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Single-Lung Ventilation for Right-Sleeve Pneumonectomy With a Modified Nasal RAE Endotracheal Tube
Single-Lung Ventilation for Right-Sleeve Pneumonectomy With a Modified Nasal RAE Endotracheal Tube Nahel N. Saied, MB, BCh, Mohammad Helwani, MD, and Ehab Morcos, MB, BCh
A
NESTHETIC MANAGEMENT OF patients with carinal lesions is challenging. Distal tracheal lesions are managed by serial dilatations or rarely limited resections. Subsequent advances in anesthetic and surgical techniques, and postoperative care have allowed the successful primary resection and reanastomosis of a wide range of complex airway lesions.1 A variety of anesthetic techniques have been described for the management of sleeve pneumonectomy (SP) and carinal resection. Jet ventilation, reconstructed tubes, endobronchial tubes, and direct intubation of the main bronchus through the surgical field are among many of the techniques used to provide ventilation and oxygenation in such procedures.2 The technique used to provide one-lung ventilation (OLV) is extremely important to optimize the surgical field for the proposed surgery. The technique should be least obstructive while providing adequate oxygenation and ventilation throughout the procedure in a compromised patient. Careful preoperative planning and continuous vigilance are essential for successful anesthetic management tailored to each patient’s needs. In this case report, a new technique to provide OLV for right-side SP using a modified nasal Ring-Adair-Elwyn (RAE) endotracheal tube (NRETT) is presented. CASE REPORT The patient was a 57-year-old white man (6= 1⬙, 216 lbs) who presented with a dry cough. He had a history of smoking (60 pack years), hypertension, and gastroesophageal reflux disease. A chest computed tomography scan revealed a right mainstem mass (1.25 ⫻ 2.0 cm), nearly obstructing the lumen and extending into the posterior lateral tracheobronchial junction (Fig 1). Biopsy of the lesion confirmed squamous cell carcinoma, but further tests were negative for metastatic disease. After discussing the proposed procedure with the surgeon, it was clear that OLV of the left side would need to be achieved with the narrowest tube possible to facilitate right SP. A modified 6.0-mm NR-ETT (Mallinckrodt Inc, Hazelwood, MO) (Fig 2) was used as an endobronchial tube for lung isolation. To prepare the NR-ETT for the procedure, the authors placed 1-inch adhesive silk tape on the proximal part of the NR-ETT cuff to decrease the cuff-to-tip (C-to-T) distance to 3.5 cm. A silk ligature was tied around the distal end of the adhesive tape. The modified cuff was inflated fully and evenly with 4 to 5 cm of air, and the measured pressure was 25 cmH2O. General anesthesia was induced after placement of a thoracic epidural catheter at the level of the sixth thoracic vertebra. The trachea was then intubated with an 8.0-mm cuffed ETT, and the necessary invasive catheters were placed. Fiberoptic bronchoscopy revealed a right mainstem bronchus mass partially obstructing the lumen at the origin of the right mainstem. Mediastinoscopy was then performed to provide multiple lymph node biopsies, all of which were negative for malignancy. The 8.0-mm ETT was then replaced with the modified NR-ETT. A stylet was placed into the modified NR-ETT to facilitate oral tracheal intubation with direct laryngoscopy. Fiberoptic bronchoscopy (4-mm Olympus Inc, Center Valley, PA) was then used to guide the modified NR-ETT and place its tip 0.5 cm above the most proximal division of the left mainstem bronchus (LMSB). The cuff was inflated with 3 to 4 mL of air, and OLV was successfully achieved as confirmed by chest auscultation and bronchoscopy before and after the patient was placed in the left lateral-dependent position. The tidal volume was set to 500 mL, and the respiratory rate ranged from 12 to 16 breaths/min with an
inspiratory-to-expiratory ratio of 1:1.5. Peak airway pressures ranged from 28 to 37 cmH2O, and SpO2 ranged from 96% to 100% throughout the procedure. The chest was entered through the right fourth intercostal space, and, after obtaining the necessary surgical exposure, the stapler (Proximate Linear Stapler 60 mm; Ethicone Endo-Surgery, Inc, Cincinnati, OH) was placed across the right main bronchus at the carina to include the right wall of the distal trachea (Fig 3A). The cuff was deflated, and the modified NR-ETT was withdrawn to the middle of the trachea (Fig 3B). Bronchoscopy confirmed that there was no significant narrowing of the distal trachea into the LMSB. Ventilation was held momentarily until the stapler was deployed; then, ventilation was resumed and the right SP was completed (Fig 3C). At the end of the procedure, the trachea was extubated, and the patient was transferred to the postanesthesia care unit in stable condition. DISCUSSION
SP is an uncommon operation in lung cancer surgery. It is a technically demanding procedure that requires careful planning and close communication between the surgeon and the anesthesiologist. In addition to radiologic evaluation of the required resection, bronchoscopy may be necessary to determine the actual anatomy, the extent of the tumor, and the feasibility of the resection. Coordinating OLV and the position of the tube used for ventilation is critical to successful resection while safe and effective ventilation is provided. Although OLV is commonly performed by using a double-lumen endobronchial tube (DLT), it is generally not useful for surgery involving the distal part of the trachea.3 Several different methods of ventilation and airway management have been proposed. In 1963, Grillo et al4 advocated intubation of the left mainstem bronchus across the operative field, with sterile tubing passed off to the anesthesiologist. This technique entails a great deal of effort on the part of the surgeon and involves intermittent loss of control of the airway during the switching process. It also adds significant time to the procedure because of the added step of reanastomosis of the trachea to the remaining mainstem bronchus, if required. In the mid-1970s, some anesthesiologists used a standard but uncut long orotracheal tube placed above the tracheal lesion that is merely manipulated by the surgeon past the area of stenosis or mass.5,6 Although this method is relatively easy to use, the large diameter of a standard tube may traumatize the lesion and cause bleeding or dislodgement of tissue, resulting in further airway obstruction. The technique is also limited to patients with relatively mild stenosis, and the presence of an endotracheal tube may interfere with surgical repair.
From the Department of Anesthesiology, St Louis University, School of Medicine, St Louis, MO. Address reprint requests to Nahel N. Saied, MB, BCh, Department of Anesthesiology, St Louis University Hospital, 3635 Vista Ave at Grand Blvd, St Louis, MO 63110. E-mail: [email protected] © 2007 Elsevier Inc. All rights reserved. 1053-0770/07/2106-0023$32.00/0 doi:10.1053/j.jvca.2007.01.022 Key words: one-lung ventilation, sleeve, pneumonectomy, nasal RAE, endotracheal tube
Journal of Cardiothoracic and Vascular Anesthesia, Vol 21, No 6 (December), 2007: pp 883-886
883
884
Fig 1. row).
SAIED, HELWANI, AND MORCOS
Chest computed tomography scan showing the right bronchial tumor at the carina extending into the right main bronchus (ar-
In an effort to overcome these problems, high-frequency jet ventilation (HFJV) was tried. HFJV uses jet pulses of 100 to 400/min through a small catheter. With this technique, acceptable blood gases have been maintained, and there have been no deleterious effects on the circulation. With only a small catheter in the field, the surgeon can more easily perform the tracheal resection and/or anastomosis. However, the disadvantages of this technique include possible inadequate escape of air around the jet catheter during exhalation with subsequent pneumothorax. Other complications include plugging of the catheter with blood, displacement of the catheter, aspiration of blood, and technical difficulties with high-pressure injectors.7,8 High-frequency positive-pressure ventilation (HFPPV) was described by Eriksson et al9 in 1975. They applied small positive-pressure tidal volumes (50-250 mL) at a rate of 60 to 100/min. Advantages of using HFPPV for tracheal resection include a relatively unobstructed surgical field, no interruption of ventilation during surgery, minimized contamination of the lungs from blood and debris by a continuous outflow of gas, and minimized lung and mediastinal movement. In addition, the production of continuous positive airway pressure lessens the risk of alveolar collapse. The disadvantages of the HFPPV technique include decreasing blood flow to the ventilated lung and indirectly increasing blood flow to the collapsed lung, resulting in increased shunt and risk of hypoxia.10 Hannallah11 described a modified oral RAE ETT during the repair of tracheoesophageal fistula. To prevent endobronchial intubation with the modified tube, he cut the ETT tip distal to the cuff. This modification left the inflation channel open (because it travels distal to the cuff), which was then blocked by using a small segment of a straight surgical needle. He also used an unmodified nasal RAE for resection of midtracheal stenosis allowing more distal placement of the ETT into the trachea. Another technique for airway management involves the insertion of a specially constructed single-lumen endobron-
chial tube. The most commonly used tube is constructed by joining standard red rubber endotracheal tubes with the cuff end cut off to the proximal end of a Tovell endotracheal tube using a metal connector.12 The Tovell ETT has a short cuff and short segment distal to the cuff but is no longer manufactured. A 6.0-mm NR-ETT was chosen for 2 reasons: (1) it allowed the authors to perform left mainstem intubation with enough length (34 cm) if used orally, and (2) the tube would be least obstructive at the distal part of the trachea and the carina during the procedure. Using the unmodified NR-ETT would have resulted in 2 problems: (1) obstruction of the left upper lobe bronchus (LULB) because the NR-ETT has a C-to-T distance of 5 cm (Fig 4A) or (2) the cuff could encroach on the surgical field if the cuff was allowed to herniate above the carina (Fig 4B). To solve those problems, the C-to-T distance had to be shortened. But cutting the
Fig 2. A diagram showing the measurements of the modified nasal RAE endotracheal tube.
SINGLE-LUNG VENTILATION
885
Fig 3. (A) The surgical stapler was applied at the origin of the right mainstem bronchus at the carina including the right side of the distal trachea. (B) The modified NR-ETT was withdrawn into the trachea to perform bronchoscopy before deployment of the stapler. (C) Then, the stapler was deployed, and the SP was completed.
886
SAIED, HELWANI, AND MORCOS
Fig 4. The unmodified ETT poses the risk of (A) obstruction of the left upper lobe bronchus if the cuff was to be placed entirely into the LMSB, or (B) herniation of the cuff at the carina, which may interfere with distal tracheal resection, whereas (C) the modified ETT allowed the proper positioning of the ETT in the LMSB as an endobronchial tube.
tip of the NR-ETT distal to the cuff would have resulted in a sharp traumatic edge and would render the cuff unusable because of a leak through the inflation channel that runs to the end of the NR-ETT. By reducing the cuff size with the adhesive silk tape, the authors were able to decrease the C-to-T distance to 3.5 cm, allowing LMSB intubation without risking obstruction of the LULB or herniation of the cuff at the carina (Fig 4C). A silk ligature was tied around the distal end of the adhesive tape to prevent it from loosening under cuff pressure. By using this technique, the authors were able to provide uninterrupted ventilation and reduce time needed for tube switch across the surgical field. The authors were also able to avoid complications of HFJV and provide the surgeon with the least obstructive surgical field. The modified tube would not have been helpful in patients who require left SP because of obstruction of the right upper lobe bronchus by the modified ETT cuff. Interestingly, over a period of 10 years, Roviaro et al13 performed 48 right SP procedures and only 1 left SP. The use of a smaller left DLT (35F) was considered but was found to be inappropriate because of the larger outer diameter
(OD) of the DLT (13 mm) compared with the modified tube (8.2 mm). The large OD could have interfered with distal tracheal resection during the application of the stapler. Another option would have been to use the 6.0 Univent (Fuji Systems Corp, Tokyo, Japan) instead of the modified tube as an endobronchial tube. The OD of the 6.0 Univent tube is large (oval, 9.7 ⫻ 11.5 mm), which would have caused difficulty with placement into the LMSB or caused bronchial injury. Although not commonly used in the United States, singlelumen endobronchial tubes manufactured by Rüsch Inc (Duluth, GA) could have been used instead of the modified tube that was used in the present case. They are long (45 cm) tubes to allow deep endobronchial placement, come in variable sizes (6.5 and 8.0 mm), and have both left and right configuration.14 In summary, the modified ETT provides safe and effective ventilation during right SP. The technique saves time and provides uninterrupted ventilation throughout the procedure. This modified ETT is constructed from equipment readily available in the operating rooms.
REFERENCES 1. Porhanov VA, Poliakov IS, Selvaschuk AP, et al: Indications and results of sleeve carinal resection. Eur J Cardiothorac Surg 22:685-694, 2002 2. Sandberg W: Anesthesia and airway management for tracheal resection and reconstruction. Int Anesthesiol Clin 38:55-75, 2000 3. Rogers RC, Gibbons J, Cosgrove J, et al: High-frequency jet ventilation for tracheal surgery. Anaesthesia 40:32-36, 1985 4. Grillo HC, Bendixen HH, Gephart T: Resection of the carina and lower trachea. Ann Surg 158:889-893, 1963 5. Theman TE, Kerr JH, Nelems JM, et al: Carinal resection. A report of two cases and a description of the anesthetic technique. J Thorac Cardiovasc Surg 71:314-320, 1976 6. Kemvyssi-Dea S, Kritikon P, Exarhos N, et al: Anaesthetic management of reconstruction of the lower part of the trachea. Br J Anaesth 47:82-84, 1975 7. Baraka A: Oxygen-jet ventilation during tracheal reconstruction in patients with tracheal stenosis. Anesth Analg 56:429-432, 1977 8. Dzuberova I, Sabakova L, Jurakova O, et al: High-frequency jet ventilation in trachea reconstructions—Its advantages in our experience. Acta Chir Hung 38:31-34, 1999
9. Eriksson I, Nilsson LG, Nordstrom S, et al: High-frequency positive-pressure ventilation (HFPPV) during transthoracic resection of tracheal stenosis and during perioperative bronchoscopic examination. Acta Anaesthesiol Scand 19:113-119, 1975 10. EL-Baz J, Jensik R, Faber LP, et al: One-lung high-frequency ventilation of tracheoplasty and bronchoplasty: A new technique. Ann Thorac Surg 34:564-571, 1982 11. Hannallah M: The optimal breathing tube for tracheal resection and reconstruction. Anesthesiology 83:419-421, 1995 12. Geffin B, Bland J, Grillo G: Anesthetic management of tracheal resection and reconstruction. Anesth Analg 48:884-894, 1969 13. Roviaro G, Varoli F, Romanelli A, et al: Complications of tracheal sleeve pneumonectomy: Personal experience and overview of the literature. J Thorac Cardiovasc Surg 121:234-240, 2001 14. Harte BH, Jaklitsch MT, McKenna SS, et al: Use of a modified single-lumen endobronchial tube in severe tracheobronchial compression. Anesthesiology 96:510-511, 2002
A
NESTHETIC MANAGEMENT OF patients with carinal lesions is challenging. Distal tracheal lesions are managed by serial dilatations or rarely limited resections. Subsequent advances in anesthetic and surgical techniques, and postoperative care have allowed the successful primary resection and reanastomosis of a wide range of complex airway lesions.1 A variety of anesthetic techniques have been described for the management of sleeve pneumonectomy (SP) and carinal resection. Jet ventilation, reconstructed tubes, endobronchial tubes, and direct intubation of the main bronchus through the surgical field are among many of the techniques used to provide ventilation and oxygenation in such procedures.2 The technique used to provide one-lung ventilation (OLV) is extremely important to optimize the surgical field for the proposed surgery. The technique should be least obstructive while providing adequate oxygenation and ventilation throughout the procedure in a compromised patient. Careful preoperative planning and continuous vigilance are essential for successful anesthetic management tailored to each patient’s needs. In this case report, a new technique to provide OLV for right-side SP using a modified nasal Ring-Adair-Elwyn (RAE) endotracheal tube (NRETT) is presented. CASE REPORT The patient was a 57-year-old white man (6= 1⬙, 216 lbs) who presented with a dry cough. He had a history of smoking (60 pack years), hypertension, and gastroesophageal reflux disease. A chest computed tomography scan revealed a right mainstem mass (1.25 ⫻ 2.0 cm), nearly obstructing the lumen and extending into the posterior lateral tracheobronchial junction (Fig 1). Biopsy of the lesion confirmed squamous cell carcinoma, but further tests were negative for metastatic disease. After discussing the proposed procedure with the surgeon, it was clear that OLV of the left side would need to be achieved with the narrowest tube possible to facilitate right SP. A modified 6.0-mm NR-ETT (Mallinckrodt Inc, Hazelwood, MO) (Fig 2) was used as an endobronchial tube for lung isolation. To prepare the NR-ETT for the procedure, the authors placed 1-inch adhesive silk tape on the proximal part of the NR-ETT cuff to decrease the cuff-to-tip (C-to-T) distance to 3.5 cm. A silk ligature was tied around the distal end of the adhesive tape. The modified cuff was inflated fully and evenly with 4 to 5 cm of air, and the measured pressure was 25 cmH2O. General anesthesia was induced after placement of a thoracic epidural catheter at the level of the sixth thoracic vertebra. The trachea was then intubated with an 8.0-mm cuffed ETT, and the necessary invasive catheters were placed. Fiberoptic bronchoscopy revealed a right mainstem bronchus mass partially obstructing the lumen at the origin of the right mainstem. Mediastinoscopy was then performed to provide multiple lymph node biopsies, all of which were negative for malignancy. The 8.0-mm ETT was then replaced with the modified NR-ETT. A stylet was placed into the modified NR-ETT to facilitate oral tracheal intubation with direct laryngoscopy. Fiberoptic bronchoscopy (4-mm Olympus Inc, Center Valley, PA) was then used to guide the modified NR-ETT and place its tip 0.5 cm above the most proximal division of the left mainstem bronchus (LMSB). The cuff was inflated with 3 to 4 mL of air, and OLV was successfully achieved as confirmed by chest auscultation and bronchoscopy before and after the patient was placed in the left lateral-dependent position. The tidal volume was set to 500 mL, and the respiratory rate ranged from 12 to 16 breaths/min with an
inspiratory-to-expiratory ratio of 1:1.5. Peak airway pressures ranged from 28 to 37 cmH2O, and SpO2 ranged from 96% to 100% throughout the procedure. The chest was entered through the right fourth intercostal space, and, after obtaining the necessary surgical exposure, the stapler (Proximate Linear Stapler 60 mm; Ethicone Endo-Surgery, Inc, Cincinnati, OH) was placed across the right main bronchus at the carina to include the right wall of the distal trachea (Fig 3A). The cuff was deflated, and the modified NR-ETT was withdrawn to the middle of the trachea (Fig 3B). Bronchoscopy confirmed that there was no significant narrowing of the distal trachea into the LMSB. Ventilation was held momentarily until the stapler was deployed; then, ventilation was resumed and the right SP was completed (Fig 3C). At the end of the procedure, the trachea was extubated, and the patient was transferred to the postanesthesia care unit in stable condition. DISCUSSION
SP is an uncommon operation in lung cancer surgery. It is a technically demanding procedure that requires careful planning and close communication between the surgeon and the anesthesiologist. In addition to radiologic evaluation of the required resection, bronchoscopy may be necessary to determine the actual anatomy, the extent of the tumor, and the feasibility of the resection. Coordinating OLV and the position of the tube used for ventilation is critical to successful resection while safe and effective ventilation is provided. Although OLV is commonly performed by using a double-lumen endobronchial tube (DLT), it is generally not useful for surgery involving the distal part of the trachea.3 Several different methods of ventilation and airway management have been proposed. In 1963, Grillo et al4 advocated intubation of the left mainstem bronchus across the operative field, with sterile tubing passed off to the anesthesiologist. This technique entails a great deal of effort on the part of the surgeon and involves intermittent loss of control of the airway during the switching process. It also adds significant time to the procedure because of the added step of reanastomosis of the trachea to the remaining mainstem bronchus, if required. In the mid-1970s, some anesthesiologists used a standard but uncut long orotracheal tube placed above the tracheal lesion that is merely manipulated by the surgeon past the area of stenosis or mass.5,6 Although this method is relatively easy to use, the large diameter of a standard tube may traumatize the lesion and cause bleeding or dislodgement of tissue, resulting in further airway obstruction. The technique is also limited to patients with relatively mild stenosis, and the presence of an endotracheal tube may interfere with surgical repair.
From the Department of Anesthesiology, St Louis University, School of Medicine, St Louis, MO. Address reprint requests to Nahel N. Saied, MB, BCh, Department of Anesthesiology, St Louis University Hospital, 3635 Vista Ave at Grand Blvd, St Louis, MO 63110. E-mail: [email protected] © 2007 Elsevier Inc. All rights reserved. 1053-0770/07/2106-0023$32.00/0 doi:10.1053/j.jvca.2007.01.022 Key words: one-lung ventilation, sleeve, pneumonectomy, nasal RAE, endotracheal tube
Journal of Cardiothoracic and Vascular Anesthesia, Vol 21, No 6 (December), 2007: pp 883-886
883
884
Fig 1. row).
SAIED, HELWANI, AND MORCOS
Chest computed tomography scan showing the right bronchial tumor at the carina extending into the right main bronchus (ar-
In an effort to overcome these problems, high-frequency jet ventilation (HFJV) was tried. HFJV uses jet pulses of 100 to 400/min through a small catheter. With this technique, acceptable blood gases have been maintained, and there have been no deleterious effects on the circulation. With only a small catheter in the field, the surgeon can more easily perform the tracheal resection and/or anastomosis. However, the disadvantages of this technique include possible inadequate escape of air around the jet catheter during exhalation with subsequent pneumothorax. Other complications include plugging of the catheter with blood, displacement of the catheter, aspiration of blood, and technical difficulties with high-pressure injectors.7,8 High-frequency positive-pressure ventilation (HFPPV) was described by Eriksson et al9 in 1975. They applied small positive-pressure tidal volumes (50-250 mL) at a rate of 60 to 100/min. Advantages of using HFPPV for tracheal resection include a relatively unobstructed surgical field, no interruption of ventilation during surgery, minimized contamination of the lungs from blood and debris by a continuous outflow of gas, and minimized lung and mediastinal movement. In addition, the production of continuous positive airway pressure lessens the risk of alveolar collapse. The disadvantages of the HFPPV technique include decreasing blood flow to the ventilated lung and indirectly increasing blood flow to the collapsed lung, resulting in increased shunt and risk of hypoxia.10 Hannallah11 described a modified oral RAE ETT during the repair of tracheoesophageal fistula. To prevent endobronchial intubation with the modified tube, he cut the ETT tip distal to the cuff. This modification left the inflation channel open (because it travels distal to the cuff), which was then blocked by using a small segment of a straight surgical needle. He also used an unmodified nasal RAE for resection of midtracheal stenosis allowing more distal placement of the ETT into the trachea. Another technique for airway management involves the insertion of a specially constructed single-lumen endobron-
chial tube. The most commonly used tube is constructed by joining standard red rubber endotracheal tubes with the cuff end cut off to the proximal end of a Tovell endotracheal tube using a metal connector.12 The Tovell ETT has a short cuff and short segment distal to the cuff but is no longer manufactured. A 6.0-mm NR-ETT was chosen for 2 reasons: (1) it allowed the authors to perform left mainstem intubation with enough length (34 cm) if used orally, and (2) the tube would be least obstructive at the distal part of the trachea and the carina during the procedure. Using the unmodified NR-ETT would have resulted in 2 problems: (1) obstruction of the left upper lobe bronchus (LULB) because the NR-ETT has a C-to-T distance of 5 cm (Fig 4A) or (2) the cuff could encroach on the surgical field if the cuff was allowed to herniate above the carina (Fig 4B). To solve those problems, the C-to-T distance had to be shortened. But cutting the
Fig 2. A diagram showing the measurements of the modified nasal RAE endotracheal tube.
SINGLE-LUNG VENTILATION
885
Fig 3. (A) The surgical stapler was applied at the origin of the right mainstem bronchus at the carina including the right side of the distal trachea. (B) The modified NR-ETT was withdrawn into the trachea to perform bronchoscopy before deployment of the stapler. (C) Then, the stapler was deployed, and the SP was completed.
886
SAIED, HELWANI, AND MORCOS
Fig 4. The unmodified ETT poses the risk of (A) obstruction of the left upper lobe bronchus if the cuff was to be placed entirely into the LMSB, or (B) herniation of the cuff at the carina, which may interfere with distal tracheal resection, whereas (C) the modified ETT allowed the proper positioning of the ETT in the LMSB as an endobronchial tube.
tip of the NR-ETT distal to the cuff would have resulted in a sharp traumatic edge and would render the cuff unusable because of a leak through the inflation channel that runs to the end of the NR-ETT. By reducing the cuff size with the adhesive silk tape, the authors were able to decrease the C-to-T distance to 3.5 cm, allowing LMSB intubation without risking obstruction of the LULB or herniation of the cuff at the carina (Fig 4C). A silk ligature was tied around the distal end of the adhesive tape to prevent it from loosening under cuff pressure. By using this technique, the authors were able to provide uninterrupted ventilation and reduce time needed for tube switch across the surgical field. The authors were also able to avoid complications of HFJV and provide the surgeon with the least obstructive surgical field. The modified tube would not have been helpful in patients who require left SP because of obstruction of the right upper lobe bronchus by the modified ETT cuff. Interestingly, over a period of 10 years, Roviaro et al13 performed 48 right SP procedures and only 1 left SP. The use of a smaller left DLT (35F) was considered but was found to be inappropriate because of the larger outer diameter
(OD) of the DLT (13 mm) compared with the modified tube (8.2 mm). The large OD could have interfered with distal tracheal resection during the application of the stapler. Another option would have been to use the 6.0 Univent (Fuji Systems Corp, Tokyo, Japan) instead of the modified tube as an endobronchial tube. The OD of the 6.0 Univent tube is large (oval, 9.7 ⫻ 11.5 mm), which would have caused difficulty with placement into the LMSB or caused bronchial injury. Although not commonly used in the United States, singlelumen endobronchial tubes manufactured by Rüsch Inc (Duluth, GA) could have been used instead of the modified tube that was used in the present case. They are long (45 cm) tubes to allow deep endobronchial placement, come in variable sizes (6.5 and 8.0 mm), and have both left and right configuration.14 In summary, the modified ETT provides safe and effective ventilation during right SP. The technique saves time and provides uninterrupted ventilation throughout the procedure. This modified ETT is constructed from equipment readily available in the operating rooms.
REFERENCES 1. Porhanov VA, Poliakov IS, Selvaschuk AP, et al: Indications and results of sleeve carinal resection. Eur J Cardiothorac Surg 22:685-694, 2002 2. Sandberg W: Anesthesia and airway management for tracheal resection and reconstruction. Int Anesthesiol Clin 38:55-75, 2000 3. Rogers RC, Gibbons J, Cosgrove J, et al: High-frequency jet ventilation for tracheal surgery. Anaesthesia 40:32-36, 1985 4. Grillo HC, Bendixen HH, Gephart T: Resection of the carina and lower trachea. Ann Surg 158:889-893, 1963 5. Theman TE, Kerr JH, Nelems JM, et al: Carinal resection. A report of two cases and a description of the anesthetic technique. J Thorac Cardiovasc Surg 71:314-320, 1976 6. Kemvyssi-Dea S, Kritikon P, Exarhos N, et al: Anaesthetic management of reconstruction of the lower part of the trachea. Br J Anaesth 47:82-84, 1975 7. Baraka A: Oxygen-jet ventilation during tracheal reconstruction in patients with tracheal stenosis. Anesth Analg 56:429-432, 1977 8. Dzuberova I, Sabakova L, Jurakova O, et al: High-frequency jet ventilation in trachea reconstructions—Its advantages in our experience. Acta Chir Hung 38:31-34, 1999
9. Eriksson I, Nilsson LG, Nordstrom S, et al: High-frequency positive-pressure ventilation (HFPPV) during transthoracic resection of tracheal stenosis and during perioperative bronchoscopic examination. Acta Anaesthesiol Scand 19:113-119, 1975 10. EL-Baz J, Jensik R, Faber LP, et al: One-lung high-frequency ventilation of tracheoplasty and bronchoplasty: A new technique. Ann Thorac Surg 34:564-571, 1982 11. Hannallah M: The optimal breathing tube for tracheal resection and reconstruction. Anesthesiology 83:419-421, 1995 12. Geffin B, Bland J, Grillo G: Anesthetic management of tracheal resection and reconstruction. Anesth Analg 48:884-894, 1969 13. Roviaro G, Varoli F, Romanelli A, et al: Complications of tracheal sleeve pneumonectomy: Personal experience and overview of the literature. J Thorac Cardiovasc Surg 121:234-240, 2001 14. Harte BH, Jaklitsch MT, McKenna SS, et al: Use of a modified single-lumen endobronchial tube in severe tracheobronchial compression. Anesthesiology 96:510-511, 2002