Anesth Analg 2008; 107:1644-1645
© 2008 International Anesthesia Research Society
doi: 10.1213/ane.0b013e31818479ac
CRITICAL CARE AND TRAUMA
Endobrochial Blockade Through a Tracheostomy Tube for Lung Isolation
George Vretzakis, MD, PhD*,
Elena Theodorou, MD*, and
Dimitrios Mikroulis, MD, PhD
From the *Department of Anesthesiology, University Hospital of Larissa, Greece; and Cardiothoracic Surgery Clinic, University Hospital of Alexandroupolis, Greece.
Address correspondence and reprint requests to Elena Theodorou, MD, Department of Anesthesiology, University Hospital of Larissa, Greece. Address e-mail to man.lena{at}g.mail.com.
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Abstract
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We present an alternative technique for one-lung ventilation as safe way of treating patients with tracheostomy using a fiberoptic bronchoscope and a Fogarty catheter.
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Introduction
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Lung isolation in patients with tracheostomy can be achieved by various methods, including replacement of the tracheostomy tube with a double-lumen endotracheal tube, by a single-lumen tube combined with a Fogarty catheter, or by a Univent tube. These techniques, either orally or through the tracheostomy site, require removal of the tracheostomy tube. Alternatively, leaving the tracheostomy tube in place, bronchial blockade can be performed with a Fogarty catheter passed between the vocal cords with the cuff of the tracheostomy tube temporarily deflated1 or via a fiberoptic bronchoscope port.2 We propose a simpler technique for single-lung ventilation in patients with tracheostomies which do not require any change in the ventilatory mode during bronchial blocker placement.
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Case Description
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A 47-yr-old man was transported to the operating room from the intensive care unit (ICU) for video-assisted thoracoscopic left pleural biopsy. Two and a half months previously, the patient was admitted to the ICU for respiratory insufficiency and cardiovascular instability with a body temperature of 38.9° and positive findings for pneumonia on the chest radiograph. On admission, he was cachectic with clinical findings of multiple mononeuritis. On the sixth day of hospitalization, a percutaneous tracheostomy tube was placed. After gradual improvement the patient was weaned from mechanical ventilatory support. During his stay and under intensive treatment, he underwent extensive imaging and laboratory tests with no result or clear diagnosis. When scheduled for the pleural biopsy, because of his neurological status he was capable of moving only his left upper limb. His body temperature was normal. He was breathing through a T-piece (Fio2 = 0.5, flow = 10 Lt/min) and was fed by a tube, taking only water per os with a syringe. He was receiving daily treatment with 1 g cyclophosphamide and 50 mg prednisolone.
General anesthesia was induced and maintained with sevoflurane and remifentanil. The patient's lungs were mechanically ventilated (Julian, Draeger, Germany) after the administration of cisatracurium for muscle relaxation. With a Bispectral Index value of around 40 (BIS/XP, Aspect Medical systems), a flexible 3.5 mm bronchoscope (Olympus, ENF/P3, Tokyo, Japan) was passed through the hole of the self-sealing diaphragm of an elbow-shaped connector of the tracheostomy. A 7F Fogarty catheter was also passed with a technique similar to the one we have already described (Fig. 1A).3 Under direct visualization, the Fogarty, used as a bronchial blocker, was guided to bypass the take-off into the left mainstem bronchus. The wire stylette was then removed and a three-way stopcock with a 5 mL syringe was connected to the embolectomy catheter. Fiberoptically visualized, the isolation of the left lung was achieved with the inflation of 3 mL of air. The bronchoscope was removed and single-lung ventilation was then successfully attempted. The patient's oxygen saturation decreased from 98% to 91% but it was increased to 96% with Fio2 = 1. Minute ventilation was also increased with proper adjustment of the ventilator to keep Paco2 within normal range. The operation proceeded uneventfully and 40 min later the patient was returned to the supine position with ventilation of both lungs. He awoke in the operating room and was transported to the ICU breathing through the T-piece with a continuous infusion of remifentanil. Two days later, he was re-anesthetized for biopsy of the left kidney. Unfortunately, he died in the ICU 1 month later.
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Figure 1. Schematic presentation of the introduction of the Fogarty catheter and the bronchoscope into the tracheostomy tube: A, sealed connector; B, sealed connector with self-made diaphragm after the removal of the bronchoscope.
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DISCUSSION
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Techniques allowing lung isolation in patients with tracheostomy are advantageous, when removal of the tube and disturbance to the site are avoided, ventilation is uninterrupted, bacterial migration is also avoided and control with a fiberoptic bronchoscope is permitted. Our method is simple and easily provides single-lung ventilation. In case of thicker bronchoscopes, an elastic, cone-shaped, self-made, sealing diaphragm can be provided from the embolus of a 2.5 or 5 mL syringe. Aseptically, a hole is made and the Fogarty passes through it. Then, the diaphragm of the connector is unlocked and both the bronchoscope and the Fogarty pass to the trachea (Fig. 1B). After lung isolation and bronchoscope removal, the connector is sealed with the new diaphragm until the termination of the procedure. We have also used this technique (Fig. 2) when a pediatric bronchoscope was not available and the patient's condition allowed a small but necessary period of apnea.
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Figure 2. One-lung ventilation achieved with a Fogarty as blocker through a tracheostomy tube. The connector is sealed as it is shown in Figure 1B (from our patients).
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Footnotes
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Accepted for publication April 24, 2008.
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REFERENCES
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- Veit A, Allen B. Single-lung ventilation in a patient with a freshly placed percutaneous tracheostomy. Anesth Analg 1996;82:1292–3[Web of Science][Medline]
- Oxorn DC, Pagliarello G. Traumatic rupture of the thoracic aorta: diagnosis on fiberoptic bronchoscopy. Can J Anaesth 1992;39: 296–8[Web of Science][Medline]
- Vretzakis G, Dragoumanis C, Papaziogas B, Mikroulis D. Improved oxygenation during one-lung ventilation achieved with an embolectomy catheter acting as a selective lobar endobronchial blocker. J Cardiothor Vasc Anesth 2005;19:270–2[Web of Science][Medline]
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Achieving Lung Isolation Via a Tracheostomy
Anesth. Analg.,
April 1, 2009;
108(4):
1356 - 1356.
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Abstract
Introduction
