- Email: [email protected]
The bronchial blocker: why will it not come out?
Journal of Pediatric Surgery (2011) 46, 2426–2428
www.elsevier.com/locate/jpedsurg
Correspondence
The bronchial blocker: why will it not come out? To the Editor, Bronchial blockers are used routinely in pediatric lung surgery. These devices are valuable because they optimize exposure of the pulmonary vascular anatomy to facilitate safe dissection [1-3]. Several complications related to the use of a bronchial blocker have been reported over the past 10 years. It can be associated with airway injury resulting in hoarseness and sore throat, although less frequently than with doublelumen endotracheal tubes [4,5]. More serious complications such as avulsion of the bronchial blocker cuff in the trachea [6] and accidental fracture of the tip of the bronchial blocker have been described [7]. Displacement of the bronchial blocker can lead to ventilation problems and even cardiac arrest [8]. Finally, entrapment of the bronchial blocker catheter by a surgical stapler has been Fig. 2
Fig. 1
Insertion of the endobronchial blocker.
0022-3468/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
Positioning of the endobronchial blocker.
reported in both humans and dogs [9,10]. Because these devices are usually inserted by anesthesia, most pediatric surgeons are unfamiliar with them. In this report, the proper insertion of the bronchial blocker is described; and recommendations are made to minimize the risk of catheter entrapment. A Cook Arndt Endobronchial Blocker set (5F catheter/50 cm) device (Cook Medical, Inc, Bloomington, IN) was used in a 6-month-old female infant undergoing a right lower lobectomy for a large congenital cystic adenomatoid malformation. Fig. 1 demonstrates the insertion of the bronchial blocker through the Arndt Multiport Airway Adapter. The bronchial blocker was inserted through the side port, and the flexible bronchoscope passed through the diaphragm of the bronchoscopy port. The bronchoscope was passed through the guide loop; and then, the bronchoscope snared with the guide loop to couple the two. The endobronchial blocker was appropriately positioned in the right mainstem bronchus; and then, guide loop loosened to release it (Fig. 2). The device worked effectively during the case with effective collapse of the entire right lung. However, it could not
Correspondence
2427
Fig. 5
Fig. 3 Endobronchial blocker guide loop (large arrow) protruding from tip of catheter. Inflated bronchial blocker (smaller arrow) proximal to guide loop. Endobronchial blocker guide loop protruding from tip of catheter.
be removed after the chest was closed. Bronchoscopy demonstrated that the bronchial blocker balloon was completely decompressed. The cause of the tethering could not be
Endobronchial blocker after removal from patient.
determined. On inspection of an unused bronchial blocker, the guide loop (Fig. 3) used to attach the bronchial blocker to the bronchoscope during insertion (Figs. 1 and 2) was thought to be the culprit. This loop had not been pulled back after insertion and was likely entrapped by one of the bronchial closure sutures. The guide loop (Fig. 4) was cut external to the patient. This released the catheter, and it was successfully removed using the bronchoscopic forceps. Note the curled end of the guide loop where it had been pulled out from under the bronchial closure suture (Fig. 5). There was no bronchial air leak postoperatively. The patient recovered uneventfully without sequelae related to this complication. This is the first case report of an Arndt bronchial blocker guide loop being entrapped by a bronchial closure suture. Young children are at highest risk for this complication owing to the short length of their mainstem bronchus. It also details the minimally invasive technique for bronchial blocker removal without the need for repeat thoracotomy. Recommendations to avoid entrapment of the bronchial blocker are (1) complete removal of the guide loop after the bronchial blocker balloon is appropriately positioned and inflated and (2) removal of the bronchial blocker catheter after the stapler is applied to the bronchus but before firing it. If the bronchus is closed with sutures, the bronchial blocker should be removed after the bronchial closure but before closing the chest. James J. Murphy Department of Pediatric Surgery British Columbia Children's Hospital Vancouver, British Columbia, Canada V6h 3V4 E-mail address: [email protected]
Fig. 4
Intact guide loop (removed from catheter).
doi:10.1016/j.jpedsurg.2011.05.026
2428
Correspondence
References [6] [1] Campos JH. Progress in lung separation. Thorac Surg Clin 2005;15(1): 71-83. [2] Hammer GB, Harrison TK, Vricella LA, et al. Single lung ventilation in children using a new paediatric bronchial blocker. Paediatr Anaesth 2002;12(1):69-72. [3] Wald SH, Mahajan A, Kaplan MB, et al. Experience with the Arndt paediatric bronchial blocker. Br J Anaesth 2005;94(1):92-4. [4] Zhong T, Wang W, Chen J, et al. Sore throat or hoarse voice with bronchial blockers or double-lumen tubes for lung isolation: a randomised, prospective trial. Anaesth Intensive Care 2009;37(3): 441-6. [5] Knoll H, Ziegeler S, Schreiber JU, et al. Airway injuries after one-lung ventilation: a comparison between double-lumen tube and endobron-
[7]
[8] [9]
[10]
chial blocker: a randomized, prospective, controlled trial. Anesthesiology 2006;105(3):471-7. Thomas T, Dimitrova G, Awad H. Avulsion of a bronchial blocker cuff in the trachea when using a parker flex-tip endotracheal tube. J Cardiothorac Vasc Anesth 2010 [Epub ahead of print]. Venkataraju A, Rozario C, Saravanan P. Accidental fracture of the tip of the Coopdech bronchial blocker during insertion for one lung ventilation. Can J Anaesth 2010;57(4):350-4. Sandberg WS. Endobronchial blocker dislodgement leading to pulseless electrical activity. Anesth Analg 2005;100(6):1728-30. Soto RG, Oleszak SP. Resection of the Arndt Bronchial Blocker during stapler resection of the left lower lobe. J Cardiothorac Vasc Anesth 2006;20(1):131-2. Levionnois OL, Bergadano A, Schatzmann U. Accidental entrapment of an endo-bronchial blocker tip by a surgical stapler during selective ventilation for lung lobectomy in a dog. Vet Surg 2006;35(1):82-5.
www.elsevier.com/locate/jpedsurg
Correspondence
The bronchial blocker: why will it not come out? To the Editor, Bronchial blockers are used routinely in pediatric lung surgery. These devices are valuable because they optimize exposure of the pulmonary vascular anatomy to facilitate safe dissection [1-3]. Several complications related to the use of a bronchial blocker have been reported over the past 10 years. It can be associated with airway injury resulting in hoarseness and sore throat, although less frequently than with doublelumen endotracheal tubes [4,5]. More serious complications such as avulsion of the bronchial blocker cuff in the trachea [6] and accidental fracture of the tip of the bronchial blocker have been described [7]. Displacement of the bronchial blocker can lead to ventilation problems and even cardiac arrest [8]. Finally, entrapment of the bronchial blocker catheter by a surgical stapler has been Fig. 2
Fig. 1
Insertion of the endobronchial blocker.
0022-3468/$ – see front matter © 2011 Elsevier Inc. All rights reserved.
Positioning of the endobronchial blocker.
reported in both humans and dogs [9,10]. Because these devices are usually inserted by anesthesia, most pediatric surgeons are unfamiliar with them. In this report, the proper insertion of the bronchial blocker is described; and recommendations are made to minimize the risk of catheter entrapment. A Cook Arndt Endobronchial Blocker set (5F catheter/50 cm) device (Cook Medical, Inc, Bloomington, IN) was used in a 6-month-old female infant undergoing a right lower lobectomy for a large congenital cystic adenomatoid malformation. Fig. 1 demonstrates the insertion of the bronchial blocker through the Arndt Multiport Airway Adapter. The bronchial blocker was inserted through the side port, and the flexible bronchoscope passed through the diaphragm of the bronchoscopy port. The bronchoscope was passed through the guide loop; and then, the bronchoscope snared with the guide loop to couple the two. The endobronchial blocker was appropriately positioned in the right mainstem bronchus; and then, guide loop loosened to release it (Fig. 2). The device worked effectively during the case with effective collapse of the entire right lung. However, it could not
Correspondence
2427
Fig. 5
Fig. 3 Endobronchial blocker guide loop (large arrow) protruding from tip of catheter. Inflated bronchial blocker (smaller arrow) proximal to guide loop. Endobronchial blocker guide loop protruding from tip of catheter.
be removed after the chest was closed. Bronchoscopy demonstrated that the bronchial blocker balloon was completely decompressed. The cause of the tethering could not be
Endobronchial blocker after removal from patient.
determined. On inspection of an unused bronchial blocker, the guide loop (Fig. 3) used to attach the bronchial blocker to the bronchoscope during insertion (Figs. 1 and 2) was thought to be the culprit. This loop had not been pulled back after insertion and was likely entrapped by one of the bronchial closure sutures. The guide loop (Fig. 4) was cut external to the patient. This released the catheter, and it was successfully removed using the bronchoscopic forceps. Note the curled end of the guide loop where it had been pulled out from under the bronchial closure suture (Fig. 5). There was no bronchial air leak postoperatively. The patient recovered uneventfully without sequelae related to this complication. This is the first case report of an Arndt bronchial blocker guide loop being entrapped by a bronchial closure suture. Young children are at highest risk for this complication owing to the short length of their mainstem bronchus. It also details the minimally invasive technique for bronchial blocker removal without the need for repeat thoracotomy. Recommendations to avoid entrapment of the bronchial blocker are (1) complete removal of the guide loop after the bronchial blocker balloon is appropriately positioned and inflated and (2) removal of the bronchial blocker catheter after the stapler is applied to the bronchus but before firing it. If the bronchus is closed with sutures, the bronchial blocker should be removed after the bronchial closure but before closing the chest. James J. Murphy Department of Pediatric Surgery British Columbia Children's Hospital Vancouver, British Columbia, Canada V6h 3V4 E-mail address: [email protected]
Fig. 4
Intact guide loop (removed from catheter).
doi:10.1016/j.jpedsurg.2011.05.026
2428
Correspondence
References [6] [1] Campos JH. Progress in lung separation. Thorac Surg Clin 2005;15(1): 71-83. [2] Hammer GB, Harrison TK, Vricella LA, et al. Single lung ventilation in children using a new paediatric bronchial blocker. Paediatr Anaesth 2002;12(1):69-72. [3] Wald SH, Mahajan A, Kaplan MB, et al. Experience with the Arndt paediatric bronchial blocker. Br J Anaesth 2005;94(1):92-4. [4] Zhong T, Wang W, Chen J, et al. Sore throat or hoarse voice with bronchial blockers or double-lumen tubes for lung isolation: a randomised, prospective trial. Anaesth Intensive Care 2009;37(3): 441-6. [5] Knoll H, Ziegeler S, Schreiber JU, et al. Airway injuries after one-lung ventilation: a comparison between double-lumen tube and endobron-
[7]
[8] [9]
[10]
chial blocker: a randomized, prospective, controlled trial. Anesthesiology 2006;105(3):471-7. Thomas T, Dimitrova G, Awad H. Avulsion of a bronchial blocker cuff in the trachea when using a parker flex-tip endotracheal tube. J Cardiothorac Vasc Anesth 2010 [Epub ahead of print]. Venkataraju A, Rozario C, Saravanan P. Accidental fracture of the tip of the Coopdech bronchial blocker during insertion for one lung ventilation. Can J Anaesth 2010;57(4):350-4. Sandberg WS. Endobronchial blocker dislodgement leading to pulseless electrical activity. Anesth Analg 2005;100(6):1728-30. Soto RG, Oleszak SP. Resection of the Arndt Bronchial Blocker during stapler resection of the left lower lobe. J Cardiothorac Vasc Anesth 2006;20(1):131-2. Levionnois OL, Bergadano A, Schatzmann U. Accidental entrapment of an endo-bronchial blocker tip by a surgical stapler during selective ventilation for lung lobectomy in a dog. Vet Surg 2006;35(1):82-5.