bronchus. Although the lower and middle lobes were inflated, there were minimal respiratory movements and with the right upper lobe collapsed, there was adequate surgical exposure and good operative conditions. Expiratory flow limitation leading to increased lung volume, especially in the context of chronic obstructive airway disease, is an eminent danger. Care was taken to ensure proper positioning of the catheter fiberoptically and the catheter secured to prevent distal migration into a single lobe, which would further increase the risk of barotrauma.
Although the use of a ventilating catheter passed into the distal bronchus for tracheal and carinal resection has been described, this case shows an adaptation; treatment of hypoxemia on OLV by placement in the bronchus intermedius. The indications for HFJV are expanded beyond ventilating both lungs or a single lung to that of ventilating 2 lobes during management of hypoxemia on OLV. For those without ready access to HFJV, an intermediate ventilation mode (e.g., low frequency jet ventilation with an injector) may be a viable option in a similar situation. This case demonstrates a novel way of managing hypoxia on OLV when the nondependent bronchus is open to the atmosphere.
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Footnotes
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Accepted for publication May 3, 2005.
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References
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Abstract
Introduction
