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Endotracheal Tube with Movable Blocker to Prevent Aspiration of Intratracheal Bleeding
Endotracheal Tube with Movable Blocker to Prevent Aspiration of Intratracheal Bleeding Hiroshi Inoue, M.D., Akira Shohtsu, M.D., Junichi Ogawa, M.D., Shirosaku Koide, M.D., and Shiaki Kawada, M.D. ABSTRACT A newly developed endotracheal tube with a movable blocker was found to be lifesaving in patients with copious and persistent intratracheal bleeding. The cases of 4 patients are presented. In 3 patients, severe intratracheal bleeding was attributed to the extensive bronchopulmonary laceration caused by blunt chest trauma. In the remaining patient, the bleeding was due to rupture of the sutured site in the right pulmonary artery; the rupture was caused by a postoperative bronchopleural fistula. In these patients, spread of blood was completely prevented and pulmonary resection was performed safely by using the blocker in this new device.
In May, 1981, we developed a new device for one-lung anesthesia-the endotracheal tube with a movable blocker.* It allows the whole or part of the target lung to be collapsed but still offers advantages of the conventional endotracheal tube [l].The device consists of an endotracheal tube with a small channel through the anterior internal wall, which contains an endobronchial blocker with a low-pressure high-volume cuff. In a modified type of our endotracheal tube, an aspiration or insufflation duct is made in the shaft of the blocker. The distal portion of the blocker is housed in the small channel of the endotracheal tube. The blocker can be advanced gently and an airtight seal achieved with its cuff (Figure). The blocker is introduced into the targeted main bronchus with the aid of the fiberoptic bronchoscope, but its introduction can be achieved using a technique described elsewhere [ 11, the ”tube rotation method.” The endotracheal tube with a movable blocker has been used in more than 150 thoracic procedures in our institution. Recently, we noticed that the bronchial occlusion obtained with this device can be lifesaving in patients with severe intratracheal bleeding. The cases of 4 such patients follow.
‘Fuji Systems Co., Ltd., 1-11-1. Ebisu, Shibuya-ku, Tokyo 150, Japan. From the First Department of Surgery, School of Medicine, Tokai University, lsehara, Kanagawa, Japan. Presented at the Vlll Asia-Pacific Congress on Diseases of the Chest, Tokyo, Japan, July 11-15, 1983. Accepted for publication Nov 10, 1983. Address reprint requests to Dr.lnoue, The First Department of Surgery, School of Medicine, Tokai University, lsehara 259-11, Japan.
497
Material and Methods
Patient 1 A 72-year-old man with lung cancer underwent a middle lobectomy and partial resection with suture repair of the inferior pulmonary artery because of direct tumor invasion. On the seventh postoperative day, a high fever and cough productive of purulent sputum developed. A chest roentgenogram showed an air-fluid level in the right hilar region. A bronchial fistula was diagnosed. The patient was observed very closely because the pulmonary artery had been sutured but not ligated. Nine hours after the diagnosis, he abruptly coughed up a small amount of blood and subsequently collapsed, signs suggesting rupture of the suture line of the pulmonary artery. Our device was inserted into his trachea immediately, and the blocker was advanced into the right main bronchus by the tube rotation method. The cuff of the blocker was inflated to occlude the bronchial lumen. The intratracheal bleeding stopped. A chest roentgenogram made shortly after this management showed a massive hemothorax and radiopaque blocker on the right side. The patient‘s condition was stabilized by this procedure, and he underwent an emergency thoracotomy. There was 1,500 ml of blood in the right thorax. The inferior pulmonary artery and middle lobe bronchus had opened at the sutured site. The lower lobe was resected uneventfully, and the patient recovered well. Patient 2 A 23-year-old man was admitted one hour after an automobile accident. He was comatose and had anisocoria. A chest roentgenogram revealed subcutaneous emphysema, right-sided hemopneumothorax, and patchy pulmonary infiltration. Tracheal intubation and tube thoracotomy were performed. Evacuation of air and blood from the right pleural space gradually decreased, but intratracheal bleeding from the right bronchus continued. The endotracheal tube with a movable blocker was substituted. The intermediate bronchus was occluded with the cuff of the blocker under direct observation with the fiberoptic bronchoscope. Then a right thoracotomy was carried out. The right middle lobe with a small but deep laceration in the hilar portion was removed safely. The patient regained consciousness thirty days after the operation and was well as of this writing. Patient 3 A 21-year-old man was admitted fifty minutes after a motorcycle accident. A chest roentgenogram showed a
498 The Annals of Thoracic Surgery Vol 37 No 6 June 1984
Endotracheal tube with movable blocker (a modified type).
left hemopneumothorax and diffuse pulmonary opacity. Although intrapleural bleeding and air leakage ceased within an hour after tube thoracotomy, severe hemorrhage from the endotracheal tube continued and acute respiratory failure progressed. The endotracheal tube was removed, and our device was applied to block the left main bronchus without the aid of a fiberoptic bronchoscope. The patient’s condition was improved by this procedure, and a left thoracotomy was performed. A jagged, deep laceration near the pulmonary hilus was found and removed without incident from the left upper lobe.
Patient 4 A 41-year-old man was transferred from another hospital shortly after an automobile accident. A chest roentgenogram revealed extensive subcutaneous emphysema, right-sided pneumothorax, and diffuse opacity of the partially collapsed right lung. An endotracheal tube and chest tube had been inserted. On arrival at our institution, the patient was unconscious. Profuse air leakage from the chest tube was seen, and there was copious intratracheal bleeding which necessitated frequent suction toilet. The trachea was extubated and immediately reintubated with an endotracheal tube with a movable blocker. With the aid of a fiberoptic bronchoscope, the blocker was introduced into the right main bronchus. Then the cuff of the blocker was inflated to occlude the bronchial lumen. The intratracheal bleeding and air leakage from the chest ceased. A right thoracotomy was performed. A complete transection and a longitudinal tear of the intermediate bron-
chus were found. Part of the inflated cuff of the blocker was exposed in the operative field through the disrupted bronchus. The adjacent pulmonary artery was noted to have a small tear. Resection of the middle and lower lobes was performed safely. However, prominent contused brain swelling was noted in the left hemisphere postoperatively, and the patient died on the sixth postoperative day.
Comment Copious and persistent hemorrhage into the tracheobronchial tree is a great threat to life, because patients tend to drown and be asphyxiated in their own blood. Clouding of consciousness makes the effort to cough poor, and this worsens a dangerous situation. Immediate protection of the nonbleeding lung from aspiration of blood holds the highest priority in the management of these patients. The causes of intratracheal bleeding are numerous. Case reports of endobronchial hemorrhage from pulmonary artery catheterization are increasing [2]. The methods for separating the bleeding lung from the nonbleeding lung include the use of the singlelumen endobronchial tube, the double-lumen endobronchial tube (Carlens or Robertshaw tube), and the endobronchial blocker (Fogarty catheter). Single-lumen endobronchial tubes and double-lumen endobronchial tubes, especially in an emergency, may be extremely difficult to insert and accurately place in the targeted main bronchus. Furthermore, in these types of endobronchial tube the lumen inevitably is too small, thereby producing an increased resistance to air flow and greater difficulty in removing blood. Garzon and associates [3] emphasized that the most useful technique to stop bleeding and prevent aspiration was endobronchial blockade of the bleeding site with a
499
Inoue et al: Endotracheal Tube with Movable Blocker
Fogarty catheter combined with the rigid bronchoscope. Our device appears to represent a refinement of their technique. When the endotracheal tube with a movable blocker is employed for this purpose, an endotracheal tube and endobronchial blocker can be inserted into the trachea simultaneously. Then the blocker can be slid or pushed out of the endotracheal tube and easily manipulated into position under direct observation with the fiberoptic bronchoscope inserted through the endotracheal tube. In addition, the blocker can be advanced into the targeted main bronchus without the aid of the bronchoscope, as in Patients 1 and 3 in our series. In patients with copious and persistent intratracheal bleeding, the cause of death is not blood loss but suffocation. Immediate prevention of blood aspiration fol-
lowed by early resection of the source of hemorrhage constitutes ideal management. The endotracheal tube with a movable blocker appears to be of great help in successfully achieving such management.
References 1. Inoue H, Shohtsu A, Ogawa J, et al: New device for onelung anesthesia: endotracheal tube with movable blocker. J Thorac Cardiovasc Surg 83:940, 1982 2. Cervenko FW, Shelley SE, Spence DG, et al: Massive endobronchial hemorrhage during cardiopulmonary bypass: treatable complication of balloon-tipped catheter damage to the pulmonary artery. Ann Thorac Surg 35:326, 1983 3. Garzon AA, Cerruti MM, Golding ME: Exsanguinating hemoptysis. J Thorac Cardiovasc Surg 84:829, 1982
Notice from the American Board of Thoracic Surgery The American Board of Thoracic Surgery will begin its recertification process in 1984. Diplomates interested in participating in this examination should maintain a documented list of the cardiothoracic operations they performed during the year prior to application for recertification. They should also keep a record of their attendance at thoracic surgical meetings and other continuing medical education activities for the two years prior to application for recertification. In place of a cognitive examination, candidates for recertification will be required to complete both the general thoracic and cardiac portions of the SESATS (Self-
Education/Self-Assessment in Thoracic Surgery) I1 Syllabus. Diplomates whose 10-year certificates will expire in 1986 may begin the recertification process in 1984. Their new certificate will be dated 10 years from the time of expiration of the original certificate. Recertification is also open to any Diplomate with an unlimited certificate. The deadline for submission of applications is July 1, 1984. A recertification brochure outlining the rules and requirements for recertification in thoracic surgery is available on request from the American Board of Thoracic Surgery, 14640 E Seven Mile Rd, Detroit, MI 48205.
In May, 1981, we developed a new device for one-lung anesthesia-the endotracheal tube with a movable blocker.* It allows the whole or part of the target lung to be collapsed but still offers advantages of the conventional endotracheal tube [l].The device consists of an endotracheal tube with a small channel through the anterior internal wall, which contains an endobronchial blocker with a low-pressure high-volume cuff. In a modified type of our endotracheal tube, an aspiration or insufflation duct is made in the shaft of the blocker. The distal portion of the blocker is housed in the small channel of the endotracheal tube. The blocker can be advanced gently and an airtight seal achieved with its cuff (Figure). The blocker is introduced into the targeted main bronchus with the aid of the fiberoptic bronchoscope, but its introduction can be achieved using a technique described elsewhere [ 11, the ”tube rotation method.” The endotracheal tube with a movable blocker has been used in more than 150 thoracic procedures in our institution. Recently, we noticed that the bronchial occlusion obtained with this device can be lifesaving in patients with severe intratracheal bleeding. The cases of 4 such patients follow.
‘Fuji Systems Co., Ltd., 1-11-1. Ebisu, Shibuya-ku, Tokyo 150, Japan. From the First Department of Surgery, School of Medicine, Tokai University, lsehara, Kanagawa, Japan. Presented at the Vlll Asia-Pacific Congress on Diseases of the Chest, Tokyo, Japan, July 11-15, 1983. Accepted for publication Nov 10, 1983. Address reprint requests to Dr.lnoue, The First Department of Surgery, School of Medicine, Tokai University, lsehara 259-11, Japan.
497
Material and Methods
Patient 1 A 72-year-old man with lung cancer underwent a middle lobectomy and partial resection with suture repair of the inferior pulmonary artery because of direct tumor invasion. On the seventh postoperative day, a high fever and cough productive of purulent sputum developed. A chest roentgenogram showed an air-fluid level in the right hilar region. A bronchial fistula was diagnosed. The patient was observed very closely because the pulmonary artery had been sutured but not ligated. Nine hours after the diagnosis, he abruptly coughed up a small amount of blood and subsequently collapsed, signs suggesting rupture of the suture line of the pulmonary artery. Our device was inserted into his trachea immediately, and the blocker was advanced into the right main bronchus by the tube rotation method. The cuff of the blocker was inflated to occlude the bronchial lumen. The intratracheal bleeding stopped. A chest roentgenogram made shortly after this management showed a massive hemothorax and radiopaque blocker on the right side. The patient‘s condition was stabilized by this procedure, and he underwent an emergency thoracotomy. There was 1,500 ml of blood in the right thorax. The inferior pulmonary artery and middle lobe bronchus had opened at the sutured site. The lower lobe was resected uneventfully, and the patient recovered well. Patient 2 A 23-year-old man was admitted one hour after an automobile accident. He was comatose and had anisocoria. A chest roentgenogram revealed subcutaneous emphysema, right-sided hemopneumothorax, and patchy pulmonary infiltration. Tracheal intubation and tube thoracotomy were performed. Evacuation of air and blood from the right pleural space gradually decreased, but intratracheal bleeding from the right bronchus continued. The endotracheal tube with a movable blocker was substituted. The intermediate bronchus was occluded with the cuff of the blocker under direct observation with the fiberoptic bronchoscope. Then a right thoracotomy was carried out. The right middle lobe with a small but deep laceration in the hilar portion was removed safely. The patient regained consciousness thirty days after the operation and was well as of this writing. Patient 3 A 21-year-old man was admitted fifty minutes after a motorcycle accident. A chest roentgenogram showed a
498 The Annals of Thoracic Surgery Vol 37 No 6 June 1984
Endotracheal tube with movable blocker (a modified type).
left hemopneumothorax and diffuse pulmonary opacity. Although intrapleural bleeding and air leakage ceased within an hour after tube thoracotomy, severe hemorrhage from the endotracheal tube continued and acute respiratory failure progressed. The endotracheal tube was removed, and our device was applied to block the left main bronchus without the aid of a fiberoptic bronchoscope. The patient’s condition was improved by this procedure, and a left thoracotomy was performed. A jagged, deep laceration near the pulmonary hilus was found and removed without incident from the left upper lobe.
Patient 4 A 41-year-old man was transferred from another hospital shortly after an automobile accident. A chest roentgenogram revealed extensive subcutaneous emphysema, right-sided pneumothorax, and diffuse opacity of the partially collapsed right lung. An endotracheal tube and chest tube had been inserted. On arrival at our institution, the patient was unconscious. Profuse air leakage from the chest tube was seen, and there was copious intratracheal bleeding which necessitated frequent suction toilet. The trachea was extubated and immediately reintubated with an endotracheal tube with a movable blocker. With the aid of a fiberoptic bronchoscope, the blocker was introduced into the right main bronchus. Then the cuff of the blocker was inflated to occlude the bronchial lumen. The intratracheal bleeding and air leakage from the chest ceased. A right thoracotomy was performed. A complete transection and a longitudinal tear of the intermediate bron-
chus were found. Part of the inflated cuff of the blocker was exposed in the operative field through the disrupted bronchus. The adjacent pulmonary artery was noted to have a small tear. Resection of the middle and lower lobes was performed safely. However, prominent contused brain swelling was noted in the left hemisphere postoperatively, and the patient died on the sixth postoperative day.
Comment Copious and persistent hemorrhage into the tracheobronchial tree is a great threat to life, because patients tend to drown and be asphyxiated in their own blood. Clouding of consciousness makes the effort to cough poor, and this worsens a dangerous situation. Immediate protection of the nonbleeding lung from aspiration of blood holds the highest priority in the management of these patients. The causes of intratracheal bleeding are numerous. Case reports of endobronchial hemorrhage from pulmonary artery catheterization are increasing [2]. The methods for separating the bleeding lung from the nonbleeding lung include the use of the singlelumen endobronchial tube, the double-lumen endobronchial tube (Carlens or Robertshaw tube), and the endobronchial blocker (Fogarty catheter). Single-lumen endobronchial tubes and double-lumen endobronchial tubes, especially in an emergency, may be extremely difficult to insert and accurately place in the targeted main bronchus. Furthermore, in these types of endobronchial tube the lumen inevitably is too small, thereby producing an increased resistance to air flow and greater difficulty in removing blood. Garzon and associates [3] emphasized that the most useful technique to stop bleeding and prevent aspiration was endobronchial blockade of the bleeding site with a
499
Inoue et al: Endotracheal Tube with Movable Blocker
Fogarty catheter combined with the rigid bronchoscope. Our device appears to represent a refinement of their technique. When the endotracheal tube with a movable blocker is employed for this purpose, an endotracheal tube and endobronchial blocker can be inserted into the trachea simultaneously. Then the blocker can be slid or pushed out of the endotracheal tube and easily manipulated into position under direct observation with the fiberoptic bronchoscope inserted through the endotracheal tube. In addition, the blocker can be advanced into the targeted main bronchus without the aid of the bronchoscope, as in Patients 1 and 3 in our series. In patients with copious and persistent intratracheal bleeding, the cause of death is not blood loss but suffocation. Immediate prevention of blood aspiration fol-
lowed by early resection of the source of hemorrhage constitutes ideal management. The endotracheal tube with a movable blocker appears to be of great help in successfully achieving such management.
References 1. Inoue H, Shohtsu A, Ogawa J, et al: New device for onelung anesthesia: endotracheal tube with movable blocker. J Thorac Cardiovasc Surg 83:940, 1982 2. Cervenko FW, Shelley SE, Spence DG, et al: Massive endobronchial hemorrhage during cardiopulmonary bypass: treatable complication of balloon-tipped catheter damage to the pulmonary artery. Ann Thorac Surg 35:326, 1983 3. Garzon AA, Cerruti MM, Golding ME: Exsanguinating hemoptysis. J Thorac Cardiovasc Surg 84:829, 1982
Notice from the American Board of Thoracic Surgery The American Board of Thoracic Surgery will begin its recertification process in 1984. Diplomates interested in participating in this examination should maintain a documented list of the cardiothoracic operations they performed during the year prior to application for recertification. They should also keep a record of their attendance at thoracic surgical meetings and other continuing medical education activities for the two years prior to application for recertification. In place of a cognitive examination, candidates for recertification will be required to complete both the general thoracic and cardiac portions of the SESATS (Self-
Education/Self-Assessment in Thoracic Surgery) I1 Syllabus. Diplomates whose 10-year certificates will expire in 1986 may begin the recertification process in 1984. Their new certificate will be dated 10 years from the time of expiration of the original certificate. Recertification is also open to any Diplomate with an unlimited certificate. The deadline for submission of applications is July 1, 1984. A recertification brochure outlining the rules and requirements for recertification in thoracic surgery is available on request from the American Board of Thoracic Surgery, 14640 E Seven Mile Rd, Detroit, MI 48205.