Single-lung ventilation via a tracheostomy using a fibreoptically-directed 'steerable' endobronchial blocker.

Abstract

One-lung ventilation in patients with tracheostomies can be achieved with a double lumen tracheostomy tube, a tracheal tube with a bronchus blocker, or deliberate endobronchial intubation with a single lumen tube. Previous reports describe use of a Univent tube [1] and a Fogarty catheter with endoscopic guidance [2]. We should like to describe the use of a fibreoptically directable wire-guided endobronchial blocker (WEB) (Cook Critical Care) in a patient with an existing tracheostomy. A 66-year-old woman presented for right upper lobectomy for squamous cell carcinoma. She had previously undergone laryngo-pharyngo-oesophagectomy for squamous cell carcinoma and had a permanent tracheostomy in situ. Following administration of midazolam and 10% lidocaine spray to the stoma, the patient's uncuffed tracheostomy tube was exchanged for an 8-mm Portex (SIMS Portex, Kent) tracheostomy tube. Anaesthesia was induced with fentanyl and propofol, muscle relaxation was achieved with atracurium and the patient's lungs were ventilated with oxygen, nitrous oxide and isoflurane. The WEB system was lubricated generously with medical-grade silicone grease and placed through the tracheostomy tube via the Arndt multiport airway. The adapter has three ports: a 15-mm-diameter side port for ventilation, an axial bronchoscopy port and one incorporating a Tuohy–Borst type fitting (Fig. 5). This incorporates a compressible diaphragm which maintains a gas-tight seal but allows the blocker to be manipulated and then locked once correctly located. The bronchus blocker is supplied with an adjustable guide-wire loop at its distal end and is normally positioned bronchoscopically [3]. The bronchoscope is passed through the wire loop and the coupled scope and blocker are directed down the appropriate bronchus. The bronchoscope is then withdrawn into the trachea, the blocker inspected to confirm appropriate placement and finally the wire loop is removed. When the kit was checked prior to use, we discovered that when the blocker was passed through the right angle bend of the tracheostomy tube, the distal end could be ‘steered’ to the right or left simply by rotating the proximal shaft clockwise or anticlockwise, respectively. This technique was employed to advance the blocker into the right main bronchus and the bronchoscope was then used to optimise its position relative to the carina and to monitor cuff inflation. The patient was positioned for a right thoracotomy and correct location of the blocker was confirmed prior to surgery. Peroperatively, one-lung ventilation was achieved without difficulty and the operative lung collapsed fully. Surgery was uneventful and the right lower and middle lobes re-inflated easily when the bronchial blocker cuff was deflated. The use of a bronchus blocker has advantages in patients with tracheotomies. In contrast to double lumen tracheostomy tubes, the WEB comes in a single size suitable for all adult patients. Placement of the WEB was easy and the steerability of the device used in this context meant that the wire loop to guide the catheter was not required. The special multiport Arndt adapter allows simultaneous ventilation and bronchoscopy whilst providing an effective seal and locking device for the catheter. Bronchoscopy can be leisurely, and critical positioning and cuff inflation confirmed. The contour of the cuff was such that the right upper lobe bronchus was not occluded allowing complete collapse of that lobe. The central lumen of the blocker, once vacated by the guide-wire, allows for suctioning of secretions or oxygen insufflation should oxygenation prove difficult. Although the WEB has been used successfully via both oral and nasal single lumen tubes, we could find no reference in the literature to its use with a tracheostomy. We recommend the WEB as a simple and effective way to achieve one-lung ventilation through an existing tracheostomy.