One-lung ventilation (OLV) can be accomplished utilizing a double-lumen tube (DLT) and an endobronchial blocker (EBB) or intentionally placing a standard endotracheal tube (ETT) into a mainstem bronchus. However, secondary options must be available should the primary method fail. We present a case where an EBB and a fiberoptic bronchoscope (FOB) were successfully passed through a left-sided DLT to reestablish right-lung isolation after the DLT bronchial cuff was surgically damaged. We advocate competency in placing both DLTs and EBBs, as well as having EBBs readily accessible as a secondary isolation method during OLV.
Maintaining airway control is critical during surgery, but especially during one-lung ventilation (OLV). OLV controls ventilation to each lung separately and protects against cross-contamination.1 OLV is often complicated by patient positioning and surgical approach, such as left lateral decubitus (LLD) position and thoracotomy. Additionally, artificial airways can be compromised; therefore, providers should be familiar with multiple methods of maintaining OLV. Given how rapidly patients can deteriorate, providers must also rapidly use secondary measures or combine approaches should the primary method fail. The CAse REports (CARE) guidelines were referenced in creating this case report.2 Written Health Insurance Portability and Accountability Act authorization was obtained from the patient.
A 178-cm 98.6-kg 49-year-old man developed dysphagia and increased oral secretions 6 weeks after a traumatic jejunal injury repair, secondary to a motor vehicle crash. Other than his jejunal injury, the patient was healthy and active with normal cardiac and pulmonary functions. His postoperative course following his jejunal repair was uneventful until 7 days before presentation in which he reported intolerance to solids and liquids causing coughing. Contrast chest-computed tomography indicated a tracheoesophageal fistula (TEF). There was no evidence of necrosis on imaging nor were any cardiac structures or great vessels involved. The TEF was most likely caused by the rapid deceleration injury with compression between the sternum and vertebral body, which created a crush injury in the trachea and esophagus. This generally presents 10 to 14 days after the resultant hematoma resolves and a fistula ensues. In this case, the injury was likely potentiated by underlying chronic esophagitis from extensive nonsteroidal anti-inflammatory drug and alcohol use.3 The following day, esophagogastroduodenoscopy (EGD) revealed a large midesophageal TEF; additional findings were severe esophagitis, gastritis, and duodenal ulcer with erosion that were not amenable to endoscopic treatment. Bronchoscopy on the subsequent day confirmed a 0.5-cm left-posterior TEF 1 cm above the carina, which was performed under general anesthesia with an endotracheal tube (ETT) and propofol infusion with the end goal to stent the tracheal side of the fistula. This was unsuccessful, and given the concern for further lung contamination, a thoracotomy was scheduled.
The surgical plan was for a right thoracotomy, TEF ligation, esophageal repair, and patch tracheoplasty. The right-sided approach was selected because the distal trachea, carina, and proximal left mainstem bronchus are best accessed from the right, as these structures are generally situated to the right of midline and the aortic arch obstructs a left exposure. Rapid sequence induction utilizing videolaryngoscopy and bronchoscopy positioned a 37-Fr left-sided double-lumen tube (DLT) with the bronchial cuff 2 cm distal to the left-sided TEF. A 37-Fr DLT was selected, after discussion with the surgeon, to mitigate tissue damage from a larger tube. An arterial line, 18 and 20 gauge intravenous lines, and a triple-lumen central line were placed. An epidural catheter was deferred for intercostal nerve blocks performed by the surgeon. Right-lung isolation and proper placement of the DLT tube were confirmed after LLD positioning.
Approximately 1.5 hours into the case, the systolic blood pressure (SBP) decreased to 80 mm Hg, and 50 mL of urine output was recorded despite receiving 1 L of 5% albumin and 2 L of crystalloid. It was presumed that this initial fluid requirement was due to decreased oral intake and nasogastric suction output with possible sepsis. The blood pressure did not improve with phenylephrine boluses or a norepinephrine infusion. Concerned for septic shock, a vasopressin infusion was initiated. The SBP improved to >100 mm Hg, and although a rapid 100 mL of blood loss occurred due to end-bronchial bleeding, control was achieved with cautery and ligation. During the attempts to regain hemostasis, the bronchial cuff was damaged. Consequently, right-sided lung isolation and tidal volumes were lost, resulting in desaturation to a nadir of pulse oximetry readings in the high 70s for 5 minutes. We continued OLV because bleeding was brisk and right-lung ventilation obscured any view needed to surgically control the bleeding. Given the desaturation, ongoing hemorrhage, patient positioning, and open nature of the surgery, using an alternative approach to achieve OLV was critical.
We placed a dual balloon endobronchial blocker (EBB) (Figure 1) down the tracheal lumen of the DLT under fiberoptic bronchoscope (FOB) visualization. Both cuffs were inflated in the right main bronchus, before the RUL takeoff, resulting in right-sided lung isolation (Figure 2). On retracting the DLT 2 cm, the compression of the DLT bronchial cuff against the TEF provided an adequate seal for OLV on ventilating through the tracheal lumen. Arterial blood gases drawn after resecuring the airway showed acidosis with poor ventilation and oxygenation. Other notable labs included a white blood cell count of 26,000/mm3 (increased from 9000/mm3 preoperatively), hemoglobin of 8.2 g/dL (down from 12.7 g/dL preoperatively), and platelet count of 933,000/mm3. Although a lactate level was not sent, the clinical picture was consistent with possible septic shock compounded by hypovolemia. Two units of red blood cells and an additional 2 L of crystalloid were administered, allowing discontinuation of the vasopressin and norepinephrine infusions favoring a hypovolemic state over sepsis.
The remainder of the case was uneventful, and the DLT was exchanged for a single-lumen tube (SLT). The distal tip of the SLT was secured 2 cm proximal to the patch repair under FOB observation. The patient was transferred to the ICU with propofol sedation and extubated the following morning.
Our case highlights the use of an EBB and FOB through a left-sided DLT with a damaged bronchial cuff while in the LLD position. The advancement of the FOB and EBB was difficult, as the internal diameter of the 37-Fr DLT’s lumens was 5.1 mm, the diameter of the EBB was 2.3 mm, and the diameter of the FOB was 3.5 mm.4–6 Although the combined diameters of the FOB and EBB were larger than the internal diameter of the tracheal lumen by 0.7 mm, there existed enough DLT malleability to advance both pieces of equipment. Given the bronchial cuff’s seal on the fistula, we positioned both EBB balloons down the right bronchus.
For comparison, the internal diameter of the 35-Fr DLT’s lumens is 4.8 and 5.3 mm for a 39-Fr DLT.4 The external diameter of a 35-Fr DLT is 11.7 mm, 12.3 mm for a 37-Fr DLT, and 13 mm for a 39-Fr tube.4 A smaller patient requiring a 35-Fr DLT would have required a pediatric FOB. We could have placed a para-axial EBB with a left mainstem SLT, but there have been case reports of bronchial damage with an EBB, although neither of these reports utilized an EBB external to a DLT.7–9 We also initially required a cuff distal to the TEF to maintain ventilation of the left lung without gastric insufflation through the TEF; something that would be lost with retraction of the SLT to evaluate proper EBB placement, although deflating the SLT cuffs during critical suturing moments may have prevented the cuff from being damaged. With ongoing surgical repair of the tracheal wall, an external EBB technique may have been suboptimal.
Our backup plan was to place a left mainstem SLT and a para-axial EBB to achieve right-sided isolation. Our concern with the EBB was increased difficulty to place and potential for further damage to the TEF with the rigid edge of the most distal portion of a deflated EBB balloon. We had less concern for damage with the smoother edges of the left-sided DLT. In retrospect, there was the possibility of placing a backup deflated right-sided EBB through the DLT after intubation. Until our intraoperative issues, we had never performed this technique in a clinical setting, and immediate placement of a backup deflated EBB though all DLTs in a controlled setting should be strongly considered in cases where there is a high likelihood of damage to the DLT.
Multiple techniques for manipulation of the airway and preventing aspiration during TEF repair with and without lung isolation are found in the literature. Chennakeshavallu and Sruthi10 report retracting a left-sided DLT to accommodate an EBB through the bronchial lumen into the left mainstem to regain left-lung isolation. The difference in this case was that the patient remained in stable condition throughout due to a small leak, allowing for a more purposeful approach. Ni et al11 and Malik et al12 both offered solutions for preventing aspiration while utilizing an SLT in the standard fashion for TEF repair but offered no further discussion on lung isolation or secondary measures.
Recently, case reports regarding extracorporeal membrane oxygenation (ECMO) as a management option during difficult TEF cases have been published.13 There are currently no guidelines for ECMO use in these cases, but they have been described.13 Patients at high risk for airway compromise could be considered for transfer to an institution with ECMO capability, necessitating a preoperative multidisciplinary approach. Our case highlights one of the unexpected risks of these procedures, a lifesaving measure to mitigate such an event, and proposes strategies to minimize these risks in a controlled setting when preoperatively discussed in a multidisciplinary fashion.