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From the Department of Anesthesia, Stanford University School of Medicine, Stanford, California.
Address correspondence to Dr. Jay Brodsky, MD, Department of Anesthesia, H3580, Stanford University Medical Center, Stanford, CA 94305. Address e-mail to Jbrodsky{at}stanford.edu.
Abstract
A patient with a prior left pneumonectomy required surgical drainage of a right upper lobe aspergilloma. A left double-lumen endobronchial tube was placed in the right bronchus intermedius, isolating the right upper lobe while allowing ventilation of the right middle and lower lobes.
Pulmonary upper lobe fibrobullous disease is a complication of advanced ankylosing spondylitis (AS) (1). The medical treatment of AS predisposes patients to pulmonary aspergillosis. Since standard antifungal medical therapy for aspergillosis in an immunocompromised patient results in <5% survival (2), surgery remains the only effective treatment (3–5). Resection or drainage of infected lung can endanger healthy tissue so lung isolation is indicated (6). We describe the management of a patient with AS who presented with a right upper-lobe aspergilloma after left pneumonectomy.
CASE REPORT
A 50-yr-old man with AS was scheduled for drainage of a right upper lobe apical aspergilloma. The patient had a history of treatment with intermittent steroids and Infliximab (7). Eight years earlier, he had a left upper lobectomy for an aspergilloma. Two years later, he underwent completion left pneumonectomy for an aspergilloma in his left lower lobe. Subsequently, he experienced low-grade fever and intermittent hemoptysis. Chest computed tomography demonstrated right apical pleural thickening with a crescentric cavitary lesion suggestive for aspergilloma (Fig. 1). He was scheduled for cavernostomy and marsupialization of the cavity via a limited right anterior thoracotomy (8,9).
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After topical anesthesia of the patient's airway with 4% lidocaine, a 7.0 mm endotracheal tube (ETT) was advanced into the trachea over a fiberoptic bronchoscope. General anesthesia was then induced with propofol and fentanyl, with vecuronium for muscle relaxation. A long Cook Tube-Exchange-Catheter (Cook Critical Care, Bloomington, IN) was placed through the ETT and then the ETT was removed, and a 37 French left double-lumen endobronchial tube (DLT) (BronchoCath®, Mallinckrodt Medical, Athlone, Ireland) was guided over the tube exchanger into the trachea. Under direct fiberoptic bronchoscopic vision, the DLT was advanced until the bronchial cuff's proximal edge was just distal to the orifice of the right upper lobe bronchus (Fig. 2). The bronchial and tracheal cuffs were inflated, and the middle and lower lobes were ventilated through the bronchial lumen with an Fio2 = 1.0 with a tidal volume of 550 mL at a rate of 10/min. Peak inspiratory pressure was 32 mm Hg.
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At the completion of surgery, direct intercostal nerve blocks at four levels were performed. The patient's airway was extubated in the operating room after muscle relaxants were reversed and he was fully awake. He was transferred to the intensive care unit. Initial postoperative recovery was complicated by an air leak and drowsiness secondary to hypercarbia. He was discharged from the intensive care unit 48 h later, but his respiratory status soon worsened and he was readmitted to the intensive care unit. The following day he developed multiorgan failure, and after discussion with his family, life-support was withdrawn and he died shortly thereafter.
DISCUSSION
It is not uncommon for a patient with previous pulmonary surgery to present with pathology in the other lung (10). This is especially true for aspergillosis, where surgery is the mainstay for treatment (11,12). Although cavernostomy is associated with a high mortality and morbidity, it is the only procedure available for patients unfit for further lung resection.
To provide suitable surgical conditions while isolating the right upper lobe, we considered several options. A bronchial blocker positioned at the orifice to the right upper-lobe bronchus through a standard ETT (13) or with a Univent® tube (14) could have isolated the aspergilloma and allowed ventilation of the remaining lung (15). However, infected material behind the blocker would enter the healthy lung once the blocker balloon was deflated. Intraoperative blocker dislodgement would have made ventilation difficult or impossible and would have exposed the entire lung to contamination. Since the cuff of a standard ETT is wide (2.5 cm) and the distance from its proximal edge to the tube tip is 5.5 cm, an ETT could not be positioned beyond the right upper-lobe bronchus without entering either the lower or middle lobe bronchus (16). The angulated bronchial cuff of a right DLT would also prevent positioning it below the orifice of the right upper lobe without the tube entering the middle or lower bronchus.
A small (37 French) left DLT was intentionally chosen to allow us to advance it deeper into the airway. The distance from the proximal edge of the bronchial cuff to the tube tip is only 2.5 cm. This allowed isolation of the right upper lobe and unobstructed ventilation to both the right middle and lower lobes. Material entering the airway from the right upper lobe was trapped between the inflated bronchial and tracheal cuffs where it could be removed by a suction catheter passed down the tracheal lumen.
For the increasing number of patients coming for lung resection after previous pulmonary surgery, innovative means of isolating the operated lung must be considered. This case illustrates one such approach.
Footnotes
Accepted for publication April 19, 2007.
REFERENCES
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