Anesth Analg 2002;95:621-623
© 2002 International Anesthesia Research Society
PEDIATRIC ANESTHESIA
Colobronchial Fistula in a Pediatric Patient: Diagnostic Value of Isolated Single-Lung Ventilation and Intraoperative Use of High Frequency Oscillatory Ventilation
Holger K. Eltzschig, MD*
,
Greta Palmer, MBBS FANZCA
, and
Robert Brustowicz, MD FAAP, FACMQ
*Department of Anesthesia, Brigham and Women’s Hospital; Department of Anesthesia, Harvard Medical School; and Department of Anesthesia (Pain Management), Children’s Hospital, Boston, MA
Address correspondence and reprint requests to Robert Brustowicz, MD, FAAP, FACMQ, Department of Anesthesiology, Children’s Hospital Boston, Harvard Medical School, 300 Longwood Ave., Boston, MA 02115. Address e-mail to robert.brustowicz{at}tch harvard.edu.
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Abstract
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IMPLICATIONS: We describe the anesthetic management of a pediatric patient who underwent thoracotomy repair of a colobronchial fistula. Single-lung ventilation confirmed the diagnosis and the position of the fistula. In addition, the intraoperative use of high frequency oscillatory ventilation in combination with conventional ventilation of the nonoperative side is described.
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Introduction
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Colobronchial fistula (CBF) is a complication of Crohn’s disease, carcinoma of the colon, subphrenic abscess, or traumatic diaphragmatic rupture (1–5). We describe a pediatric patient who developed CBF after intrahepatic iridium implants. A pediatric double-lumen tube (DLT) and isolated single-lung ventilation assisted in diagnosis and localization of the fistula. Volume-controlled ventilation of the dependent lung in combination with high frequency oscillatory ventilation (HFOV) of the operative lung was used during thoracotomy repair of the fistula to achieve adequate oxygenation.
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Case Report
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An 11-yr-old female patient with a history of hepatoblastoma treated with partial hepatectomy and iridium implantation at the age of 15 mo presented with a diagnosis of pneumonia. Her respiratory status worsened within hours, and she developed acute respiratory distress syndrome (ARDS). Immediately after intubation, her abdomen became distended, and she started passing flatus. A radiograph of her abdomen confirmed colonic distension (Fig. 1), and a rectal tube was placed. Air drainage through this tube increased in conjunction with increased levels of airway pressures. Concurrently, feculent material was suctioned from the endotracheal tube. However, computed tomography could not demonstrate a fistula. Within 4 h, her respiratory status deteriorated, requiring the initiation of HFOV to maintain oxygenation.
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Figure 1. Abdominal radiograph after tracheal intubation. After tracheal intubation, the patient’s abdomen immediately became distended. The radiograph shows dilated loops of colon.
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The patient was quickly taken to the operating room for a diagnostic colonoscopy, with consideration for surgical repair of the suspected CBF. The single-lumen endotracheal tube was changed to a left-sided 28F DLT, and placement was confirmed fiberoptically. Feculent material was suctioned from the right lung. Upon ventilating the isolated right lung, the rectal tube drained flatus, which immediately stopped during ventilation of the left lung. Thus, the diagnosis of a right-sided CBF was confirmed, and the planned colonoscopy was abandoned.
The patient then underwent a right-sided thoracotomy with resection of the supradiaphragmatic component of the CBF, requiring partial right lower lobectomy and right hemi-diaphragm repair. Attempts to ventilate the patient with either a continuation of HFOV or volume-controlled ventilation of the dependent lung with additional insufflation of the operative lung or continuous positive pressure of various degrees failed to achieve a SpO2 more than 80% on a fraction of inspired oxygen of 1. At that time, an arterial blood gas analysis showed a pH value of 7.20, PaCO2 of 77 mm Hg, and PaO2 of 51 mm Hg. Therefore, the dependent lung was ventilated with volume-controlled ventilation at tidal volumes of 8 mL/kg and a positive end-expiratory pressure of 10 cm H2O (peak airway pressure, 32 cm H2O) in combination with HFOV of the operative side at a mean distending airway pressure of 20 cm H2O and a frequency of 4 Hz. A SpO2 more than 85% was achieved with only minimal lung movement of the operative field. The patient was anesthetized throughout the surgery using balanced anesthesia consisting of isoflurane in combination with IV fentanyl and midazolam. Muscle paralysis was maintained with pancuronium. The patient remained hemodynamically stable throughout the procedure. An arterial blood gas analysis obtained during surgery showed a pH value of 7.26, PaCO2 of 70 mm Hg, and PaO2 of 74 mm Hg.
Postoperatively, her respiratory status deteriorated and veno-venous extracorporeal membrane oxygenation (ECMO) was initiated (Fig. 2). She subsequently recovered from ARDS, and ECMO was discontinued after 6 days. The patient was then weaned from the ventilator and extubated on postoperative Day 20. After a protracted hospitalization, she was finally discharged home from the hospital.
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Figure 2. Radiograph of the chest after initiation of extracorporal membrane oxygenation. After surgical closure of the colobronchial fistula and return to the intensive care unit, the patient’s respiratory status deteriorated over the next 12 h. Therefore, extracorporal membrane oxygenation (ECMO) was initiated to provide adequate oxygenation. An ECMO cannula in the superior vena cava and the 28F left-sided double-lumen tube (DLT) that was intraoperatively used can be visualized.
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Discussion
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This case describes the usefulness of a DLT in combination with isolated single-lung ventilation to diagnose and localize a CBF in a pediatric patient. This management permitted differential lung ventilation with HFOV of the operative lung and volume-controlled ventilation of the dependent lung. Intraoperative application of HFOV in conjunction with differential lung ventilation has not been previously described.
HFOV is a ventilation mode delivering high mean distending airway pressures in combination with minimal pressure changes, oscillating at rates between 2 and 8 Hz. This mode of ventilation is often used in the neonatal and pediatric intensive care of patients with ARDS. Experimental (6) and clinical data (7–9) support the use of HFOV in pediatric patients with severely injured lungs. However, experience with intraoperative use of HFOV is limited (10).
The improvement of oxygenation after the use of HFOV to the operative lung in this patient is because of an alteration in the distribution of ventilation and perfusion of both lungs. Higher mean airway pressure to the operative lung possibly diverted pulmonary blood flow from the operative to the dependent lung, which was less affected by the ARDS. At the same time, oxygenation of blood perfusing the operative lung that otherwise would have contributed to ventilation-perfusion mismatch was improved. This enabled the patient to remain oxygenated and avoided the need for intraoperative ECMO. Intraoperative ECMO is associated with an increased risk of hemorrhage because it requires systemic anticoagulation.
In conclusion, lung isolation can be helpful with diagnosing and localizing a CBF. In addition, it can provide a venue for the introduction of HFOV to the operative lung to improve oxygenation. However, this technique is limited to larger pediatric patients whose airway will safely accommodate a 26F or larger DLT.
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References
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Accepted for publication May 14, 2002.
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Abstract
Introduction
