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CARDIOVASCULAR ANESTHESIA

Bronchial Rupture by a Double-Lumen Endobronchial Tube During Staging Thoracoscopy

Timothy B. Gilbert, MD, FACC^*, Craig W. Goodsell, DO^*, and Mark J. Krasna, MD

Departments of *Anesthesiology and Surgery, University of Maryland Medical School, Baltimore, MD

Address correspondence and reprint requests to Timothy B. Gilbert, MD, FACC, Division of Cardiothoracic Anesthesiology, Room S11-C10, 22 South Greene St., Baltimore, MD 21201-1595. Address e-mail to tgilbert{at}anesth.ab.umd.edu

	Introduction

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Single-lung ventilation using a double-lumen endobronchial tube (EBT) is often performed for surgical procedures involving the thorax. The ability to isolate and collapse the nondependent lung is particularly imperative for thoracoscopic procedures, because adequate visualization of most intrathoracic structures depends on near complete atelectasis. Despite proper placement and use of an EBT, severe airway injury by the tube tip or either of its cuffs may occur occasionally. Previous reports seem to be limited to injury during open thoracotomy, in which broad visual exposure of the entire thorax is possible. We report a case of iatrogenic bronchial rupture during the use of an EBT for staging thoracoscopy in which the site of injury was not appreciated initially during the videoscopic examination.

	Case Report

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A 53-yr-old, previously healthy patient presented for right-sided thoracoscopic evaluation for staging of biopsy-proven esophageal adenocarcinoma. Physical examination was unremarkable; height and weight were 160 cm and 68 kg, respectively. Following the uneventful induction of general anesthesia, a 37F, left-sided, styletted EBT (Broncho-Cath^®; Mallinckrodt, Glen Falls, NY) was passed easily through the vocal cords and into the left mainstem bronchus. We performed fiberoptic bronchoscopy (FOB) to confirm proper tube placement and to visualize inflation of the endobronchial balloon cuff; <3 mL of air was required to achieve an adequate seal. Appropriate lung isolation was then confirmed by auscultation. After turning the patient to a left-lateral decubitus position, thoracoscopy commenced with trochar insertion and carbon dioxide insufflation (peak pressure 20 cm H₂O). The initial videoscopic inspection of the pleural cavity revealed poor nondependent lung collapse; therefore, FOB was repeated several times, confirming no significant change in the EBT position. In addition, the patient's positioning on the operative table (i.e., extent of flexion and rotation) was adjusted several times to assist the surgeon's views. Twice, ventilation was discontinued and the EBT advanced slightly with both cuffs deflated, then reinflated. Ultimately, intermittent apneic oxygenation was required to achieve acceptable lung collapse for accessing the retropleural space. No significant change in hemodynamic variables was noted throughout. One hour later, during mobilization of mediastinal and paraesophageal tissues, a dark, spherical, cystic-appearing structure was discovered emanating between the esophagus and trachea in the mediastinum (Fig. 1). During dissection in preparation for biopsy of this mass, the surgical team realized that this artifact was the blue-colored endobronchial cuff protruding laterally from a ruptured left mainstem bronchus and into the right pleural space. An urgent open thoracotomy was performed to oversew the bronchial injury and to apply an intercostal muscle flap to enhance the air seal. During repair, the EBT was advanced manually under FOB guidance beyond the site of bronchial injury. A postrepair FOB showed adequate surgical closure of the bronchus with minimal luminal narrowing. The esophageal tumor ultimately was found quite distant from the site of the bronchial injury. After completion of the planned staging procedure, the patient was allowed to emerge from anesthesia and was tracheally extubated without difficulty. No subcutaneous emphysema, pneumomediastinum, or pneumothorax was noted postoperatively, and the patient had an otherwise uneventful recovery. She was discharged on Postoperative Day 4.

View larger version (118K): [in this window] [in a new window]   Figure 1. The dark, spherical, cyst-appearing structure (arrow) emanating laterally from the mediastinum was found to be the tinted endobronchial cuff protruding from the site of the ruptured left mainstem bronchus. The thoracoscopic grasper is seen to the far right. The poorly collapsed nondependent lung is also shown (directly beneath the arrow).

	Discussion

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Factors that seem to increase the risk of injury by an EBT include: use of an undersized tube that requires excessive cuff inflation (3); use of tube too large for a patient's mainstem bronchial lumen (4); malposition of the tip of the tube (5); rapid cuff inflation (6); use of older tubes with low-compliance cuffs (red rubber) or carinal hooks (e.g., Carlens or White tubes) (4); use of adjuncts such as bronchial blockers (7) or tube-exchangers (8); the presence of invasive disease of the airways (2,6); use in patients at the extremes of age (2,7); and use of N₂O (4,6). In this particular patient, none of these risk factors were present. The mechanism of injury was undoubtedly either direct injury by the tip of the EBT during its initial placement (or manipulations) or by later injury secondary to inflation of the distal cuff. Unfortunately, there is no way to determine which of these occurred because the poor collapse of the nondependent lung was not noted until the surgeon entered the chest, some time after EBT placement.

Tracheobronchial injury during thoracoscopy has not been previously reported. Thoracoscopy could increase the risk of such an injury for several reasons. First, because thoracoscopy requires exquisite lung collapse for good visualization, more manipulations of the EBT (e.g., repositioning, inflations, or deflations of the cuffs, or FOB) may be necessary than with an open thoracotomy. Second, carbon dioxide insufflation (9) could cause more rapid or complete lung collapse and excessive torsion on at-risk airway structures. Third, depending on the area of the thorax being examined, the patient and operative table often require readjustment to optimize the surgeon's view. Finally, because of the field of view and variability in quality of the videoscopic image, diagnosis of an injury may be somewhat delayed, as was the case in this patient. Because thoracoscopy is generally performed in a darkened room, recognition of certain physical signs (e.g., cyanosis, subcutaneous emphysema) can be problematic. For these reasons, use of endobronchial intubation and single-lung ventilation should be performed with substantial vigilance during thoracoscopy in order to detect or possibly prevent similar airway injury.

	References

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1. Guernelli N, Bragaglia R, Briccoli A, et al. Tracheobronchial ruptures due to cuffed Carlens tubes. Ann Thorac Surg 1979;28:66–8.[Abstract]
2. Patel KD, Palmer SK, Phillips MF. Mainstem bronchial rupture during general anesthesia. Anesth Analg 1979;58:59–61.[Free Full Text]
3. Wilson RS. Endobronchial intubation. In: Kaplan JA, ed. Thoracic anesthesia. New York:Churchill Livingstone, 1983:389–402.
4. Hannallah M, Gomes M. Bronchial rupture associated with the use of a double-lumen tube in a small adult. Anesthesiology 1989;71:457–9.[ISI][Medline]
5. Sakuragi T, Kumano K, Yasumoto M, Dan K. Rupture of the left main-stem bronchus by the tracheal portion of a double-lumen endobronchial tube. Acta Anaesthesiol Scand 1997;41:1218–20.[Medline]
6. Benumof JL, Alfery DD. Anesthesia for thoracic surgery. In: Miller RD, ed. Anesthesia. 4th ed. Philadelphia:Churchill Livingstone, 1994:1699–700.
7. Borchardt RA, LaQuaglia MP, McDowall RH, Wilson RS. Bronchial injury during lung isolation in a pediatric patient. Analg 1998;87:324–5.[Free Full Text]
8. Seitz PA, Gravenstein N. Endobronchial rupture from endotracheal reintubation with an endotracheal tube guide. J Clin Anesth 1989;1:214–7.[Medline]
9. Wolfer RS, Krasna MJ, Hasnain JU, McLaughlin JS. Hemodynamic effects of carbon dioxide insufflation during thoracscopy. Ann Thorac Surg 1994;58:404–8.[Abstract]

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999