Authors: Gupta S et al.
Cureus, June 9, 2026.
Summary
This case report describes the anesthetic management of two adults with retained metallic foreign bodies in the chest located close to major mediastinal structures.
Both patients required one-lung ventilation for surgical exposure. The anesthesia team used the same sequential airway strategy in each case:
• First, secure the airway with a standard single-lumen endotracheal tube using video laryngoscopy
• Then place an Arndt bronchial blocker into the left main bronchus under fiberoptic guidance
• Use the blocker to isolate the left lung and provide one-lung ventilation
This approach allowed the airway to be secured before attempting lung isolation, which was especially important in the trauma setting and in the patient with a potentially difficult airway.
Case 1 involved a 40-year-old factory worker injured by a high-velocity iron nail ejected from an industrial sewing machine. Imaging showed a retained metallic foreign body in the left paratracheal region with a hemopneumothorax.
The patient also had chronic obstructive pulmonary disease and loose lower incisors. After induction of general anesthesia, the trachea was intubated on the first attempt with a C-MAC video laryngoscope and an 8.5-mm single-lumen tube.
A 9-Fr Arndt bronchial blocker was positioned in the left main bronchus using fiberoptic bronchoscopy. One-lung ventilation was performed using lung-protective settings, including a tidal volume of approximately 7 mL/kg ideal body weight and 5 cm H₂O of positive end-expiratory pressure.
Oxygenation and ventilation remained satisfactory despite the patient’s chronic obstructive pulmonary disease. The nail was removed successfully using video-assisted thoracoscopic surgery without injury to the airway, esophagus, or nearby vascular structures.
Case 2 involved a 34-year-old man with a gunshot wound. Imaging showed a bullet in the superior mediastinum lying against the left brachiocephalic vein.
Because of the risk of major vascular injury during removal, the surgical team selected open thoracotomy to provide better exposure and immediate access for vascular control.
The patient had obesity, a Mallampati class IV airway, restricted neck flexion, and a short thyromental distance. The anesthesia team again secured the airway first with a single-lumen tube using C-MAC video laryngoscopy.
A 9-Fr Arndt bronchial blocker was then placed in the left main bronchus under fiberoptic guidance. One-lung ventilation was maintained successfully, and the bullet was removed without major vascular injury. Small fragments embedded in the sternum were left in place because removing them would have increased the risk of additional injury.
Both patients received planned postoperative mechanical ventilation in the intensive care unit and recovered without complications.
What You Should Know
Retained intrathoracic foreign bodies near the airway, heart, great vessels, or esophagus require careful coordination between anesthesia and surgery.
A single-lumen endotracheal tube followed by bronchial blocker placement can be safer than initial double-lumen tube placement in trauma patients or those with a difficult airway.
The main advantage is that the airway is secured first. Lung isolation is then added in a controlled second step.
Fiberoptic bronchoscopy is essential for accurate bronchial blocker placement and for confirming its position after patient movement or surgical manipulation.
Bronchial blockers may be particularly useful when:
• A difficult airway is anticipated
• Dental injury is a concern
• The trachea must be secured quickly
• A conventional endotracheal tube is preferred for postoperative ventilation
• Placement of a bulky double-lumen tube may increase risk
Bronchial blockers also have limitations. Lung collapse may be slower, suctioning of the isolated lung is more difficult, and the device may become displaced during surgery.
Patients with chronic obstructive pulmonary disease or obesity are at increased risk of hypoxemia during one-lung ventilation. Lung-protective ventilation, positive end-expiratory pressure, arterial blood gas monitoring, and careful airway-pressure management are important.
Video-assisted thoracoscopic surgery may reduce pain and respiratory morbidity when the foreign body can be safely removed with a minimally invasive approach.
Open thoracotomy remains appropriate when the foreign body lies next to a major vessel and immediate vascular control may be necessary.
These two cases support a planned, sequential airway strategy for complex thoracic trauma but do not establish that bronchial blockers are superior to double-lumen tubes in all patients.
Thank you to Cureus for allowing us to summarize this article.