Anesth Analg 2000;91:1370-1371
© 2000 International Anesthesia Research Society
CARDIOVASCULAR ANESTHESIA
The Use of a Bronchial Blocker To Rescue an Ill-Fitting Double-Lumen Endotracheal Tube
Mauricio Nino, MD,
Simon C. Body, MBChB, and
Philip M. Hartigan, MD
Department of Anesthesiology, Perioperative and Pain Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
Address correspondence and reprint requests to Philip Hartigan, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115.
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Abstract
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Implications: Using certain specialized endotracheal tubes designed to allow single-lung ventilation for certain thoracic surgical procedures may be fraught with technical difficulties owing to common anatomic anomalies. This case report describes a simple solution for an ill-fitting right double-lumen endotracheal tube using a balloon-tipped catheter.
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Introduction
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Right-sided double lumen endotracheal tubes (DLTs) have well known advantages over alternative lung isolation techniques for certain patients undergoing left pneumonectomy (1). However, in patients who have a short right mainstem bronchus, the positioning of a right-sided DLT with the right upper lobe (RUL) fenestration aligned with the RUL bronchus may leave the bronchial cuff positioned high in the carina with inadequate contact surface area to accomplish an adequate seal (see Figure 1).
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Figure 1. A, Normal bronchial anatomy and a properly fitted right-sided double-lumen tube. B, Anomalous short right mainstem bronchus reduces available contact surface area for bronchial cuff seal.
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Case Report
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A 71-year-old male with left upper lobe adenocarcinoma was scheduled for a left pneumonectomy. The patient was 175 cm, 75 kg, with a Mallampati class I airway and otherwise unremarkable physical examination. Preoperatively, a right radial arterial line and a thoracic epidural catheter were inserted. After induction of anesthesia, the trachea was intubated via direct laryngoscopy with a 39F right DLT (Bronchopart®; Rüsch Inc., Duluth, GA). Auscultation suggested that the tube was correctly positioned in the right mainstem bronchus. Flexible fiberoptic bronchoscopy via the bronchial lumen was used to align the RUL fenestration with the RUL bronchus. Notably, withdrawal of the DLT by 1.5 cm was required to accomplish this alignment. After positioning the patient in right lateral decubitus position and fiberoptically confirming the DLT position, one-lung ventilation was initiated by clamping the tracheal lumen. A leak across the bronchial cuff was noticed and the left lung failed to collapse. Adequate inflation of the bronchial pilot balloon was confirmed and the fiberoptic bronchoscope was passed down the tracheal lumen to visualize the carina. The bronchial cuff was observed to be partially above the carina, failing to provide a satisfactory seal. Advancing the tube to gain more contact surface area resulted in occlusion of the RUL bronchus. An 8/22F bronchial blocker (Fogarty Occlusion Catheter model #62080822F, Baxter Healthcare Corporation, Irvine, CA) was then placed through the tracheal lumen of the DLT with the blocker balloon positioned at the level of the carina. Measurement of the bronchial blocker against a clean DLT allowed us to blindly insert it to the desired depth (Figure 2A). The balloon was inflated with 5 cc of air, and the air leak and inflation of the left lung ceased (Figure 2B).
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Figure 2. A, Bronchial blocker is premeasured against a clean double-lumen tube and marked for proper depth of insertion which will position the cuff just beyond the tracheal orifice. B, Bronchial blocker inserted via tracheal lumen to the premeasured depth completes the air seal. The bronchial balloon of the double-lumen tube is left inflated as it may contribute to the air seal, depending on the depth of insertion of the bronchial blocker. The tracheal balloon of the double-lumen tube may be deflated to prevent trapping air between the bronchial blocker and the tracheal cuff.
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After surgery, bronchoscopy revealed that the RUL bronchus arose from the right mainstem bronchus 3 mm below the carina. The trachea was then extubated, and the patient recovered uneventfully.
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Discussion
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The average length of the adult right mainstem bronchus is 18 mm (1). Manufacturers have designed the position of the RUL fenestration in right DLTs in accordance with population averages (2). Of the major airway anomalies, however, the RUL orifice is the most frequent abnormality (3). Ten percent of patients have a right mainstem bronchus <10 mm in length (2,3). Approximately 0.4%–2% of patients have a RUL orifice arising at or above the level of the carina (2).
Ill-fitting DLTs may be a result of anatomic anomalies or improper size selection. No preoperative variable (including gender, age, height, and left mainstem bronchus diameter by chest radiograph or computed tomography) has proven to be a universally reliable guide to proper DLT size selection (4,5). Three-dimensional reconstruction of the tracheobronchial image from spiral computed tomography scans are reliable but not readily available (6). It has been estimated that as much as 10% of the adult population cannot be safely intubated with any right-sided DLT that is currently available (2,7).
Marginally ill-fitting right DLTs might not be recognized until the patient is positioned laterally. We describe a simple, effective solution to such situations, avoiding the need to extubate and reintubate a trachea with the patient in the lateral position.
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References
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Hannallah MS, Benumof JL, Ruttimann UE. The relationship between left mainstem bronchial diameter and patient size. J Cardiothorac Vasc Anesth 1995; 9: 119–21.[Web of Science][Medline]
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Brodsky JB. Separation of the lungs. In: Cohen E, ed. The practice of thoracic anesthesia. 1st ed. Philadelphia: JB Lippincott Company, 1995: 288.
Accepted for publication August 11, 2000.
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Abstract
Introduction
