Independent Placement of a Bronchial Blocker for Single-Lung Ventilation

Abstract

Functional separation of the lungs may be accomplished by double-lumen (DL) endotracheal intubation, bronchial blockade with the Univent tube (Fuji Systems Corp., Tokyo, Japan), bronchial blockade independent of a single-lumen tube (SLT), or endobronchial intubation with a SLT. In patients with abnormal upper airways who require one-lung ventilation, DL tube placement may not be possible. Nasotracheal intubation and one-lung ventilation using a Univent tube has been previously reported [1]. However, Univent placement in small patients may be traumatic because of the large outer diameter of these tubes. The short length of a conventional SLT also prohibits endobronchial intubation via the nasal route. Recently, we managed a patient with restricted mouth opening requiring nasotracheal intubation and lung separation for thoracoscopy with an independent bronchial blocker placed outside a SLT. Case Report A 43-yr-old, 45-kg female presented for thoracoscopic left lung biopsy for suspected carcinoma. Her past medical history was significant for previous temporomandibular joint surgery that restricted her mouth opening to 20 mm. The surgeon requested lung separation for the operative procedure. After light sedation with midazolam and fentanyl, a transtracheal block was performed and topical anesthesia applied to the nose and upper airway. A Univent tube could not be passed nasally given the size of this patient's nares without risk of excessive trauma. A 6.0-mm endotracheal tube was passed blindly into the trachea through the right naris without difficulty. General anesthesia was induced, and neuromuscular blockade established. However, despite adequate relaxation, the oral aperture remained fixed at 20 mm, precluding direct laryngoscopy. Maximal advancement of the endotracheal tube did not result in lung separation. A fiberoptic bronchoscope (FOB) (Olympus, Tokyo, Japan) was passed through the left naris into the posterior pharynx. A styleted size 8 (22 F), 80-cm Fogarty occlusion catheter (Baxter, Irvine, CA) with a curvature placed at the distal tip to facilitate entry into the larynx was passed alongside the FOB. The Fogarty catheter was passed into the glottis using fiberoptic guidance, then the FOB was withdrawn and inserted into the SLT through an elbow connector with a self-sealing diaphragm. The Fogarty catheter was advanced until it could be seen below the tip of the SLT, then twirled with the fingertips until the distal tip entered the left mainstem bronchus. The catheter balloon was inflated under direct visualization, and the FOB withdrawn. Lung separation was accomplished without difficulty with inflation of the catheter balloon. Discussion This patient's restricted mouth opening and small nares limited options for single-lung ventilation. The large outer diameter and distal curvature of the DL tube would have made nasal intubation difficult, if not impossible. The bronchial blocker channel adds significantly to the outside diameter of the Univent tube such that it is larger than an equivalent SL tube [2]. The chosen method of placement of a bronchial blocker independent of a SLT allowed for nasal intubation with an appropriate-sized tube for this patient and single-lung ventilation. Placement of a bronchial blocker independent of a SLT can be accomplished either inside or outside the SLT. Others have described Fogarty catheter placement inside the SLT using two FOB adapters (Concord/Portex, Keene, NH) connected in series to the anesthesia circuit to allow FOB passage through one diaphragm while directing the bronchial blocker through the other [3]. While effective, this method can be cumbersome and is reliant on an airtight diaphragm in the elbow connector for adequate ventilation. Passage of the Fogarty catheter outside the SLT has been accomplished previously by exposure of the larynx via direct laryngoscopy or rigid bronchoscopy. In our case, fiberoptic visualization of an independent bronchial blocker passed outside a SLT was accomplished with relative ease. A bronchial blocker placed independent of a SL tube should be considered when lung separation is necessary in a small patient requiring nasotracheal intubation.