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1.  One lung ventilation in a patient with an upper and lower airway abnormality 
Indian Journal of Anaesthesia  2012;56(6):567-569.
One-lung ventilation for a thoracotomy procedure was achieved with the help of a endobronchial blocker in a young girl with limited mouth opening, minimal neck extension, and a distorted tracheo-bronchial anatomy. As the patient would not cooperate for an awake nasotracheal intubation despite adequate preperation, an inhalational anesthetic was used to make the patient unconscious, taking care that spontaneous breathing was maintained. Nasotracheal intubation was done with the help of a fiberoptic bronchoscope. A wire-guided Arndt endobronchial blocker was placed coaxially through the endotracheal tube using a fiberoptic bronchoscope. This case report highlights that in a scenario of both upper and lower airway distortion, a bronchial blocker positioned through a nasotracheal tube under fiberoptic guidance might be the best option when one-lung ventilation is required.
doi:10.4103/0019-5049.104578
PMCID: PMC3546245  PMID: 23325943
Bronchoscopy; fiberoptic; Intratracheal intubation; nasotracheal; thoracic surgical procedures
2.  Bronchial obstruction by tumor embolus of contralateral lung during pneumonectomy: report of a case 
Bronchial obstruction due to a tumor embolus of the contralateral lung during pneumonectomy is an uncommon and fatal complication. According to previous cases, a bronchial balloon of double-lumen endotracheal tube (DLT) could prevent a dislodged tumor from traveling to the contralateral lung. We experienced a tumor embolism from the bronchus with cancer to the other bronchus despite applying DLT. A 59-year-old male with endobronchial lung cancer underwent a left pneumonectomy. One-lung ventilation was established by the right-sided DLT. After a left bronchial division, a sudden increase of peak airway pressure and reduction of the expired tidal volume to 50 ml was observed. Intraoperative fiberoptic bronchoscopy showed a near total obstruction of the right main bronchus due to tumor emboli. It was not possible to remove the tumor embolus through bronchoscopic suction and forceps. Therefore, we reopened the left bronchial stump and successfully extracted tumor embolus under bronchoscopic guidance.
doi:10.1186/1749-8090-8-26
PMCID: PMC3598947  PMID: 23421935
Airway obstruction; Bronchial neoplasm; Pneumonectomy; Double-lumen endotracheal tube
3.  Anaesthesia for serial whole-lung lavage in a patient with severe pulmonary alveolar proteinosis: a case report 
Introduction
Pulmonary alveolar proteinosis is a rare condition that requires treatment by whole-lung lavage. We report a case of severe pulmonary alveolar proteinosis and discuss a safe and effective strategy for the anaesthetic management of patients undergoing this complex procedure.
Case presentation
A 34-year-old Caucasian man was diagnosed with severe pulmonary alveolar proteinosis. He developed severe respiratory failure and subsequently underwent serial whole-lung lavage. Our anaesthetic technique included the use of pre-oxygenation, complete lung separation with a left-sided double-lumen endotracheal tube, one-lung ventilation with positive end-expiratory pressure, appropriate ventilatory monitoring, cautious use of positional manoeuvres and single-lumen endotracheal tube exchange for short-term postoperative ventilation.
Conclusion
Patients with pulmonary alveolar proteinosis may present with severe respiratory failure and require urgent whole-lung lavage. We have described a safe and effective strategy for anaesthesia for whole-lung lavage. We recommend our anaesthetic technique for patients undergoing this complex and uncommon procedure.
doi:10.1186/1752-1947-2-360
PMCID: PMC2607303  PMID: 19038019
4.  Endobronchial hemorrhage after intubation with double-lumen endotracheal tube in a patient with idiopathic thrombocytopenic purpura for minimally invasive cardiac surgery: a case report 
Minimally invasive cardiac surgery (MICS) requires lung isolation. Lung isolation is usually achieved with double-lumen endotracheal tube (DLT). Patients with idiopathic thrombocytopenic purpura (ITP) have an increased risk of bleeding events. We suspected endobronchial hemorrhage after exchange of DLT during induction of anesthesia for replacement of mitral valve in a 62-year-old man with a known ITP. The MICS was stopped and bronchial artery embolization was performed in the angiographic room. In the present case, in order to reduce the risk of bronchial arterial injury in ITP patient we intubated with single lumen endotracheal tube. Lung isolation led to achievement of intermittent total lung deflation. Based on the results, we recommend a high-dose intravenous immunoglobulin therapy and platelet transfusion prior to cardiac surgery in patients with ITP to increase platelet count. Moreover, it is proposed that in order to clear the vision during the operation, ventilation can be held or made intermittent both prior to cardiopulmonary bypass or at its conclusion to permit exposure.
doi:10.4097/kjae.2014.66.1.59
PMCID: PMC3927003  PMID: 24567815
Cardiac surgery; Double-lumen endotracheal tube; Endobronchial hemorrhage; Idiopathic thrombocytopenic purpura; Minimally invasive surgical procedures
5.  Iatrogenic Left Main Bronchus Injury following Atraumatic Double Lumen Endotracheal Tube Placement 
Case Reports in Anesthesiology  2013;2013:524348.
Tracheobronchial disruption is an uncommon but severe complication of double lumen endotracheal tube placement. The physical properties of a double lumen tube (large external diameter and length) make tracheobronchial injury more common than that associated with smaller single lumen endotracheal tubes. Here we present the case of an iatrogenic left main bronchus injury caused by placement of a double lumen tube in an otherwise unremarkable airway.
doi:10.1155/2013/524348
PMCID: PMC3833405  PMID: 24288629
6.  Esophageal misplacement of a single-lumen tube after its exchange for a double-lumen tube despite the use of an airway-exchange catheter 
Saudi Journal of Anaesthesia  2013;7(2):194-196.
An airway-exchange catheter (AEC) can increase the safety of exchanges of endotracheal tubes (ETTs); however, the procedure is associated with potential risks. We describe a case of esophageal misplacement of a single-lumen ETT after switching from a double-lumen tube, despite the use of an AEC as a guidewire. To avoid this, physicians should consider the insertion depth and maintenance depth of the AEC and should verify its position before changing ETTs and should perform, if possible, with simultaneous visualization of the glottis with direct or video laryngoscopy during the exchange. Additionally, the new ETT position should be confirmed by auscultation, end-tidal carbon dioxide, and portable chest X-ray.
doi:10.4103/1658-354X.114050
PMCID: PMC3737699  PMID: 23956723
Airway extubation; esophagus; intratracheal; intubation
7.  Tracheal laceration during intubation of a double-lumen tube and intraoperative fiberoptic bronchoscopic evaluation through an LMA in the lateral position -A case report- 
Korean Journal of Anesthesiology  2011;60(4):285-289.
A 76-year-old, 148-cm woman was scheduled for right upper lobectomy. A 32 Fr left-sided double lumen tube was placed using a conventional technique. Despite several attempts under fiberoptic bronchoscope-guidance, we could not locate the double lumen tube properly. We thus decided to proceed with the bronchial tube in the right mainstem bronchus. During surgery, 8-cm-long laceration was noted on the posterolateral side of the trachea. To check the possibility of laceration of the proximal trachea, the double lumen tube was changed to an LMA for use as a conduit for fiberoptic bronchoscopic evaluation in the lateral position. A plain endotracheal tube with the cuff modified and collapsed was re-intubated after evaluation. And then she was transferred to SICU.
doi:10.4097/kjae.2011.60.4.285
PMCID: PMC3092965  PMID: 21602980
Fiberoptic bronchoscope; Intubation; Laceration; LMA; Trachea
8.  Transient bilateral vocal cord paralysis after endotracheal intubation with double-lumen tube -A case report- 
Korean Journal of Anesthesiology  2010;59(Suppl):S9-S12.
Vocal cord paralysis is one of the most serious anesthetic complications related to endotracheal intubation. The practitioner should take extreme care, as bilateral vocal cord paralysis can obstruct the airway and lead to disastrous respiratory problems. There have been many papers on bilateral vocal cord paralysis after neck surgery, but reports on such a condition after lung surgery are very rare. We report a case of bilateral vocal cord paralysis detected after removal of a double-lumen endotracheal tube in a 67-year-old patient who underwent wedge resection by video-assisted thoracoscopic surgery. We also note that he recovered spontaneously without complications within a day.
doi:10.4097/kjae.2010.59.S.S9
PMCID: PMC3030066  PMID: 21286470
Bilateral vocal cord paralysis; Double-lumen endotracheal tube; Postoperative stridor
9.  Effective Use of Bronchial Blockers in Lung Isolation Surgery: An Analysis of 130 Cases 
The Ochsner Journal  2013;13(3):389-393.
Background
One-lung ventilation (OLV) is necessary for selected surgical settings and medical conditions. Different methods have been described and used to isolate 1 lung, including the double-lumen endotracheal tube (DLT) and a variety of bronchial blockers (BBs). This selection is often based on the preferences and experiences of the anesthesiologist and surgeon. Complications associated with OLV isolation tubes have been previously described, but complications specifically associated with the Cohen BB (CBB) (Cook Medical, Bloomington, IN) have not been investigated. The purpose of this retrospective review was to determine the incidence of vocal cord injury, tracheobronchial injury, and hoarseness in adult patients who underwent OLV with the CBB.
Methods
We reviewed electronic anesthesia records, operative dictation, and inpatient progress notes to collect information about vocal cord injury, bronchial injury, hoarseness, and sore throat for adults who underwent surgical and diagnostic procedures requiring OLV. Secondary endpoints were types of surgical procedures, degree of difficulty with orotracheal intubation, ability of the patient to tolerate extubation in the operating room, and whether the thoracic surgeon deemed the lung separation adequate. P<0.05 was considered significant.
Results
Of 130 patients, 113 underwent OLV with a CBB, and 17 patients underwent OLV with a DLT. The thoracic surgeon deemed the lung isolation adequate in all cases. Airway injury occurred in 2 patients with a CBB and none with a DLT (P=0.86). Both airway injuries were attributed to surgical technique. Two cases of postoperative hoarseness occurred in the CBB group (P=0.86). One injury was attributed to vagus nerve transection, and the other injury was diagnosed as vocal cord paralysis of unknown etiology. In 1 case, orotracheal intubation with a DLT was unsuccessful because of intubation difficulty and required conversion to a regular endotracheal tube and CBB for successful lung isolation.
Conclusion
This study demonstrates that the use of CBB can be successful in a wide variety of thoracic operations, has minimal complications, eliminates the need for tracheal tube exchange when postoperative mechanical ventilation is required, and effectively isolates the lungs of critically ill patients.
PMCID: PMC3776516  PMID: 24052770
Bronchi; intubation–intratracheal; one-lung ventilation; thoracic surgical procedures
10.  A Rare Complication of Tracheal Intubation: Tongue Perforation 
Case Reports in Anesthesiology  2012;2012:281791.
Aim. To describe the subsequent treatment of airway trauma sustained during laryngoscopy and endotracheal intubation. Methods. A rare injury occurring during laryngoscopy and endotracheal intubation that resulted in perforation of the tongue by an endotracheal tube and the subsequent management of this unusual complication are discussed. A 65-year-old female with intraparenchymal brain hemorrhage with rapidly progressive neurologic deterioration had the airway secured prior to arrival at the referral institution. The endotracheal tube (ETT) was noted to have pierced through the base of the tongue and entered the trachea, and the patient underwent operative laryngoscopy to inspect the injury and the ETT was replaced by tracheostomy. Results. Laryngoscopy demonstrated the ETT to perforate the base of the tongue. The airway was secured with tracheostomy and the ETT was removed. Conclusions. A wide variety of complications resulting from direct and video-assisted laryngoscopy and tracheal intubation have been reported. Direct perforation of the tongue with an ETT and ability to ventilate and oxygenate subsequently is a rare injury.
doi:10.1155/2012/281791
PMCID: PMC3465871  PMID: 23056962
11.  An awake double lumen endotracheal tube intubation using the Clarus Video System in a patient with an epiglottic cyst: a case report 
Korean Journal of Anesthesiology  2014;66(2):157-159.
A 54-year-old male patient was scheduled for an elective pylorus-preserving pancreaticoduodenectomy combined with video-assisted thoracic surgery at our hospital. This patient had a history of intubation failure in other institutions due to an epiglottic cyst. An airway assessment of the patient was normal. A preoperative laryngoscopy revealed a bulging epiglottic mass covering most of the epiglottis and occupying most of the pharyngeal space. The patient was administered intravenous midazolam 1 mg, fentanyl 50 µg, and glycopyrrolate 0.2 mg. A bilateral superior laryngeal nerve block was then performed with 2% lidocaine 2 ml on each side. A 10% lidocaine spray was applied on to the oropharynx. After preoxygenation with 100% oxygen over 10 minutes, a rigid fiberscope with an optical stylet loaded with a 37 Fr double lumen endotracheal tube was inserted orally and passed into the glottic aperture. The patient was fully awakened after surgical procedure and was transferred to the recovery room after extubation.
doi:10.4097/kjae.2014.66.2.157
PMCID: PMC3948444  PMID: 24624275
Airway obstruction; Difficult intubation; Laryngeal mass
12.  A comparison of Bonfils intubation fiberscopy and fiberoptic bronchoscopy in difficult airways assisted with direct laryngoscopy 
Korean Journal of Anesthesiology  2010;58(3):249-255.
Background
To evaluate the usefulness of Bonfils intubation fiberscope assisted by direct laryngoscopy (BIF-DL) and flexible fiberoptic bronchoscope assisted by direct laryngoscopy (FOB-DL) using video recording in cases of unanticipated difficult intubation with respect to the time required to visualize the vocal cords and place the endotracheal tube. We compared two fiberscopes in patients with authentic difficult airways.
Methods
In this randomized, controlled clinical trial, 40 patients (grade 3 according to grades of difficulty in laryngoscopy), scheduled for surgery under general anesthesia were randomly allocated to BIF-DL group or FOB-DL group. Number of attempts, time required for visualization of the vocal cord (T1) and placement of the endotracheal tube (T2) from insertion of instrument during the last successful attempt, and duration of scope manipulation during all attempts (Ttotal) were recorded. If intubation failed with one method, the other method was tried; these cases were then excluded. The incidence of sore throat and hoarseness was assessed.
Results
T1, T2, and Ttotal were significantly shorter in BIF-DL group (T1: 21.9 ± 8.2 sec vs. 80.4 ± 29.9 sec, P < 0.001, Ttotal: 77.9 ± 41.2 sec vs. 145.5 ± 83.9 sec, P = 0.003). In two cases, it was impossible to intubate with BIF-DL, but the procedure was subsequently successful using fibreoptic bronchoscope.
Conclusions
Intubation of difficult airways can be performed more rapidly with BIF-DL, but sometimes it may not be possible to intubate with the scope.
doi:10.4097/kjae.2010.58.3.249
PMCID: PMC2872830  PMID: 20498773
Bronchoscopes; Fiberoptics; Intubation; Laryngoscopy; Video recording
13.  Airway Tube Exchanger Techniques in Morbidly Obese Patients 
Morbidly obese patients may present a challenge during airway management. When airway tube exchange is required, it can even be more challenging than the primary intubation. With the increasing prevalence of morbid obesity over the years, there will be increasing numbers of these patients presenting for surgical procedures, including ones that require endotracheal tube exchanges. It is therefore important for anesthesiologists to be familiar with options and limitations of the airway tube exchanger techniques.
doi:10.1155/2012/968642
PMCID: PMC3287032  PMID: 22400023
14.  Managing difficult airway in patients with post-burn mentosternal and circumoral scar contractures 
Securing the airway is a crucial aspect during reconstructive surgeries of patients with extensive post-burn mentosternal scar contractures; however, the American Society of Anesthesiologists Difficult Airway Management Algorithm recommendation of initial direct laryngoscopy may not be appropriate for these complicated patients. Consequently, there is a significant risk for failure of intubation and airway emergency. We suggest that initial attempts at securing the airway be made with indirect laryngoscopy. Many airway techniques have been effectively used in burn patients, but the role of awake blind or fiberoptic bronchoscopy, although well established in the non-burn population, has yet to be evaluated in burn patients. We report a case series of successful management of difficult airways with fiberoptic bronchoscopy in patients with varying degrees of post-burn head and neck scar contractures.
PMCID: PMC3462526  PMID: 23071905
Burn airway; neck contracture; fiberoptic bronchoscopy; laryngeal mask airway
15.  Unexpected difficulty in ventilating the lungs after tracheal intubation -A case report- 
Korean Journal of Anesthesiology  2011;60(6):437-439.
We experienced difficulty in ventilating the lungs of a patient after tracheal intubation. After intubation, an insufficient amount of tidal volume (VT) was delivered to the patient and the fiberoptic bronchoscopic examination identified partial abutment of the endotracheal tube (ETT) orifice against the tracheal wall. After various attempts to correctly place the ETT, a double-lumen endotracheal tube was placed to achieve a sufficient VT. It is important to notice that even an appropriately placed ETT may get obstructed due to the left sided bevel at its tip.
doi:10.4097/kjae.2011.60.6.437
PMCID: PMC3121092  PMID: 21738848
Airway obstruction; Bronchoscopy; Double lumen tube; Tracheal abutment
16.  Assessment of airway length of Korean adults and children for otolaryngology and ophthalmic surgery using a fiberoptic bronchoscope 
Korean Journal of Anesthesiology  2010;59(4):249-255.
Background
Knowledge regarding normal upper airway anatomy is essential for airway management and is required to prevent malpositioning of endotracheal tubes. We evaluated the length of the upper airway in Korean children and adults who had no abnormality of the upper airway using a fiberoptic bronchoscope.
Methods
Eighty seven patients aged 5 to 81 years undergoing noninvasive elective surgery were included in this study. After induction of anesthesia was complete, we measured the distance from the upper incisor to various components of the upper airway by fiberoptic bronchoscopy.
Results
In adults, the mean length between the upper incisor and midtrachea was found to be 21.8 ± 1.8 cm in males and 19.9 ± 1.3 cm in females, while the mean length of the trachea was 10.1 ± 1.3 cm in males and 10.3 ± 1.6 cm in females. The length between the upper incisor and midtrachea (IT) were correlated with height both in children (IT [cm] = 2.531 + 0.109 × height [cm]) and adults (IT [cm] = 0.167 + 0.127 × height [cm]), which shows that they differ from the western standard (length of tube [cm] = 5 + 0.1 × height [cm]).
Conclusions
In adults and children, the length from the incisor to the midtrachea was significantly different when compared with western standards. Therefore, re-evaluation of the proper and precise depth of endotracheal tube in Koreans should be considered.
doi:10.4097/kjae.2010.59.4.249
PMCID: PMC2966705  PMID: 21057614
Bronchoscopy; Intratracheal; Intubation
17.  Airway obstruction by extrinsic tracheal compression during spinal surgery under prone position -A case report- 
Korean Journal of Anesthesiology  2010;59(Suppl):S45-S48.
Tracheal compression by vascular anomalies in adults is uncommon and most related reports are of children. A 79-year-old woman without any respiratory history underwent a lumbar spine surgery under general anesthesia. She suddenly developed airway obstruction after a position change from supine to prone. A fiberoptic bronchoscopy showed the obstruction of endotracheal tube. The obstruction was relieved after we changed the depth of endotracheal tube and supported the patient's neck with a cotton roll. The surgery ended without any other event and the patient recovered safely. A computed tomography revealed the rightward tracheal deviation and tortuous innominate artery contact with trachea. The patient didn't manifest any respiratory related symptoms during postoperative period, and she was discharged without any treatment.
doi:10.4097/kjae.2010.59.S.S45
PMCID: PMC3030054  PMID: 21286458
Fiberoptic bronchoscopy; Prone position; Tracheal compression; Vascular anomaly
18.  Safe intubation in Morquio-Brailsford syndrome: A challenge for the anesthesiologist 
Morquio-Brailsford syndrome is a type of mucopolysaccharidoses. It is a rare disease with features of short stature, atlantoaxial instability with risk of cord damage, odontoid hypoplasia, pectus carinatum, spine deformities, hepatomegaly, and restrictive lung disease. Neck movements during intubation are associated with the risk of quadriparesis due to cervical instability. This, along with the distortion of the airway anatomy due to deposition of mucopolysaccharides makes airway management arduous. We present our experience in management of difficult airway in a 3-year-old girl with Morquio-Brailsford syndrome posted for magnetic resonance imaging and computerized tomography scan of a suspected unstable cervical spine. As utmost sagacity during intubation is required, the child was intubated inside operation theatre in the presence of experienced anesthesiologists and then shifted to the peripheral location. Intubation was done with an endotracheal tube railroaded over a pediatric fibreoptic bronchoscope passed through the lumen of a classic laryngeal mask airway, keeping head in neutral position.
doi:10.4103/0970-9185.111666
PMCID: PMC3713682  PMID: 23878456
Cervical instability; classic laryngeal mask airway; cord damage; difficult airway
19.  Usefulness of a Cook® airway exchange catheter in laryngeal mask airway-guided fiberoptic intubation in a neonate with Pierre Robin syndrome -A case report- 
Korean Journal of Anesthesiology  2013;64(2):168-171.
The case of a 33-day-old boy with Pierre Robin syndrome using a Cook® airway exchange catheter in laryngeal mask airway-guided fiberoptic intubation is presented. After induction with sevoflurane, classical reusable laryngeal mask airway (LMA) #1 was inserted and ultrathin fiberoptic bronchoscope (FOB) was passed through. A Cook® airway exchange catheter (1.6 mm ID, 2.7 mm OD) was passed through the LMA under the guidance of the FOB but failed to enter the trachea despite many trials. Then, an endotracheal tube (3.0 mm ID) was mounted on the FOB and railroaded over the FOB. After successful intubation, the Cook® airway exchange catheter was placed in the midtrachea through the lumen of the endotracheal tube. Even though the tracheal tube was accidentally displaced out of the trachea during LMA removal, the endotracheal tube could be easily railroaded over the airway exchange catheter.
doi:10.4097/kjae.2013.64.2.168
PMCID: PMC3581788  PMID: 23458916
Airway exchange catheter; Fiberoptic intubation; Laryngeal mask airway; Pierre robin syndrome
20.  Use of intubating laryngeal mask airway in a morbidly obese patient with chest trauma in an emergency setting 
A morbidly obese male who sustained blunt trauma chest with bilateral pneumothorax was referred to the intensive care unit for management of his condition. Problems encountered in managing the patient were gradually increasing hypoxemia (chest trauma with multiple rib fractures with lung contusions) and difficult mask ventilation and intubation (morbid obesity, heavy jaw, short and thick neck). We performed awake endotracheal intubation using an intubating laryngeal mask airway (ILMA) size 4 and provided mechanical ventilation to the patient. This report suggests that ILMA can be very useful in the management of difficult airway outside the operating room and can help in preventing adverse events in an emergency setting.
doi:10.4103/0970-9185.86605
PMCID: PMC3214566  PMID: 22096294
Blunt trauma chest; intubating laryngeal mask airway; morbid obese
21.  Parker Flex-Tip and Standard-Tip Endotracheal Tubes: A Comparison During Nasotracheal Intubation 
Anesthesia Progress  2010;57(1):18-24.
Abstract
The placement of endotracheal tubes in the airway, particularly through the nose, can cause trauma. Their design might be an important etiologic factor, but they have changed little since their introduction. Recently Parker Medical (Bridgewater, Conn ) introduced the Parker Flex-Tip (PFT) tube, suggesting that it causes less trauma. This study aimed to compare the PFT endotracheal tube to a side-beveled, standard-tip endotracheal tube (ETT) for nasotracheal intubation (Figures 1 and 2). Forty consecutive oral surgery patients requiring nasotracheal intubation were randomized to receive either a standard ETT or the PFT tube. Intubations were recorded using a fiber-optic camera positioned proximal to the Murphy eye of the tube. This allowed visualization of the path and action of the tube tip as it traversed the nasal, pharyngeal, laryngeal, and tracheal airway regions. Video recordings made during intubation and extubation were evaluated for bleeding, trauma, and intubation time. Both bleeding and trauma were recorded using a visual analogue scale (VAS) and by 3 different evaluators. The PFT received significantly better VAS values than the standard tubes from all 3 raters (P < 0.05) in both the extent of trauma and bleeding. Since the intubations were purposefully conducted slowly for photographic reasons, neither tube displayed a time advantage. This study suggests that the PFT tube design may be safer by causing less trauma and bleeding than standard tube designs for nasotracheal intubation.
doi:10.2344/0003-3006-57.1.18
PMCID: PMC2844234  PMID: 20331335
Nasotracheal intubation; Parker Flex-Tip tube; Endotracheal intubation; Endotracheal tube; Fiber-optic intubation
22.  Left mainstem bronchial rupture during one-lung ventilation with Robertshaw double lumen endobronchial tube -A case report- 
Korean Journal of Anesthesiology  2010;59(Suppl):S21-S25.
Lung separation using a double-lumen endobronchial tube is necessary for video assisted thoracoscopy (VATs). Bronchial rupture after intubation with a double-lumen endobronchial tube has been rarely reported. We report a case of a 70-year-old man who had solitary pulmonary nodule in his right upper lobe. He was intubated with a left-sided Robertshaw double-lumen endobronchial tube. He underwent a VATs right upper lobectomy with the one-lung ventilation of left lung. During the operation, the rupture of the left mainstem bronchus was detected. Immediately, the thoracotomy was performed and the ruptured left mainstem bronchus was repaired with absorbable sutures (vicryl). Seven days later he had a bronchoscopy to examine the left mainstem bronchus. There was no evidence of the bleeding, leakage and inflammation. Subsequent course was uneventful. Tracheobronchial injuries related to the double-lumen endobronchial tube are discussed.
doi:10.4097/kjae.2010.59.S.S21
PMCID: PMC3030039  PMID: 21286443
Bronchial rupture; Complication; Double lumen endobronchial tube; Intubation
23.  Right upper lobe tracheal bronchus: anesthetic challenge in one-lung ventilated patients -A report of three cases- 
Korean Journal of Anesthesiology  2013;64(5):448-450.
Tracheal bronchus (TB) is an aberrant, accessary or ectopic bronchus arising almost exclusively from the right side of the tracheal wall above the carina. In our center, 673 bronchoscopic examinations were performed from 2009 to 2011 in patients undergoing one lung ventilation (OLV) and 3 TB were found. The incidence of a TB at bronchoscopy was 0.45% in our research, which is consistent with the reported incidence range from 0.1-5%. The clinician should consider the possibility of anomalous right upper lobe bronchus and perform bronchoscopy prior to the right bronchial blocker insertion, when left-sided OLV using bronchial blocker is planned. Also, for the patient with TB, a double lumen tube insertion is recommended than a blocker insertion to achieve OLV completely.
doi:10.4097/kjae.2013.64.5.448
PMCID: PMC3668108  PMID: 23741569
Bronchial blocker; Double lumen tube; One lung ventilation; Tracheal bronchus
24.  Clinical review: Independent lung ventilation in critical care 
Critical Care  2005;9(6):594-600.
Independent lung ventilation (ILV) can be classified into anatomical and physiological lung separation. It requires either endobronchial blockade or double-lumen endotracheal tube intubation. Endobronchial blockade or selective double-lumen tube ventilation may necessitate temporary one lung ventilation. Anatomical lung separation isolates a diseased lung from contaminating the non-diseased lung. Physiological lung separation ventilates each lung as an independent unit. There are some clear indications for ILV as a primary intervention and as a rescue ventilator strategy in both anatomical and physiological lung separation. Potential pitfalls are related to establishing and maintaining lung isolation. Nevertheless, ILV can be used in the intensive care setting safely with a good understanding of its limitations and potential complications.
doi:10.1186/cc3827
PMCID: PMC1414047  PMID: 16356244
25.  Placement of a double-lumen tube using LMA C Trach and an exchanger catheter in difficult airway intubation -A case report- 
Korean Journal of Anesthesiology  2012;62(6):565-567.
During insertion of the double lumen tube in patients with cervical vertebral fixation, the cervical neutral position should be maintained. Although flexible fiberoptic bronchoscopic intubation is the gold standard, novel techniques are needed to facilitate intubation of patients with cervical vertebral fixation in neutral position according to institutional capabilities. In this case report, insertion of the double lumen tube in the neutral position using LMA CTrach and an airway exchanger catheter in a thoracotomy patient with extremely limited head and neck motion due to fixation of the cervical vertebrae is presented.
doi:10.4097/kjae.2012.62.6.565
PMCID: PMC3384796  PMID: 22778894
Airway management; Difficult airway; Equipment; Laryngeal masks; Lung separation

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