Failure to provide adequate one-lung ventilation with a conventional endotracheal tube using a transbronchial approach: a case report

Yuet Tong Ng Peter Chi Ho Chung Jing Ru Hsieh Chun Cheung Yu Wai Meng Lau Yun Hen Liu [Ventilation unilatrale inadquate avec un tube endotrachal traditionnel et l'utilisation d'une approche transbronchique : une tude de cas] Purpose: To report a case where failure to provide adequate onelung ventilation during transbronchial intubation resulted in a potentially fatal mishap. Clinical features: A 61-yr-old male was scheduled for right lung lobectomy. Induction of general anesthesia was smooth, and subsequent resection of the right middle lobe was uneventful. Difficult ventilation with high airway pressure and poor right lung re-expansion prompted repositioning of the double-lumen tube after the resection. The removal of the right middle bronchial clamp and associated right mainstem manipulation caused flooding of blood into the double-lumen tube. Mindful of the risk of fatal desaturation, the surgeon immediately opened the right mainstem bronchus and cleared the airway. Confirmation of a displaced double-lumen tube prompted the surgeon to insert an endotracheal tube (internal diameter 5.5 mm) from the opened right mainstem bronchus to the left main bronchus to maintain oxygenation. Although bronchoscopic examination confirmed proper location of the reinserted tube, oxygen saturation was not sufficiently (60%) improved. Another 5.5-mm endotracheal tube was inserted, with its tip inside the right upper bronchiole, for further ventilatory support. Finally, a rise in SpO2 to around 95% allowed completion of surgery. Conclusions: Displacement of the double-lumen endobronchial tube and flooding with clotted blood will result in potentially fatal ventilation difficulties. Repositioning and cleaning of the tube must be prompt to reduce the risk of hypoxemia. Where emergency single-lung ventilation is required, we suggest the utilization of a modified single-lumen endotracheal tube with a shortened cuff-tip length to ensure an adequate margin of safety for mainstem bronchus intubation. - CCIDENTAL displacement of a doublelumen tube with resultant ventilation difficulties, high airway pressures and flooding of blood inside the tube can be a major hazard to the patient. Problems need to be solved within a few minutes to avoid any hypoxia and save a life. Because of the small lumen diameters that limit suctioning and airway clearance, direct opening of the trachea or bronchus, although traumatic, can provide an efficient method to maintain the airway. Transbronchial intubation can provide a method to secure one-lung ventilation, but the conventional endotracheal tube (ETT) may require special modification due to its relative long cuff-tip-length (CTL) when compared with the mainstem bronchus. Case report A 61-yr-old male was scheduled for right middle lobectomy for a tumour in the right lung. Induction of general anesthesia was accomplished using atracurium besylate, fentanyl and sodium thiopental, and subsequently maintained with isoflurane in oxygen, fentanyl and vecuronium. A 35-French left-sided double-lumen tube [DLT; Kendall, Sher-I-Bronch The Kendall Co. (U.K.) Ltd., Basingstoke, England] was inserted in the trachea. Direct fibreoptic bronchoscopy confirmed proper positioning, with the cephalad surface of the left endobronchial cuff just below the tracheal carina. The patient was then placed in the left lateral position. Arterial blood-gas analysis of left-lung ventilation with the patient on 100% oxygen (FIO2 1.0) confirmed acceptable readings for pH (7.464), PaCO2 (51.0 mmHg), and PaO2 (73.5 mmHg). Resection of the right middle lobe was uneventful. The surgeon then requested re-expansion of the right lung to check for leakage. He then suggested repositioning of the double-lumen tube 1 cm outward from the mouth because of poor lung expansion and high airway resistance. However, no improvement was noted. After removal of the right middle bronchial clamp and associated manipulation of the right mainstem bronchus, ventilation difficulties and high airway pressures became more pronounced. Blood clots were suctioned out from both lumens but ventilation difficulties persisted. Pulse oximetry revealed progressive worsening of saturation, which fell to around 21% within minutes. Given the urgency of the situation, a bronchoscopic examination was performed to check proper positioning of the DLT, however, this proved to be in vain due to massive hemorrhage, which obscured the field. The surgeon immediately opened the right mainstem bronchus to check for ruptured blood vessels and removed the FIGURE 1 shows the actual position of the two internal diameter 5.5-mm single-lumen endotracheal tubes (ETTs) placed by the surgeon. The left endobronchial tube bypassed the orifice of the left upper lobe. Another cuffed ETT was inserted inside the right upper bronchiole. Dotted line, shade area illustrates cutting of the beveled tip of a modified ETT with ideal positioning to provide adequate one lung ventilation using a transbronchial approach. clotted blood using suction. The position of the left side endobronchial aperture of the DLT was also checked by palpation. As displacement of the DLT was confirmed, the surgeon subsequently inserted a cuffed ETT (internal diameter 5.5 mm; Kendall Curity) via the opened right mainstem bronchus through the carina to the left mainstem bronchus to ensure left lung ventilation. The DLT was simultaneously moved out and fixed at the 25-cm mark. After thorough cleaning and suctioning of the DLT, a fibreoptic examination was conducted through the DLT to check the proper placement of the 5.5-mm singlelumen ETT relative to the left mainstem bronchus. Positioning was correct, but SpO2 was still not adequate, increasing to only 60%. The anesthesiologist was not able to confirm breathing sounds in the left apex area of the lung on auscultation. Simultaneously, another cuffed 5.5-mm ETT was inserted, with its tip inside the right upper bronchiole, for further ventilatory support (Figure 1). Finally, elevation of SpO2 to around 95% permitted surgical repair of the right Ng et al.: TRANSBRONCHIAL ONE LUNG VENTILATION FIGURE 2 A shows the original design of the single-lumen endotracheal tube in anterior and lateral view. B shows the cutting of the beveled tip into a bird's mouth shape (same views) to avoid sectioning the inflating lumen. mainstem bronchus. Continuous positive-pressure ventilation in the double-lumen tube after thorough cleaning of the airway producing acceptable arterial blood gas readings. Fortunately, vital signs remained stable throughout anesthesia, even during the period when SpO2 had dropped dramatically. Following completion of surgery and exchange of the DLT for a standard size ETT (internal diameter 7.5 mm), the patient was transferred to the intensive care unit. Mechanical ventilator support was carefully withdrawn after five hours and no neurological sequelae were noted. Discussion Accidental displacement of a DLT can occur during thoracic (...truncated)