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LETTERS TO THE EDITOR

Bronchial Injury: An Avoidable Complication During Bronchial Intubation

Department of Anesthesia and Critical Care University of Chicago Chicago, IL 60637

The recent case report of left mainstem bronchus rupture after the use of a left double-lumen (LDL) tube by Gilbert et al. (1) is a reminder that such complications are bound to occur if we continue to rely on blind placement of endobronchial tubes.

A 37F LDL tube passed under direct vision into the trachea was blindly advanced into the left mainstem bronchus with the stylet in place. A flexible fiberoptic bronchoscope (FFB) was then passed through the tracheal lumen to confirm proper position of the bronchial cuff. Lung isolation was confirmed with auscultation; however, during thoracoscopy, the collapse of the upper lung was incomplete. The surgeon noticed the blue endobronchial cuff herniating out of the left mainstem bronchus and repaired the bronchus via open thoracotomy.

The laterally curved distal end of the LDL tube sustained by a metal stylet facilitates tracheal intubation and blind advancement of the tube into the left mainstem bronchus. Unfortunately, blind placement of the endobronchial tubes, with or without the stylet, increases the possibility of trauma to the trachea and the bronchial tree (2). There were 33 reports of tracheal and bronchial tree rupture with endobronchial tubes from 1972 to 1988, and we agree that this complication is underreported (2).

Blind bronchial positioning of the LDL tube results in right mainstem intubation 20% to 30% of the time (3–6). Repeated attempts may overcome this problem, but about 10% of the time, the FFB is necessary for directing the LDL tube into the left mainstem bronchus (3). Repeated attempts, as well as incorrect bronchial intubation, increase the possibility of tracheal or left and right mainstem bronchial tree rupture.

To minimize the possibility of tracheobronchial trauma, we have modified a technique described previously (7–8) by placing the LDL tube with the stylet in position inside a warm water bath. As soon as the tip of the tube is passed through the larynx with the aid of a rigid laryngoscope, the stylet is removed, and the tube is rotated 90° counterclockwise and advanced until the tracheal cuff is just past the vocal cords. The tracheal cuff is inflated, and the tube position is confirmed by auscultation and ETCO₂ monitoring. Mechanical ventilation is begun, and the FFB is passed through the bronchial lumen into the left mainstem bronchus to check the anatomy of the bronchial tree. The FFB tip is positioned 10 mm above the left upper lobe bronchus and is used as a guide for advancement of the bronchial tube into the left mainstem bronchus. Placing the tube into the warm water bath increases its softness to facilitate bronchial entry of the tubes over the FFB. The tip of the bronchial tube is positioned 5 to 10 mm above the opening of the left upper lobe bronchus. The FFB is then passed through the tracheal lumen to check bronchial cuff position and to observe bronchial cuff inflation.

It is unfortunate that blind placement of bronchial tubes is still a common practice even though the value of the FFB for proper placement of endobronchial tubes has been repeatedly documented (7,9,10). Our goal as anesthesiologists should be to use all the means at our disposal within the limits of practicality to avoid airway trauma.

References

1. Gilbert TB, Goodsell CW, Krasna MJ. Bronchial rupture by a double-lumen endobronchial tube during staging thoracoscopy. Anesth Analg 1999;88:1252–3.[Free Full Text]
2. Fitzmaurice BG, Broadsky JB. Airway rupture from double-lumen tubes. J Cardiothorac Vasc Anesth 1999;13:322–9.[Web of Science][Medline]
3. Brodsky JB, Macario A, Cannon WB, Mark JBD. "Blind" placement of plastic left double-lumen tubes. Anesth Intensive Care 1995;23:583–6.[Web of Science][Medline]
4. Alliaume B, Coddens J, Deloof T. Reliability of auscultation in positioning of double-lumen endobronchial tubes. Can J Anaesth 1992;39:687–90.[Web of Science][Medline]
5. Hurford WE, Alfille PH. A quality improvement study of the placement and complications of double-lumen endobronchial tubes. J Cardiothorac Vasc Anesth 1993;7:517–20.[Medline]
6. Conacher ID, Herrema IH, Batchelor AM. Roberthshaw double lumen tubes: a reappraisal thirty years on. Anaesth Intensive Care 1994;22:179–83.[Web of Science][Medline]
7. Ovassapian A. Fiberoptic-aided bronchial intubation. In: Ovassapian A, ed. Fiberoptic endoscopy and the difficult airway. 2nd ed. Philadelphia:Lippincott-Raven, 1996:117–56.
8. Ovassapian A. Fiberoptic positioning of right-sided double-lumen endobronchial tubes. J Bronchol 1994;1:1–8.
9. Klein H, Waheedullah K, Bloos F, et al. Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia: a prospective study. Anesthesiology 1998;88:346–50.[Web of Science][Medline]
10. Smith GB, Hirsch NP, Ehrenwerth J. Placement of double-lumen endobronchial tubes: correlation between clinical impressions and bronchoscopic findings. Br J Anaesth 1986;58:1317–20.[Abstract/Free Full Text]

Response

Department of Anesthesiology University of Maryland School of Medicine Baltimore, MD 21201

I am pleased that our recent report has rekindled some controversy regarding optimal methods for placing and positioning an endobronchial tube for one-lung ventilation. One reason to publish articles about complications is to solicit feedback from colleagues and experts in the field. Each of the respondents took issue with our commonly used method, but interestingly for different aspects: Roth (1) for altering patient position while the distal cuff remained inflated, and Ovassapian and Klafta, for use of a stylet during tube placement. Unfortunately, Ovassapian et al. misinterpret our use of a stylet during intubation. We never stated explicitly in our report that the stylet remained in place throughout the introduction of the endobronchial tube, but was used only during passage through the laryngeal orifice. As is our routine practice, the stylet is pulled back before engaging the main stem bronchus, after which fiberoptic bronchoscopy is performed to confirm proper location. Therefore, his suggested mechanism of injury was not operative in this particular patient.

References

1. Roth JV. Another potential factor that may cause bronchial rupture by a double-lumen endobronchial tube [letter]. Anesth Analg 1999;89:1591.[Free Full Text]

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