Anesth Analg 2006;102:85-86
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000181318.71935.9B
PEDIATRIC ANESTHESIA
Relief of Bronchial Obstruction Using a Fogarty® Catheter in a Patient with Bronchomalacia
Masaaki Tanino, MD,
Mamoru Takeuchi, MD, PhD,
Tatsuo Iwasaki, MD,
Yuichiro Toda, MD,
Katsunori Ohe, MD, PhD, and
Kiyoshi Morita, MD, PhD
Department of Anesthesiology and Resuscitology, Okayama University Medical School, Okayama, Japan
Address correspondence and reprint requests to Mamoru Takeuchi, MD, Department of Anesthesiology, Okayama University Medical School, 2–5–1 Shikata-cho, Okayama City, 700–8558, Japan. Address e-mail to take0412{at}cc.okayama-u.ac.jp.
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Abstract
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Tracheobronchomalacia can be latent without showing any clinical manifestations and may be incidentally found during anesthesia. In such cases, hypoxia may occur during anesthesia. We experienced obstruction of the left main bronchus caused by bronchomalacia that was incidentally found during open-heart surgery in a 4-yr-old patient. We could not reopen the airway by routine techniques, such as positive pressure, and had great difficulty in weaning the patient from cardiopulmonary bypass. The use of a Fogarty® catheter allowed the relief of airway obstruction and weaning from cardiopulmonary bypass.
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Introduction
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Tracheobronchomalacia can be latent without showing any clinical manifestations and may be incidentally found during anesthesia (1–3). We report a case of unexpected bronchomalacia that caused obstruction of the left main bronchus during open-heart surgery in a child. Several previous studies reported that airway obstruction caused by tracheobronchomalacia could be relieved by positive-pressure ventilation (2,4). In our case, however, positive-pressure ventilation failed to reopen the obstructed airway, and thus weaning from cardiopulmonary bypass (CPB) was very difficult. The use of a Fogarty® catheter allowed successful opening of the obstructed airway.
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Case Report
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A 4-yr-old boy (height, 97 cm; weight, 15 kg) had a ventricular septal defect, mitral stenosis, and subaortic stenosis. He underwent pulmonary artery banding at 6 mo of age and atrial septectomy at 20 mo of age. The patient was able to undertake normal daily activities. His arterial oxygen saturation (Spo2) was 85% during room air breathing.
During the current admission, a bidirectional Glenn and Damus-Kay-Stansel operation was conducted. Midazolam (5 mg orally) was given for premedication. General anesthesia was induced with sevoflurane and nitrous oxide in oxygen. Nasotracheal intubation (internal diameter 4.5 mm; fixed to a depth of 5 cm from the vocal cords) was performed after administration of fentanyl and pancuronium IV, followed by insertion of a probe for transesophageal echocardiography (TEE) with an 8.1-mm diameter tip. Anesthesia was maintained with fentanyl and isoflurane. Before starting surgery, 400 mg of methylprednisolone was administered. The endotracheal tube (ETT) was exposed to atmosphere during CPB. The surgical procedure was performed uneventfully, and an attempt was made to wean from CPB at 98 min; however, the first attempt failed because of the ensuing severe decrease in Spo2. Thus, CPB was re-established. We tried again to wean from CPB but found that the left lung was not inflated despite positive pressure ventilation. The TEE probe was removed and the third CPB was established. Bronchoscopy revealed an obstruction immediately under the branch of the left main bronchus. We first thought that the obstruction was a result of mechanical compression against the outside of the bronchus. Thus, we asked the surgeon to remove any possible mechanical compression, such as the neighboring left pulmonary artery. However, this did not have any effect. This failure led us to suspect bronchomalacia, and we tried to reopen the airway by manual ventilation using a high inspiratory pressure (>40 cm H2O). However, this also failed to relieve the obstruction. We thought that bronchospasm and/or bronchial edema might be contributing to the difficulty to reopen the obstruction. Accordingly, bolus IV doses of 500 mg methylprednisolone and 125 mg aminophylline were given followed by continuous IV aminophylline drip. Using a fiberoptic bronchoscope (BP1–255; Mitsubishi Cable Industries, Tokyo, Japan) with a 2.65-mm diameter tip, we then tried to advance a 3F Fogarty® catheter (2 mL liquid, 0.6 mL air) with the balloon deflated, through the ETT and into the obstructed area under direct observation. The tip of the catheter with the balloon deflated was carefully passed within the narrow segment and the balloon was then inflated by 0.6 mL air to dilate the collapsed bronchus with intermittent positive-pressure ventilation (IPPV). This procedure was repeated carefully several times to reopen the bronchus. Immediately thereafter, we manually ventilated the lungs with high inspiratory pressure and confirmed inflation of the left lung. The third attempt of weaning from CPB was successful. Thereafter, oxygenation gradually improved and Spo2 recovered to >70% under 100% inspired oxygen concentration.
After surgery, the patient was admitted to the intensive care unit (ICU) and the lungs were mechanically ventilated using a positive end-expiratory pressure of 7 cm H2O. The final diagnosis was bronchomalacia as confirmed by fiberoptic bronchoscopy before removal of the ETT on postoperative day (POD) 2. The patient was discharged from the ICU on POD 7 and from the hospital on POD 21.
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Discussion
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Several reports have described cases of airway obstruction with hypoxemia during anesthesia resulting from tracheobronchomalacia (1–4). In these reports, airway obstruction was overcome by positive-pressure ventilation after endotracheal intubation (2,4) or by surgical removal of mechanical compression against the exterior wall of the bronchus (3). However, in our patient, neither positive-pressure ventilation nor surgical removal of mechanical compression against the outside of the bronchus was effective.
Various factors may have contributed to airway collapse in our patient. One factor was failure to apply continuous positive airway pressure (CPAP) during CPB, which could have had prevented airway collapse. During normal breathing, intrapleural pressure is always slightly more negative than intratracheal pressure and thus the airway remains open during expiration (5,6). However, the intrapleural pressure and alveolar pressure markedly increase during forced expiration. Because the pressure decreases along the airway in the direction of the thoracic outlet, the trachea is subjected to a compressing transmural pressure that increases towards the thoracic outlet (5,6). When positive pressure is applied to the airway during forced expiration, the gradient between intrathoracic and intratracheal pressures is reduced; therefore, tracheal collapse is, theoretically, less likely to occur during controlled ventilation than during spontaneous breathing. In fact, several groups have reported that CPAP, with or without IPPV, alleviates tracheal collapse (6–9). The second factor is specifically related to CPB. CPB for >90 min could cause airway edema, thus resulting in airway narrowing. The third factor is secretions from the airway epithelium that could increase the internal tension of the collapsed bronchial wall. Furthermore, the TEE probe could mechanically compress the exterior wall of the bronchus because of the juxtaposition of the left main bronchus to the esophagus. Under these conditions, the bronchus is exposed to external and internal forces that tend to reduce the size of its lumen, resulting in the collapse of the cavity.
The use of the Fogarty® catheter allowed us to reopen the airway in our patient. The Fogarty® catheter physically provided space through the narrow bronchial segment, which allowed sufficient airway pressure to keep the bronchus open. The results suggest the effectiveness of the Fogarty® catheter for management of airway obstruction that could not be reopened by standard techniques.
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Footnotes
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Accepted for publication July 22, 2005.
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References
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Abstract
Introduction
