Anesth Analg 2002;95:333-335
© 2002 International Anesthesia Research Society
PEDIATRIC ANESTHESIA
Separate-Lung Ventilation Strategy for Reimplantation of Esophageal Bronchus
Clarisse Peuch, MD*,
Serge Malbezin, MD*,
Carole Saizou, MD
,
Vincent Couloigner, MD
,
Monique Elmaleh, MD
,
Yves Nivoche, MD*,
Pascal de Lagausie, MD||, and
Vincent Laudenbach, MDPhD*
Departments of *Anesthesiology, Pediatric Intensive Care, ENT Surgery, Radiology, and ||Pediatric Surgery, Hôpital Robert Debré, Paris, France
Address correspondence and reprint requests to Vincent Laudenbach, MD, Départment d’Anesthésie-Réanimation Chirurgicale, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, 48 Blvd. Sérurier, 75019, Paris, France. Address e-mail to vlaudenb{at}infobiogen.fr
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Abstract
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IMPLICATIONS: We describe an original ventilation method designed to optimize lung recruitment and gas exchanges during surgery in a newborn with congenital esophageal atresia and ectopic esophageal implantation of the left mainstem bronchus. This strategy ensured constant adaptation of the mechanical ventilatory regimen to the surgical procedure-linked constraints.
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Introduction
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Esophageal atresia (EA) usually requires neonatal surgery. Rarely, EA is associated with esophageal bronchus (1–3). In such situations, recurrent infections occur in lung territories depending on the ectopic bronchus. These result in progressive destruction of the parenchyma, of which resection may be mandatory, subsequently impairing thoracic development (3,4). Alternatively, conservative treatment (i.e., correction of the abnormal airway) may be proposed (5). Such procedures raise challenging issues regarding intraoperative ventilatory support. We report a case of successful reimplantation of an esophageal left bronchus revealed after EA repair.
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Case Report
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A 1.7-kg boy of 34 wk gestational age was admitted to the surgical ward for EA. A chest radiogram showed normal recruitment of both lungs and aeration of the gastrointestinal tract evocative of distal tracheo-esophageal fistula (TEF; Type III EA) (Fig. 1A). A surgical procedure was planned. Endotracheal intubation was performed without difficulty by using a 2.5-mm-internal-diameter (ID) cuffless tube. Bilateral lung auscultation showed symmetrical ventilation. A right thoracotomy was performed, allowing ligation of a carinal TEF and completion of a one-stage esophageal anastomosis. After transfer to the intensive care unit, a chest radiogram revealed atelectasis of the left lung (Fig. 1B). Nonetheless, adequate oxygenation was ensured by low inspired oxygen fractions (0.25–0.3), suggesting limitation of intrapulmonary shunt by potent hypoxic pulmonary vasoconstriction. A tracheobronchoscopy showed complete obstruction of the origin of the left mainstem bronchus, as well as a stenosis of both the distal trachea and the proximal right mainstem bronchus. A chest computer-assisted tomography scan displayed 1) a left mainstem bronchus of atypical cephalocaudal orientation, the origin of which appeared more cephalic than the one of the right mainstem bronchus; 2) a tracheal stenosis; and 3) close contact between the esophagus and the lumen of the left mainstem bronchus (Fig. 2). The lung vasculature appeared normal after contrast injection. The esophageal implantation of the left bronchus was assessed by combined opacification of the tracheal and gastrointestinal tracts (Fig. 3). Although tracheobronchography confirmed stenosis of the trachea and right mainstem bronchus, surrounding a normal right bronchial tree, it failed to opacify the left mainstem bronchus (Fig. 3A). However, the contrast swallow showed a left bronchogram, associated with persistent lung atelectasis (Fig. 3B). Reimplantation of the ectopic bronchus was planned. Right thoracotomy appeared appropriate, providing adequate exposition of the operating field. Yet it was exposed to intraoperative hypoxia because of the manual reclination of the right lung required for surgical access, combined with the anatomical exclusion of the left lung. Therefore, a separate-lung ventilation strategy was planned.
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Figure 1. Plain chest radiographs. A, Neonatal film, suggestive of Type III esophageal atresia (EA). Note the tip of the esophageal suction tube (arrow), indicating the lower extremity of the upper esophagus. B, Postoperative film (first surgical procedure), revealing complete atelectasis of the left lung after correction of EA.
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Figure 2. Chest computer-assisted tomography scans. Note the reduced lumen of the right mainstem bronchus (white arrow) and the close contact between the esophagus (black arrow) and the left mainstem bronchus (arrowhead).
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Figure 3. Opacification of the respiratory and gastrointestinal tracts. A, Tracheobronchogram showing a stenosis of both the distal trachea and the origin of the right mainstem bronchus (arrow) and the absence of opacification of the left mainstem bronchus. B, Esophagogram, revealing the esophageal implantation of the left mainstem bronchus (arrowheads).
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In addition to right-lung ventilation via an endotracheal 2.5-mm-ID tube, located beyond the tracheal and right mainstem bronchus stenosis, a second 2.5-mm-ID tube was introduced into the left bronchus through the upper esophagus under radioscopic control (Fig. 4). Both tubes were initially connected to the same ventilator (Aestiva 3000, pressure-control mode; Datex-Ohmeda, Helsinki, Finland). The following variables were set: frequency, 50 breaths/min; inspiratory/expiratory ratio, 1:2; peak inspiratory pressure, 20–25 cm H2O; peak end-expiratory pressure, 5 cm H2O; and fraction of inspired oxygen, 0.5–1. After the left bronchus was disconnected from the esophagus, the first left bronchial tube was removed. The bronchus was then directly catheterized in the operating field. The second left bronchial tube was connected to another ventilator, and lung recruitment was visually controlled by the surgeon. The initial variables for left lung ventilation were frequency, 50 breaths/min; inspiratory/expiratory ratio, 1:2; peak inspiratory pressure, 30 cm H2O; peak end-expiratory pressure, 8 cm H2O; and fraction of inspired oxygen, 1. The right lung was ventilated during the whole surgical procedure. The total tidal volume did not exceed 10 mL/kg body weight. Pulse oximetry showed values >90% throughout the procedure, except during the anastomosis of the left bronchus with the trachea. ETCO2 could not be reliably monitored because of frequent maneuvers on the airway, subsequently altering gas sampling quality and the ETCO2/PaCO2 gradient. Therefore, we performed repeated blood gas measurements. To shorten the delay of left lung exclusion, the tracheobronchial anastomosis was prepared by dissecting the edges and placing sutures before the removal of the left bronchial tube, so that they could be tightened rapidly. The left bronchus was successfully reimplanted orthotopically. After anastomosis was completed, the endotracheal tube was relocated from the right mainstem bronchus above the carina, allowing bilateral lung ventilation. The patient was kept under mechanical ventilatory support until his trachea was definitely extubated at 32 days of age. He was discharged home at 75 days.
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Figure 4. Second surgical procedure: intraoperative chest roentgenogram, showing separate recruitment of both lungs via an endotracheal tube (right-lung ventilation; arrow) and, on the other hand, a left bronchial tube introduced through the esophagus (arrowheads).
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Discussion
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Various, albeit rare, congenital communicating bronchopulmonary foregut malformations have been described (1–3). Such features must be considered when planning neonatal surgery for EA (3,6,7). However, in the case of our patient, several elements suggested a iatrogenic origin after the first surgical procedure, i.e., accidental anastomosis of the upper esophagus to both the inferior esophageal segment and the left mainstem bronchus, which were previously in close contact via the carinal TEF. These elements were 1) the normal aeration of both lungs immediately after birth, 2) the symmetrical ventilation after initial intubation, and 3) the location of tracheal and right mainstem bronchus stenosis at the level of the carina. Indeed, the usual exposure for primary repair of EA hardly allows clear and global visualization of the left bronchus.
Neonatal reimplantation of ectopic bronchus is associated with frequent mortality because of oxygenation failure or associated anomalies (7,8). The absence of recruitment in lung territories, depending on the ectopic bronchus, results in intrapulmonary shunt and impaired CO2 clearance. Respiratory homeostasis control may warrant high-volume, possibly deleterious, ventilation of a single lung. In this case, separate-lung ventilation ensured adequate gas exchanges throughout the surgical procedure. Although high-pressure regimens were imposed by surgical maneuvers upon the lungs and airway, separate recruitment of both lungs allowed independent adaptation of ventilation in response to specific constraints, e.g., thoracic roll or retractors.
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References
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Accepted for publication March 26, 2002.
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Abstract
Introduction
