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 Table of Contents  
Year : 2020  |  Volume : 40  |  Issue : 4  |  Page : 201-202

A modified strategy for one-lung ventilation in a patient with tracheal bronchus and difficult airway

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 Submission15-Oct-2019
Date of Decision23-Oct-2019
Date of Acceptance19-Nov-2019
Date of Web Publication03-Dec-2019

Correspondence Address:
Dr. Hou-Chuan Lai
#325, Section 2, Chenggung Road, Neihu 114, Taipei
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Source of Support: None, Conflict of Interest: None

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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 2021 Aug 2];40:201-2. Available from: https://www.jmedscindmc.com/text.asp?2020/40/4/201/272329

Dear Editor,

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.[1] Previous studies have described the challenges for OLV in patients with tracheal bronchus but successfully delivered strategies to navigate them.[2],[3] Moon et al.[2] used an Arndt endobronchial blocker for right-sided OLV in the left lower lobe lung mass resection, and Lee et al.[3] 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[4] 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.[3] Conversely, a bronchial blocker may have advantages over the conventional DLT in achieving OLV in patients with a tracheal bronchus and difficult airway,[2],[5] 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.[6] Accordingly, we did not use a tube exchanger at that time. In addition, nonintubated video-assisted thoracoscopic surgery with laryngeal mask airway[7] 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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Peragallo RA, Swenson JD. Congenital tracheal bronchus: The inability to isolate the right lung with a univent bronchial blocker tube. Anesth Analg 2000;91:300-1.  Back to cited text no. 1
Moon YJ, Kim SH, Park SW, Lee YM. The implications of a tracheal bronchus on one-lung ventilation and fibreoptic bronchoscopy in a patient undergoing thoracic surgery: A case report. Can J Anaesth 2015;62:399-402.  Back to cited text no. 2
Lee DK, Kim YM, Kim HZ, Lim SH. Right upper lobe tracheal bronchus: Anesthetic challenge in one-lung ventilated patients – A report of three cases. Korean J Anesthesiol 2013;64:448-50.  Back to cited text no. 3
Lai HC, Wu ZF. Easier double-lumen tube placement using real-time video laryngoscopy and wireless video fiberoptic bronchoscopy. J Clin Anesth 2019;55:132-3.  Back to cited text no. 4
Globokar MD, Novak-Jankovic V. Difficult airway and one lung ventilation. Acta Clin Croat 2012;51:477-82.  Back to cited text no. 5
Wu HL, Tai YH, Wei LF, Cheng HW, Ho CM. Bronchial lumen is the safer route for an airway exchange catheter in double-lumen tube replacement: Preventable complication in airway management for thoracic surgery. J Thorac Dis 2017;9:E903-6.  Back to cited text no. 6
Lai HC, Huang TW, Tseng WC, Lin WL, Chang H, Wu ZF. Sevoflurane is an effective adjuvant to propofol-based total intravenous anesthesia for attenuating cough reflex in nonintubated video-assisted thoracoscopic surgery. Medicine (Baltimore) 2018;97:e12927.  Back to cited text no. 7


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