Use of the Aintree intubation and airway exchange catheters through LMA-ProSeal for double-lumen tube placement in a morbidly obese patient with right main stem bronchus tumour

Abstract

Editor—Anaesthesia literature is replete with respect to different lung isolation strategies in patients with a difficult upper airway.1Brodsky JB Lung separation and the difficult airway.Br J Anaesth. 2009; 103: i66-i75Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar 2Campos JH Lung isolation techniques for patients with difficult airway.Curr Opin Anaesthesiol. 2010; 23: 12-17Crossref PubMed Scopus (84) Google Scholar This is in contrast to the paucity of published reports on lung isolation in patients with lower tracheobronchial pathology. A review of literature indicated that in the majority of cases of iatrogenic traumatic endobronchial tumour dislocation, the outcome is fatal.3Bollen EC Van Duin CJ Van Noord JA Janssen JG Theunissen PH Tumor embolus in lung surgery: a case report and review of the literature.Eur J Cardiothorac Surg. 1993; 7: 104-106Crossref PubMed Scopus (16) Google Scholar We report a new approach for left double-lumen tube (DLT) placement in a patient with a difficult upper airway and a right main stem bronchus tumour. A 31-yr-old morbidly obese female patient (BMI 41) was admitted to the Emergency Department with diabetic ketoacidosis, hypertension, and diminished air entry over the base of the right lung. After resuscitation, radiological investigations including computed tomography (CT)-guided biopsy and laboratory work-up suggested a diagnosis of a right lower lobe carcinoid tumour extending into the right main stem bronchus. The patient was undergoing right lower lobe sleeve resection and possible pneumonectomy. Difficult airway was suspected on preoperative assessment due to a short neck with limited extension and a Mallampati score class III. The choice of DLT for lung isolation was based on the anatomical location of the bronchial tumour and the surgical intervention to perform sleeve resection.4Campos JH Which device should be considered the best for lung isolation: double lumen endotracheal tube versus bronchial blockers.Curr Opin Anaesthesiol. 2007; 20: 27-31Crossref PubMed Scopus (129) Google Scholar The primary objective of the airway and lung isolation plans was to reduce the possibility of accidental tumour injury by a misplaced left DLT. Ranitidine 150 mg was given orally on the evening before and on the morning of surgery for aspiration prophylaxis. After the induction of anaesthesia using propofol, fentanyl, and rocuronium, direct laryngoscopy revealed a Cormack and Lehane Grade III laryngoscopic view.5Krage R van Rijn C van Groeningen D Loer SA Schwarte LA Schober P Cormack–Lehane classification revisited.Br J Anaesth. 2010; 105: 220-227Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar The patient’s airway was temporarily secured with a size 4 ProSeal laryngeal mask airway (PLMA) (Intavent Orthofix, Maidenhead, UK). Fibreoptic airway inspection via the PLMA confirmed the CT finding of a large tumour polyp occupying most of the lumen of the right main stem bronchus but not extending to the carina. Our new approach for left DLT placement was executed as illustrated in Figure 1. Intraoperatively, oxygenation, end-tidal CO2, and haemodynamics were maintained within normal levels. A right pneumonectomy was performed and the patient was discharged from the intensive care unit on the first postoperative day after a brief period of mechanical ventilation. Histopathological examination confirmed the diagnosis of a low-grade carcinoid tumour. To the best of our knowledge, this is the first report of the use of the Aintree intubation catheter (AIC) (Cook Critical Care, Bloomington, IN, USA) as a guide for DLT placement. The AIC is a semi-rigid tube of 56 cm in length with an internal and an external diameter of 4.7 and 6.5 mm, respectively. Due to its large external diameter and relatively short length, the AIC was replaced with an 11 Fr extra-firm, blunt tipped, 100 cm DLT exchange catheter (Cook Medical, Bloomington, IN, USA). A 35 Fr left DLT (Broncho-Cath, Mallinckrodt Medical, Athlone, Ireland) with an internal endobronchial diameter of 4.3 mm was railroaded over the DLT exchange catheter into the left main bronchus. The new aspects of our lung isolation plan are: (i) the fibreoptic-guided endobronchial placement of AIC, (ii) the sequential endobronchial use of AIC and a smaller calibre exchange catheter to ensure the safe placement of DLT into the left main stem bronchus, (iii) airway instrumentation was mostly performed under direct fibreoptic guidance to eliminate the possibility of inadvertent injury to the right main stem bronchial tumour. Despite the success of our technique, it is worth mentioning that DLT exchange catheters should not be advanced against resistance.1Brodsky JB Lung separation and the difficult airway.Br J Anaesth. 2009; 103: i66-i75Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar A new DLT exchanger with a soft flexible distal (7 cm) has been recently introduced into the market to reduce the possible airway trauma (Cook Medical).6Campos J Lung isolation in patients with difficult airways.in: Slinger P Principles and Practice of Anesthesia for Thoracic Surgery. Springer-Verlag, New York2011: 247-258Crossref Google Scholar None declared.