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.
Bronchoscopy; fiberoptic; Intratracheal intubation; nasotracheal; thoracic surgical procedures
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.
Airway obstruction; Bronchial neoplasm; Pneumonectomy; Double-lumen endotracheal tube
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.
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.
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.
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.
Cardiac surgery; Double-lumen endotracheal tube; Endobronchial hemorrhage; Idiopathic thrombocytopenic purpura; Minimally invasive surgical procedures
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.
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.
Airway extubation; esophagus; intratracheal; intubation
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.
Fiberoptic bronchoscope; Intubation; Laceration; LMA; Trachea
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.
Bilateral vocal cord paralysis; Double-lumen endotracheal tube; Postoperative stridor
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.
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.
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.
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.
Bronchi; intubation–intratracheal; one-lung ventilation; thoracic surgical procedures
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.
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.
Airway obstruction; Difficult intubation; Laryngeal mass
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.
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.
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.
Intubation of difficult airways can be performed more rapidly with BIF-DL, but sometimes it may not be possible to intubate with the scope.
Bronchoscopes; Fiberoptics; Intubation; Laryngoscopy; Video recording
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.
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.
Burn airway; neck contracture; fiberoptic bronchoscopy; laryngeal mask airway
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.
Airway obstruction; Bronchoscopy; Double lumen tube; Tracheal abutment
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.
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.
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]).
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.
Bronchoscopy; Intratracheal; Intubation
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.
Fiberoptic bronchoscopy; Prone position; Tracheal compression; Vascular anomaly
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.
Cervical instability; classic laryngeal mask airway; cord damage; difficult airway
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.
Airway exchange catheter; Fiberoptic intubation; Laryngeal mask airway; Pierre robin syndrome
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.
Blunt trauma chest; intubating laryngeal mask airway; morbid obese
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.
Nasotracheal intubation; Parker Flex-Tip tube; Endotracheal intubation; Endotracheal tube; Fiber-optic intubation
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.
Bronchial rupture; Complication; Double lumen endobronchial tube; Intubation
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.
Bronchial blocker; Double lumen tube; One lung ventilation; Tracheal bronchus
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.
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.
Airway management; Difficult airway; Equipment; Laryngeal masks; Lung separation