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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 2  |  Issue : 4  |  Page : 140-142

Endobronchial blocker for one-lung ventilation through a fresh tracheostomy


Department of Anaesthesia, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India

Date of Submission21-Aug-2015
Date of Acceptance22-Nov-2015
Date of Web Publication17-Mar-2016

Correspondence Address:
Vaibhavi V Baxi
H291, Raghunath Vihar, Sector 14, Kharghar, Navi Mumbai, Maharashtra 410210
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2356-9115.178910

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  Abstract 

Different methods have been described for lung isolation in patients for thoracic surgery with tracheotomies. It is important to consider whether it is a fresh stoma or a chronic tracheostomy. We would like to describe the use of endobronchial blocker directed fibreoptically in a fresh tracheostomy as a simple and safe technique for one-lung ventilation without causing any trauma to the fresh stoma site.

Keywords: bronchial blocker, double-lumen endotracheal tube, tracheostomy


How to cite this article:
Shah FR, Baxi VV. Endobronchial blocker for one-lung ventilation through a fresh tracheostomy. Res Opin Anesth Intensive Care 2015;2:140-2

How to cite this URL:
Shah FR, Baxi VV. Endobronchial blocker for one-lung ventilation through a fresh tracheostomy. Res Opin Anesth Intensive Care [serial online] 2015 [cited 2017 Oct 17];2:140-2. Available from: http://www.roaic.eg.net/text.asp?2015/2/4/140/178910


  Introduction Top


This report describes a case of successful one-lung ventilation (OLV) for thoracoscopic lung decortication of 4 h using a bronchial blocker (BB) placed endobronchially through the tracheostomy tube of a fresh tracheotomy. Techniques used for lung separation for OLV after tracheostomy are limited and requires special airway management.


  Case report Top


A 57-year-old female patient of ASA physical status 3 was scheduled for video-assisted thoracoscopic lung decortication. She was admitted to our centre with a history of moderate-to high-grade fever, nonproductive cough and progressive breathlessness for about a week and was tracheotomized for need of effective tracheal toilet and prolonged mechanical ventilation. High-resolution computer tomography revealed empyema along with lung consolidation and collapse on the right side.

Taking into consideration that the tracheostomy was performed only 2 days before surgery, to avoid causing any injury to the tissue around the stoma we decided to use an endobronchial blocker (Coopdech; Coopdech, Daiken Medical Co., Osaka, Japan) through the existing cuffed tracheostomy tube to achieve lung separation.

We administered 100% oxygen to the patient through a 7.5 no. cuffed tracheostomy tube (in situ) before induction. After intravenous administration of 2 mg midazolam, general anaesthesia was induced with intravenous 100 micrograms fentanyl and 100 mg propofol. Muscle relaxation was achieved with intravenous 50 mg atracurium, and the patient's lungs were ventilated with sevoflurane in 100% oxygen through tracheostomy. After lubrication the endobronchial blocker was placed through the tracheostomy tube through a multiport joint connector. The joint connector has four ports - a 15-mm port for ventilation to be connected to the anaesthesia circuit, a bronchoscopy port to insert and manoeuvre the fibreoptic scope with an airtight seal, a blocker port that incorporates the BB through an airtight seal and a 15 mm endotracheal tube connector to connect to tracheal tubes or tracheostomy [Figure 1]. The endobronchial blocker tube has a firm elastic shaft with an angled tip and cuff at the distal end. Under fibreoptic bronchoscope guidance the BB was steered into the right main bronchus by rotating the proximal shaft clockwise and its cuff was inflated [Figure 2]. The BB tube was anchored to the joint connector through the blocker tube clamp to avoid displacement. Placement was reconfirmed after lateral positioning both by auscultation and by fibreoptic bronchoscope. OLV was achieved with collapse of the operative lung successfully throughout the surgical procedure. Anaesthesia was maintained with 1 μg/kg/h of fentanyl, 0.5 mg/kg/h atracurium and 1-2% sevoflurane in oxygen (FiO 2 = 0.5) and air at 2 l/min.
Figure 1: Parts of a bronchial blocker.

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Figue 2: Bronchial blocker in situ.

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The total duration of anaesthesia was 4 h with OLV of 2 h 30 min. Arterial blood gas analysis during OLV was as follows: pH = 7.35, pO 2 = 265, pCO 2 = 45.1, HCO 3 = 24.8 and 98% oxygen saturation. All vital signs were maintained within normal limits throughout the surgery. At the end of the surgery the BB cuff was deflated and withdrawn from the tracheostomy tube along with the multiport adaptor. The patient was transferred to the ICU on ventilator support.


  Discussion Top


The alternatives to achieve OLV in a tracheostomized patient include the following:

  1. Insertion of a single-lumen endotracheal tube with an independent BB, coaxially or extralumenally;
  2. Use of a disposable cuffed tracheostomy tube with an independent BB;
  3. Replacement of the tracheostomy tube with a specially designed short double-lumen endotracheal tube (DLT) such as the Naruke DLT, which is made for use in tracheostomized patients [1];
  4. Placement of a small-sized DLT through the tracheotomy stoma; or
  5. If possible, oral access to the airway for standard placement of a DLT or BB (an option in patients on prolonged mechanical ventilation for respiratory failure).


A conventional DLT placed through a tracheostomy may be prone to malposition because the upper airway has been shortened and the DLT may be too long. Before placing any lung isolation devices through a tracheostomy it is important to consider whether it is a fresh stoma (e.g. as in our patient) when the airway can be lost immediately on decannulation versus a chronic tracheostomy.

Use of BB has advantage in patients with tracheostomy as its placement is easy, the multiport adaptor allows simultaneous ventilation and fibreoptic bronchoscopy, the central lumen of the BB allows suction of secretions and oxygen insufflations, and it comes in one size suitable for all adults. Not many cases of use of BB through an existing tracheostomy for OLV have been reported in the literature.

Matthews and Sanders [2] have reported a case of successful OLV for right upper lobectomy for carcinoma of the lung using a wire-guided BB through an existing permanent tracheostomy. Veit and Allen have also reported a case of attempted OLV using a BB in a patient with a fresh tracheostomy. Although they introduced the BB after direct laryngoscopy through vocal cords following deflation of the tracheostomy tube, a flexible bronchoscope through the tracheostomy tube guided the placement of the BB in the main stem bronchus [3].

Uzuki et al. [4] have reported ease of use of the same BB that we used through a spiral endotracheal tube for lobectomy in a patient with existing tracheostomy. Spicek-Macan et al. [5] have described the use of BB for lung separation through the percutaneous tracheal cannula to control active tuberculosis-related exsanguinating haemoptysis in a young patient.

Dislodgement, obstruction and trauma to lung tissue are common complications on use of BB. As malposition often occurs while turning the patient from the supine to the lateral position it is recommended to deflate the BB cuff and advance it 1 cm before lateral positioning [6]. Niwal et al. [7] have reported a case of an airway obstruction following the use of a BB for OLV for pneumonectomy, wherein deflation and withdrawal of BB lead to obstruction of the dependent bronchus with blood and secretions. Repeated suction of the BB lumen during OLV and placement of an independent suction catheter in the tracheal lumen before deflating the BB are recommended to trap any retained secretions and prevent obstruction of the dependent bronchus.

Univent tube or specially designed short DLT were not considered in our patient because of nonavailability.

Even in cases where airway access was not considered to be difficult in the beginning, extubation can become a critical event because of mucosa edema, bleeding and secretions. Change of tube in such cases while maintaining continuous access to the airway can be tricky. BB can be deflated and withdrawn easily after suction without causing any trauma to the existing stoma, and provides an easy way to maintain the airway in such cases.


  Conclusion Top


Special airway management is needed to provide OLV in a patient with tracheostomy. A fresh tracheostomy further limits the options of techniques for OLV. Placing a BB through tracheostomy and positioning it under guidance of fibreoptic bronchoscopy while maintaining continuous ventilation proved to be a simple, easy and safe way to provide OLV without causing any disturbance to the tracheostomy site. We recommend the endobronchial blocker as a simple and effective way to achieve OLV through an existing or fresh tracheostomy.


  Acknowledgements Top


Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Saito T, Naruke T, Carney E, Yokokawa Y, Hiraga K, Carlsson C. New double intrabronchial tube (Naruke tube) for tracheostomized patients. Anesthesiology 1998; 89:1038-1039.  Back to cited text no. 1
[PUBMED]    
2.
Matthews AJ, Sanders DJ. Single-lung ventilation via a tracheostomy using a fibreoptically-directed 'steerable' endobronchial blocker. Anaesthesia 2001; 56:492-493.  Back to cited text no. 2
[PUBMED]    
3.
Veit AM, Allen RB. Single-lung ventilation in a patient with a freshly placed percutaneous tracheostomy. Anesth Analg 1996; 82:1292-1293.  Back to cited text no. 3
    
4.
Uzuki M, Kanaya N, Mizuguchi A, Kurosawa S, Nakayama M, Omote K, Namiki A. One-lung ventilation using a new bronchial blocker in a patient with tracheostomy stoma. Anesth Analg 2003; 96:1538-1539.  Back to cited text no. 4
[PUBMED]    
5.
Spicek-Macan J, Hodoba N, Nikolic I, Stancic-Rokotov D, Kolaric N, Popovic-Grle S. Exsanguinating tuberculosis-related hemoptysis: bronchial blocker introduced through percutaneous tracheostomy. Minerva Anestesiol 2009; 75:405-408.  Back to cited text no. 5
    
6.
Campos JH, Kernstine KH. A comparison of a left-sided Broncho-Cath with the torque control blocker univent and the wire-guided blocker. Anesth Analg 2003; 96:283-289.  Back to cited text no. 6
    
7.
Niwal N, Ranganathan P, Divatia J. Bronchial blocker for one-lung ventilation: an unanticipated complication. Indian J Anaesth 2011; 55:636-637.  Back to cited text no. 7
[PUBMED]  Medknow Journal  


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