Low-Frequency Jet Ventilation Through a Bronchial Blocker for Tracheal Repair After a Rare Complication of Percutaneous Dilatational Tracheostomy

Abstract

p f ( t t a v t m m o r d t c t t n r l p q A67-YEAR-OLD woman was admitted to the hospital with a left hemispheric hemorrhagic insult. Previously, the atient had been treated with low-dose aspirin for a transient schemic attack and had moderate obesity (with an estimated eight of 90 kg and an estimated height of 1.70 m) but was therwise healthy and independent. Because of a lack of neuologic improvement and difficulties weaning from ventilation weeks after the insult, a decision was made to perform a edside percutaneous dilatational tracheostomy using a comercial kit set (CIAGLIA Blue Rhino; Cook Incorporated, loomington) in the intensive care unit. The procedure was erformed under bronchoscopic guidance. After puncture of the rachea and subsequent aspiration of air into a saline-filled yringe, a guidewire was placed, and the position was conrmed by bronchoscopy. The dilatational sequence was neventful, and the tracheostomy tube was placed. After a entilation check, the absence of CO2 return was noted by apnography. Bronchoscopy showed that the tracheostomy ube had passed through both the anterior and the left posteroateral tracheal wall. The tracheostomy tube was withdrawn, nd an endotracheal tube with a 7.0-mm internal diameter was eplaced beyond the lesion under bronchoscopic guidance. Efective ventilation was confirmed by CO2 return waveform with cceptable value. During the entire procedure, no significant decrease in oxyen saturation or major hemodynamic instability was noted; owever, extensive subcutaneous emphysema in the neck and pper chest was found. The chest x-ray revealed a left-sided neumothorax, which was treated by inserting a chest tube. hereafter, the patient was transferred rapidly to the operating oom for repair of the tracheal tear. The planned operative pproach was through an anterior cervical incision with the eck fully extended. It was believed this would provide good xposure to the site of injury and allow for an open tracheosomy to be performed at the end of the case. The surgeons were repared to perform a partial sternal split if necessary. Before he start of the surgery, a 2nd chest tube was inserted because f the posterior malposition of the 1st tube. Bronchoscopy was erformed through the endotracheal tube so that a bronchial lesion ould be excluded. Thereafter, a 7F Arndt bronchial blocker Arndt Endobronchial Blocker Set; Cook Incorporated, Bloomingon, IN) was advanced successfully through the single-lumen .0-internal diameter endotracheal tube into the right main ronchus under bronchoscopic guidance using the guidewire