Airway Bleeding After Double-Lumen Tube Placement

Abstract

A 78-YEAR-OLD, 45-kg, 165-cm woman, with a history of breast cancer treated with chemoradiation, and esophageal diverticulum, presented for robotic-assisted diverticulectomy. After anesthetic induction, a 37Fr left-sided, double-lumen tube (DLT) was placed without difficulty, and placement was confirmed with fiberoptic bronchoscopy. The tracheal tissue was noted to be mottled throughout. After the patient was placed in the left lateral decubitus position, the DLT position was confirmed once again, and single-lung ventilation was initiated, with inflation of the bronchial cuff with 2.5 mL of air and clamping of the tracheal limb. After entry and insufflation of the right chest, 3-5 mL of blood were noted to be emanating from the tracheal lumen, and the surgeon noted poor lung isolation. Fiberoptic evaluation noted sanguineous secretions, which, despite lavage, failed to identify an obvious cause of bleeding, and slow bleeding persisted. In an attempt to improve single-lung isolation, an additional 2 mL of air were added to the bronchial cuff. After addition of air to the bronchial cuff, bleeding ceased and no additional significant issues occurred during the rest of the surgical procedure. After completion of the surgery, bilateral lung ventilation was reinstated and the authors repositioned the patient supine. Given the lack of obvious bleeding source and the mottled appearance of the tracheal tissue, bronchoscopy was performed for pulmonary toilet and further evaluation. The DLT was exchanged for an 8.5-mm endotracheal tube under direct visualization. The following findings (Fig 1, Fig 2) were noted. What is the diagnosis? Fig 2Bronchoscopic view from the left main stem showing full thickness injury in the membranous portion of the bronchus. Anterior surface of esophagus is visible through defect (yellow star). View Large Image Figure Viewer Download Hi-res image