Single-Lung Ventilation in a Patient with a Freshly Placed Percutaneous Tracheostomy

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Various techniques have been described for providing single-lung ventilation in patients with a tracheostomy. Coe et al. [1] suggested placement of a double-lumen endotracheal tube through a tracheostomy site in 1984. Oxorn and Pagliarello [2] later described the use of a bronchial blocker (Fogarty catheter) inserted through a modified fiberoptic bronchoscope endotracheal tube adapter. More recently, Andros and Lennon [3] reported placement of a Univent Trademark tube (Fuji Systems Corp., Tokyo, Japan) through a tracheostomy site. We propose a simpler technique for single-lung ventilation in patients with either fresh or percutaneous tracheostomies. Importantly, this technique can be used in patients who require continuous ventilation during bronchial blocker placement. Case Report A 34-yr-old female was admitted to the hospital after sustaining major traumatic injury in a high-speed motor vehicle accident. Her injuries included cerebral contusion, open right humerus fracture, mesenteric hematoma, and right flail chest with massive right-sided pulmonary contusion. Initial treatment after stabilization included placement of an intracranial pressure (ICP) monitor, exploratory laparotomy for a positive diagnostic peritoneal lavage, and open reduction and internal fixation of the humerus fracture. Her postoperative course was significant for persistent fever and an unstable ICP that was exquisitely sensitive to fluctuations in PaCO (2). On the seventh day of hospitalization, an 8.0-mm Portex (Concord/Portex, Keene, NH) percutaneous tracheostomy tube was placed for long-term ventilation. The following day, a computerized tomographic scan revealed air fluid levels in the right lower lobe of her lung. She was scheduled for emergent resection of her right lower lobe. The patient was transported to the operating theater and ventilated via a Siemens model C ventilator (Siemens Elema AB, Solna, Sweden). A flexible bronchoscope adapter (Concord/Portex) was inserted between the tracheostomy tube and anesthesia circuit. General anesthesia was induced with intravenous thiopental and fentanyl. Rocuronium was administered for muscle relaxation. Direct laryngoscopy was performed, and the vocal cords were visualized. A lubricated bronchial blocker (Fogarty catheter) was passed between the vocal cords, and the cuff on the tracheostomy tube was temporarily deflated to allow passage of the catheter into the trachea. A pediatric flexible bronchoscope was then passed through the tracheostomy tube, and the bronchial blocker was guided into the right mainstem bronchus under direct visualization. The balloon on the catheter was placed at the take-off of the right upper lobe. When inflated, the concavity of the take-off held the balloon in place and allowed for isolation of the right lung. Single-lung ventilation was then attempted. The patient's oxygen saturation remained stable, but PaCO2 began to rise, precipitating an increase in ICP. The balloon on the bronchial blocker was deflated, and the blocker was advanced into the bronchus intermedius under direct visualization through the flexible bronchoscope. The balloon was then reinflated, and the right middle and lower lobes were successfully isolated. Despite adequate lung isolation and oxygenation, the patient's PaCO2 continued to increase, as did her ICP. Thus, single-lung ventilation was discontinued, and right lower lobectomy was completed without complication while ventilating both lungs. Discussion A fresh percutaneous tracheostomy in this patient limited options for single-lung ventilation. Placement of a double-lumen endotracheal tube or a Univent Trademark tube either orally or through the tracheostomy site would have required removal of the percutaneously placed tracheostomy tube and a formal surgical tracheostomy revision for tracheostomy tube replacement. Placement of a bronchial blocker via the fiberoptic bronchoscope port as described by Oxorn and Pagliarello [2] raised concerns about the ability to maintain ventilation during placement as well as the stability and potential air leak around a protruding catheter. The chosen method allowed for continuous ventilation and direct visualization of bronchial blocker placement without compromise of the fresh tracheostomy site or modification of existing equipment as suggested by Oxorn and Pagiarello [2]. Single-lung ventilation in a patient with a tracheostomy may be accomplished in a number of ways. Placing a bronchial blocker orally and positioning it under direct visualization with a flexible bronchoscope passed through the tracheostomy tube proved to be an easy, safe, and simple way to provide single-lung ventilation. Furthermore, this technique allowed for ventilation during positioning of the bronchial blocker with minimal disturbance to the tracheostomy site.