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SELECTIVE CONTRALATERAL BRONCHIAL INTUBATION IN CHILDREN WITH PNEUMOTHORAX OR BRONCHOPLEURAL FISTULA
Br. J. Anaesth. (1983), 55, 901
SELECTIVE CONTRALATERAL BRONCHIAL INTUBATION IN CHILDREN WITH PNEUMOTHORAX OR BRONCHOPLEURAL FISTULA A. BARAKA, A. DAJANI AND M. MAKTABI
The usefulness of selective contralateral bronchial intubation is illustrated by its use in two children undergoing thoracic surgery.
ventilated. The chest was closed and a water-seal drain inserted. Minimal air-leak was observed. Neuromuscular blockade, maintained with alcuronium, was antagonized and the trachea extubated. An immediate post-operative chest x-ray revealed partial expansion of the left lung with residual pneumothorax (fig. 1, right). Case report 2
Case report 1
The first report presents a boy (11 yr) with a ruptured lung abscess in whom the chest x-ray demonstrated a large left hydropneumothorax with shift of the mediastinum to the right (fig. 1, left). Arterial blood-gas tensions before operation, on room air, revealed PCh 11.97kPa, PCC>2 5.05kPa, pH7.41 unit, and base deficit 0. Following premedication with atropine and pre-oxygenation, anaesthesia was induced in the supine position, with thiopentone. Suxamethonium was administered and, under direct laryngoscopy, selective intubation of the right main bronchus was performed readily using an ordinary 6-mm cuffed tracheal tube. Artificial ventilation of the right lung was commenced, and anaesthesia maintained with 1-2% halothane in oxygen, using a modified T-piece system. Thirty minutes after the start of OLV blood-gas tensions were: PO264.1kPa, PcO24.79kPa, and pH7.39 unit. A left thoracotomy was performed and the surgeon confirmed the position and function of the bronchial tube. The lung abscess was evacuated and the pleura decorticated. After suctioning, the tube was withdrawn above the carina and both lungs were ANIS BARAKA, M.B., B.CH., D.A., D.M., M.D.; AIDA DAJANI, M.D.; MAZEN MAKTABI, M.D., B.CH.; Department of Anaesthesiology,
American University of Beirut, Beirut, Lebanon.
The patient was a 9-yr-old boy with arightlower lobe pneumonia complicated with a right empyema (fig. 2A). The child was premedicated with atropine. Anaesthesia was induced in the supine position with thiopentone and ventilation was controlled with 100% oxygen using a face-mask. Following the administration of suxamethonium and under direct laryngoscopy, a distally curved bougie was directed blindly to the left bronchus, and selective left bronchial intubation was achieved by threading an ordinary cuffed tracheal tube (5.5 mm) over the bougie. Anaesthesia was maintained with 1-2% halothane in oxygen and ventilation of the left lung was controlled using a modified T-piece system. Excessive tracheobronchial secretions were noted, and necessitated frequent suctioning. Blood-gas tensions (FlOjl.O) were PO2 7.98kPa, PCC>2 4.26kPa and pH 7.42 unit. A right thoracotomy was performed and the position and function of the bronchial tube confirmed. The empyema was evacuated and the pleura decorticated. Following suctioning, the tube was withdrawn above the carina, and both lungs were ventilated. Excessive air-leak was noted, denoting the presence of a bronchopleural fistula. The chest was closed and drained under water seal. A chest x-ray immediately after operation showed extensive infiltration involving the right lower lobe and the whole of the left lung (fig. 2B). Controlled © The Macmillan Press Ltd 1983
Downloaded from http://bja.oxfordjournals.org/ at University of Glasgow on June 30, 2015
One-lung ventilation (OLV) in children undergoing pulmonary hydatid surgery has been achieved previously by selective intubation of the main bronchus of the non-involved lung (Baraka et al., 1982). We now report utilization of this technique of selective contralateral bronchial intubation in two children undergoing thoracotomy for other pulmonary lesions.
902
BRITISH JOURNAL OF ANAESTHESIA
ventilation was continued into the period after oper- who showed normal arterial PO2 and PCO2 values ation. Twenty-four hours later, the trachea was before and during operation. Despite this complete extubated. The bronchopleural fistula healed by the compensation, nitrous oxide anaethsesia was not 7th day after the operation and the infiltration of the used in order to avoid its diffusion into the pneumothorax before the chest was opened (Eger lung was clearing (fig. 2c). and Saidman, 1965). DISCUSSION OLV was used in the child with the A change from two-lung ventilation (TLV) to OLV pneumothorax, not only to isolate the healthy lung does not usually result in a significant increase in and prevent its contamination, but also to avoid PCO2, provided the total minute volume of ventila- intermittent positive pressure ventilation (IPPV) of tion is maintained at the same value. In contrast, the diseased lung, since this may produce a tension oxygenation during OLV will be markedly impaired pneumothorax in the presence of a potential onesecondary to continued perfusion of the nonventi- way valvular mechanism. A similar complication lated lung, which will produce significant shunting can occur in patients having lobar emphysema or (Kerr, 1972). The hypoxaemia may be decreased by giant lung cysts (Gray and Edwards, 1948). In such active hypoxic pulmonary vasoconstriction which conditions, IPPV must not be started until selective results in a gradual redistribution of pulmonary contralateral bronchial intubation has been blood flow away from the collapsed lung to the achieved. ventilated lung (Benumof, 1979). This redistribuIPPV of the two lungs can be hazardous also in tion takes time to reach its maximum, and is of little patients with empyema associated with bronchovalue as a means of minimising arterial hypoxaemia pleural fistula. TLV can result in transbronchial secondary to OLV during thoractomy (Khanan and spread, the empyema flooding both lungs; it can also Branthwaite, 1973). However, long-lasting collapse result in pneumothorax before thoracotomy and in of the lung may be completely compensated, as excessive air-leak after the chest is opened. In such observed in the child with a large pneumothorax cases, OLV will prevent a leak from the broncho-
Downloaded from http://bja.oxfordjournals.org/ at University of Glasgow on June 30, 2015
FIG. 1. Left: Preoperative chest x-ray of the first child, showing a lung mass and a large hydropneumothorax on the left side, with marked shift of the heart and mediastinum to the right. Right: Postoperative chest x-ray showing incomplete expansion of the left lung with a small pneumothorax.
SELECTIVE CONTRALATERAL BRONCHIAL INTUBATION
903
pleural fistula, and isolate the healthy lung from the OLV. This could have been avoided by inducing infected lung. However, despite the selective con- anaesthesia with a head-up tilt while the child was tralateral bronchial intubation, the child with em- breathing spontaneously, or by using a sequence pyema and bronchopleural fistula developed exten- similar to that used in the child with the sive infiltrates of both the diseased and the healthy pneumothorax. Controlled ventilation should be lung. Such a serious complication can be attributed commenced only after ensuring contralateral to transbronchial spread of the empyema which bronchial intubation. Although the diagnosis of most probably occurred during induction of anaes- bronchopleural fistula was confirmed only after thesia before the selective bronchial intubation and thoracotomy and TLV, it is always safer to presume
Downloaded from http://bja.oxfordjournals.org/ at University of Glasgow on June 30, 2015
FIG. 2 A: Preoperative chest x-ray of the second child, showing loculated fluid in the right pleural space with marked elevation of the right diaphragm. B: Immediate postoperative chest x-ray showing extensive infiltrates involving the whole of the left lung and the right lower lobe. C: Chest x-ray taken 7 days after operation. There is evidence of complete clearing of the intra-alveolar infiltrates with right pleural thickening and the presence of a small radio-lucency in the right lower lobe.
904
BRITISH JOURNAL OF ANAESTHESIA
that all children with empyema or pneumothorax have an associated fistula.
SELEKTIVE KONTRALATERALE BRONCHIALINTUBATION BEI KINDERN MIT PNEUMOTHORAX ODER BRONCHOPLEURALER FISTEL
REFERENCES
INTUBATION SELECTIVE DE LA BRONCHE CONTROLATERALE CHEZ LES ENFANTS PORTEUR5 D'UN PNEUMOTHORAX OU D"UNE HSTULE BRONCHOPLEURALE RESUME
L'utihte de Pintubation selective de la bronche controlaterale est illustree par son usage chez deux enfants subissant un acte de chirurgie thoracique.
ZUSAMMENFASSUNG
Der Nutzen selektiver kontralateraler Bronchialintubation wird an ihrer Anwendung bei zwei Kindern wahrend Thoraxchirurgie dargestellt.
INTUBACION CPNTRALATERAL SELECTIVA DE LOS BRONQUIOS EN NINOS CON NEUMOTORAX O FISTULA BRONCOPLEURAL
La utilidad de la intubacion contralateral selective de los bronquios se pone de manifiesto en el caso de dos ninos sometidos a intervencion quirurjica del torax.
Downloaded from http://bja.oxfordjournals.org/ at University of Glasgow on June 30, 2015
Baraks, A., Slim, M., Dajani, A., and Lakkis, S. (1982). Onelung ventilation of children during surgical excision of hydatid cysts of the lung. Br. J. Anaath., 54, 523. Benumof, J. L. (1979). Mechanism of decreased blood flow to atelectatic lung. / . Appl. Phytiol., 56, 1047. Eger, E. I., and Saidman, L. J. (1965). Hazards of nitrous oxide anesthesia in bowel obstruction and pneumothorax. Anesthesiology, 26, 61. Gray, T. C , and Edwards, F. R. (1948). The anesthetic problem* associated with giant tension cysts of the lung. Thorax, 3, 237. Kerr, J. H. (1972). Physiologic aspects of one-lung (endobronchial) anaesthesia in thoracic surgery (ed. O. Norlander). Int. Anaesthaiol. Clin., 10,61. Khanan, T., and Branthwaite, M. A. (1973). Arterial oxygenation during one-lung anaesthesia. Anaesthesia, 28, 280.
SELECTIVE CONTRALATERAL BRONCHIAL INTUBATION IN CHILDREN WITH PNEUMOTHORAX OR BRONCHOPLEURAL FISTULA A. BARAKA, A. DAJANI AND M. MAKTABI
The usefulness of selective contralateral bronchial intubation is illustrated by its use in two children undergoing thoracic surgery.
ventilated. The chest was closed and a water-seal drain inserted. Minimal air-leak was observed. Neuromuscular blockade, maintained with alcuronium, was antagonized and the trachea extubated. An immediate post-operative chest x-ray revealed partial expansion of the left lung with residual pneumothorax (fig. 1, right). Case report 2
Case report 1
The first report presents a boy (11 yr) with a ruptured lung abscess in whom the chest x-ray demonstrated a large left hydropneumothorax with shift of the mediastinum to the right (fig. 1, left). Arterial blood-gas tensions before operation, on room air, revealed PCh 11.97kPa, PCC>2 5.05kPa, pH7.41 unit, and base deficit 0. Following premedication with atropine and pre-oxygenation, anaesthesia was induced in the supine position, with thiopentone. Suxamethonium was administered and, under direct laryngoscopy, selective intubation of the right main bronchus was performed readily using an ordinary 6-mm cuffed tracheal tube. Artificial ventilation of the right lung was commenced, and anaesthesia maintained with 1-2% halothane in oxygen, using a modified T-piece system. Thirty minutes after the start of OLV blood-gas tensions were: PO264.1kPa, PcO24.79kPa, and pH7.39 unit. A left thoracotomy was performed and the surgeon confirmed the position and function of the bronchial tube. The lung abscess was evacuated and the pleura decorticated. After suctioning, the tube was withdrawn above the carina and both lungs were ANIS BARAKA, M.B., B.CH., D.A., D.M., M.D.; AIDA DAJANI, M.D.; MAZEN MAKTABI, M.D., B.CH.; Department of Anaesthesiology,
American University of Beirut, Beirut, Lebanon.
The patient was a 9-yr-old boy with arightlower lobe pneumonia complicated with a right empyema (fig. 2A). The child was premedicated with atropine. Anaesthesia was induced in the supine position with thiopentone and ventilation was controlled with 100% oxygen using a face-mask. Following the administration of suxamethonium and under direct laryngoscopy, a distally curved bougie was directed blindly to the left bronchus, and selective left bronchial intubation was achieved by threading an ordinary cuffed tracheal tube (5.5 mm) over the bougie. Anaesthesia was maintained with 1-2% halothane in oxygen and ventilation of the left lung was controlled using a modified T-piece system. Excessive tracheobronchial secretions were noted, and necessitated frequent suctioning. Blood-gas tensions (FlOjl.O) were PO2 7.98kPa, PCC>2 4.26kPa and pH 7.42 unit. A right thoracotomy was performed and the position and function of the bronchial tube confirmed. The empyema was evacuated and the pleura decorticated. Following suctioning, the tube was withdrawn above the carina, and both lungs were ventilated. Excessive air-leak was noted, denoting the presence of a bronchopleural fistula. The chest was closed and drained under water seal. A chest x-ray immediately after operation showed extensive infiltration involving the right lower lobe and the whole of the left lung (fig. 2B). Controlled © The Macmillan Press Ltd 1983
Downloaded from http://bja.oxfordjournals.org/ at University of Glasgow on June 30, 2015
One-lung ventilation (OLV) in children undergoing pulmonary hydatid surgery has been achieved previously by selective intubation of the main bronchus of the non-involved lung (Baraka et al., 1982). We now report utilization of this technique of selective contralateral bronchial intubation in two children undergoing thoracotomy for other pulmonary lesions.
902
BRITISH JOURNAL OF ANAESTHESIA
ventilation was continued into the period after oper- who showed normal arterial PO2 and PCO2 values ation. Twenty-four hours later, the trachea was before and during operation. Despite this complete extubated. The bronchopleural fistula healed by the compensation, nitrous oxide anaethsesia was not 7th day after the operation and the infiltration of the used in order to avoid its diffusion into the pneumothorax before the chest was opened (Eger lung was clearing (fig. 2c). and Saidman, 1965). DISCUSSION OLV was used in the child with the A change from two-lung ventilation (TLV) to OLV pneumothorax, not only to isolate the healthy lung does not usually result in a significant increase in and prevent its contamination, but also to avoid PCO2, provided the total minute volume of ventila- intermittent positive pressure ventilation (IPPV) of tion is maintained at the same value. In contrast, the diseased lung, since this may produce a tension oxygenation during OLV will be markedly impaired pneumothorax in the presence of a potential onesecondary to continued perfusion of the nonventi- way valvular mechanism. A similar complication lated lung, which will produce significant shunting can occur in patients having lobar emphysema or (Kerr, 1972). The hypoxaemia may be decreased by giant lung cysts (Gray and Edwards, 1948). In such active hypoxic pulmonary vasoconstriction which conditions, IPPV must not be started until selective results in a gradual redistribution of pulmonary contralateral bronchial intubation has been blood flow away from the collapsed lung to the achieved. ventilated lung (Benumof, 1979). This redistribuIPPV of the two lungs can be hazardous also in tion takes time to reach its maximum, and is of little patients with empyema associated with bronchovalue as a means of minimising arterial hypoxaemia pleural fistula. TLV can result in transbronchial secondary to OLV during thoractomy (Khanan and spread, the empyema flooding both lungs; it can also Branthwaite, 1973). However, long-lasting collapse result in pneumothorax before thoracotomy and in of the lung may be completely compensated, as excessive air-leak after the chest is opened. In such observed in the child with a large pneumothorax cases, OLV will prevent a leak from the broncho-
Downloaded from http://bja.oxfordjournals.org/ at University of Glasgow on June 30, 2015
FIG. 1. Left: Preoperative chest x-ray of the first child, showing a lung mass and a large hydropneumothorax on the left side, with marked shift of the heart and mediastinum to the right. Right: Postoperative chest x-ray showing incomplete expansion of the left lung with a small pneumothorax.
SELECTIVE CONTRALATERAL BRONCHIAL INTUBATION
903
pleural fistula, and isolate the healthy lung from the OLV. This could have been avoided by inducing infected lung. However, despite the selective con- anaesthesia with a head-up tilt while the child was tralateral bronchial intubation, the child with em- breathing spontaneously, or by using a sequence pyema and bronchopleural fistula developed exten- similar to that used in the child with the sive infiltrates of both the diseased and the healthy pneumothorax. Controlled ventilation should be lung. Such a serious complication can be attributed commenced only after ensuring contralateral to transbronchial spread of the empyema which bronchial intubation. Although the diagnosis of most probably occurred during induction of anaes- bronchopleural fistula was confirmed only after thesia before the selective bronchial intubation and thoracotomy and TLV, it is always safer to presume
Downloaded from http://bja.oxfordjournals.org/ at University of Glasgow on June 30, 2015
FIG. 2 A: Preoperative chest x-ray of the second child, showing loculated fluid in the right pleural space with marked elevation of the right diaphragm. B: Immediate postoperative chest x-ray showing extensive infiltrates involving the whole of the left lung and the right lower lobe. C: Chest x-ray taken 7 days after operation. There is evidence of complete clearing of the intra-alveolar infiltrates with right pleural thickening and the presence of a small radio-lucency in the right lower lobe.
904
BRITISH JOURNAL OF ANAESTHESIA
that all children with empyema or pneumothorax have an associated fistula.
SELEKTIVE KONTRALATERALE BRONCHIALINTUBATION BEI KINDERN MIT PNEUMOTHORAX ODER BRONCHOPLEURALER FISTEL
REFERENCES
INTUBATION SELECTIVE DE LA BRONCHE CONTROLATERALE CHEZ LES ENFANTS PORTEUR5 D'UN PNEUMOTHORAX OU D"UNE HSTULE BRONCHOPLEURALE RESUME
L'utihte de Pintubation selective de la bronche controlaterale est illustree par son usage chez deux enfants subissant un acte de chirurgie thoracique.
ZUSAMMENFASSUNG
Der Nutzen selektiver kontralateraler Bronchialintubation wird an ihrer Anwendung bei zwei Kindern wahrend Thoraxchirurgie dargestellt.
INTUBACION CPNTRALATERAL SELECTIVA DE LOS BRONQUIOS EN NINOS CON NEUMOTORAX O FISTULA BRONCOPLEURAL
La utilidad de la intubacion contralateral selective de los bronquios se pone de manifiesto en el caso de dos ninos sometidos a intervencion quirurjica del torax.
Downloaded from http://bja.oxfordjournals.org/ at University of Glasgow on June 30, 2015
Baraks, A., Slim, M., Dajani, A., and Lakkis, S. (1982). Onelung ventilation of children during surgical excision of hydatid cysts of the lung. Br. J. Anaath., 54, 523. Benumof, J. L. (1979). Mechanism of decreased blood flow to atelectatic lung. / . Appl. Phytiol., 56, 1047. Eger, E. I., and Saidman, L. J. (1965). Hazards of nitrous oxide anesthesia in bowel obstruction and pneumothorax. Anesthesiology, 26, 61. Gray, T. C , and Edwards, F. R. (1948). The anesthetic problem* associated with giant tension cysts of the lung. Thorax, 3, 237. Kerr, J. H. (1972). Physiologic aspects of one-lung (endobronchial) anaesthesia in thoracic surgery (ed. O. Norlander). Int. Anaesthaiol. Clin., 10,61. Khanan, T., and Branthwaite, M. A. (1973). Arterial oxygenation during one-lung anaesthesia. Anaesthesia, 28, 280.