|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 4 | Page : 201-202
A modified strategy for one-lung ventilation in a patient with tracheal bronchus and difficult airway
Zhi-Fu Wu1, Meng-Fu Lai2, Jen-Yin Chen3, Hou-Chuan Lai2
1 Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei; Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
2 Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
3 Department of Anesthesiology, Chi Mei Medical Center; Department of the Senior Citizen Service Management, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
|Date of Submission||15-Oct-2019|
|Date of Decision||23-Oct-2019|
|Date of Acceptance||19-Nov-2019|
|Date of Web Publication||03-Dec-2019|
Dr. Hou-Chuan Lai
#325, Section 2, Chenggung Road, Neihu 114, Taipei
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Wu ZF, Lai MF, Chen JY, Lai HC. A modified strategy for one-lung ventilation in a patient with tracheal bronchus and difficult airway. J Med Sci 2020;40:201-2
|How to cite this URL:|
Wu ZF, Lai MF, Chen JY, Lai HC. A modified strategy for one-lung ventilation in a patient with tracheal bronchus and difficult airway. J Med Sci [serial online] 2020 [cited 2020 Sep 26];40:201-2. Available from: http://www.jmedscindmc.com/text.asp?2020/40/4/201/272329
Tracheal bronchus is a congenital anomaly in which the right upper lobe bronchus originates from the lateral tracheal wall. This anatomic variant, which occurs in approximately 1 of 250 patients at bronchoscopy, may complicate one-lung ventilation (OLV) during thoracic surgery with a bronchial blocker. Previous studies have described the challenges for OLV in patients with tracheal bronchus but successfully delivered strategies to navigate them., Moon et al. used an Arndt endobronchial blocker for right-sided OLV in the left lower lobe lung mass resection, and Lee et al. used double-lumen tubes (DLTs) for left-sided OLV in three patients undergoing esophagectomy or right upper lobe lobectomy.
Here, we encountered unanticipated difficult airway in a 67-year-old woman (ASA II; height of 166 cm and weight of 63 kg) with a tracheal bronchus undergoing video-assisted thoracoscopic surgery for right lower lobe lung mass resection. The preoperative computed tomography scan of the chest revealed a tracheal bronchus [Figure 1]a. After anesthetic induction, we attempted to intubate a 35 Fr left-sided DLT (Mallinckrodt™, Covidien, Ireland) using GlideScope® video laryngoscope for several attempts but were unsuccessful because of the abnormally high position of the glottic opening in this patient. Following the immediate discussion with surgeons, we used a bronchial blocker (Coopdech Endobronchial Blocker Tube, Daiken Medical Corp., Osaka, Japan) for left-sided OLV. However, the right upper lobe was still inflated during surgery, and so, we adjusted the tidal volume to obtain an acceptable surgical field [Figure 1]b. The surgery was performed smoothly, without any complication. The patient's hemodynamics was stable, and pulse oximetry saturation showed 100%, with 100% FiO2 throughout. Several days after surgery, the patient was discharged without any sequelae.
|Figure 1:(a) The preoperative computed tomography scan of the chest revealed a right upper lobe tracheal bronchus (TB). (b) The right upper lobe was still inflated during surgery under left-sided one-lung ventilation|
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Careful preoperative assessment of tracheobronchial anatomy is instrumental in choosing an appropriate method of OLV and preventing potential complications, despite the low incidence of tracheal bronchus. When a tracheal bronchus is found, DLT insertion is recommended instead of blocker insertion to achieve OLV completely. Conversely, a bronchial blocker may have advantages over the conventional DLT in achieving OLV in patients with a tracheal bronchus and difficult airway,, even in the right lower lobe lung mass resection due to less interference by a ventilated right upper lobe. If the right upper lobe is the operation site, an alternative modality is exchanging the single lumen for a left DLT using an airway exchange catheter for OLV, yet this procedure is not without risks, including laryngeal trauma, tracheobronchial trauma, pneumothorax, lung laceration, esophageal perforation, and dislodgement of the endotracheal tube. Accordingly, we did not use a tube exchanger at that time. In addition, nonintubated video-assisted thoracoscopic surgery with laryngeal mask airway may be an alternative technique for patients with a tracheal bronchus and difficult intubation under careful preoperative evaluation.
We thank the patient for signing the informed consent for publication.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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