- Email: [email protected]
Sudden Loss of Ventilation Through a Double-Lumen Endotracheal Tube Requiring a Surgical Bronchotomy
Ann Thorac Surg 2013;96:687– 8
References 1. Spaggiari L, D’Aiuto M, Veronesi G, et al. Extended pneumonectomy with partial resection of the left atrium, without cardiopulmonary bypass, for lung cancer. Ann Thorac Surg 2005;79:234 – 40. 2. Ettinger DS, Akerly W, Bepler G, et al. National Comprehensive Cancer Network (NCCN). Non-small cell lung cancer clinical practice guidelines in oncology. J Natl Comprehensive Cancer Network 2010;8:740 – 801. 3. Bobbio A, Carbognani P, Grapeggia M, et al. Surgical outcome of combined pulmonary and atrial resection for lung cancer. Thorac Cardiovasc Surg 2004;52:180 –2.
Sudden Loss of Ventilation Through a Double-Lumen Endotracheal Tube Requiring a Surgical Bronchotomy
687
A left completion pneumonectomy for primary lung cancer (left lower lobectomy) was complicated by sudden loss of ability to ventilate the patient through the doublelumen endotracheal tube. The problem could not be overcome by the anesthesiologist. In the face of impending cardiorespiratory arrest, a single-lumen tube was introduced through an incision in the left main bronchus through to the right main bronchus. This life-saving maneuver safeguarded the airway and permitted a successful outcome to the operation. (Ann Thorac Surg 2013;96:687– 8) © 2013 by The Society of Thoracic Surgeons
T
he sudden inability to ventilate a patient through a double-lumen endotracheal tube (DLT) is a wellrecognized event although rare. It is well recognized because of its fatal potential. In some instances, it is not possible to reventilate the patient through the same endotracheal tube (ETT). During a pneumonectomy or lobectomy procedure, this complication could be managed by making an incision in the main bronchus of the diseased lung and passing an ETT through to the unventilated lung. That may allow the patient’s oxygen saturation (SaO2) to return to a level sufficient to facilitate the replacement of the DLT. Given the speed with which such a maneuver must be accomplished, it behooves all thoracic surgeons to have given thought to the matter before actually finding themselves in this situation. A 76-year-old man was admitted for excision of a suspected left lower lobe primary lung cancer. The patient previously underwent left upper lobectomy for a T1N0 primary lung adenocarcinoma 2 years before admission. The new mass was found in the upper part of the residual left lower lobe, which at computed tomography and positron emission tomography scan appeared to be a localized tumor recurrence. Given that no preoperative tissue diagnosis was available, the plan was to conduct a frozen section examination intraoperatively and proceed to completion pneumonectomy if the lesion was found to be malignant. At operation, a right-sided Rusch Bronchopart 39F endotracheal tube (Teleflex Medical Europe Ltd, Garrycastle, Ireland) was placed so as to be able to isolate the residual left lung. At thoracotomy, the mass in the residual left lower lobe was approximately 5 cm in diameter. It was soon realized that wedge excision of this mass would not leave a functional portion of lung tissue behind, and so we proceeded directly to completion pneumonectomy. During dissection around the left main bronchus, there was a sudden loss of ability to ventilate the patient. The situation did not respond to simple anesthetic maneuvers—the patient’s SaO2 soon fell to 18% and the blood pressure fell to 50/20 mm Hg with bradycardia. The situation appeared to be one of immi-
Robert Torrance, BSc, Alan Dawson, MBChB, BSc (Hons), Jared M. Wohlgemut, BSc, and Keith Buchan, MBChB
Accepted for publication Dec 18, 2012.
School of Medicine and Dentistry, University of Aberdeen, and Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, United Kingdom
Address correspondence to Dr Buchan, Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, United Kingdom; e-mail: [email protected].
© 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.12.045
FEATURE ARTICLES
The decision regarding operability is complex, and it must take into account the risks and benefits of resection as well as the risks and benefits of nonoperative therapy. In this case, the risks of surgery are well defined and not insubstantial. However, the risks of nonoperative therapy would have included tumor embolization into systemic circulation causing stroke or other end-organ dysfunction. Moreover, treatment with radiation therapy could have resulted in cardiac perforation. In this case, the surgical option was chosen based on the relative risks and benefits of operative and nonoperative therapy, after careful deliberation in multidisciplinary tumor board and careful informed consent of the patient. Of note, the evaluation included CT scan, positron emission tomography scan, echocardiogram, mediastinoscopy, aspiration of the pleural fluid to exclude M1a disease, and complete mediastinal lymph node dissection to ascertain N0 status. The benefits of complete resection and the risks of unresectable disease were explained to this patient and his relatives in the “informed consent.” The patient and his relatives decided to receive the operation and signed the informed consent after careful consideration. The surgery was uncomplicated and resulted in excellent local control of the disease and improved the patient’s quality of life regarding hemoptysis. Ultimately, the patient died of metastatic disease. Although the use of induction chemotherapy is usually reserved for patients with N2 or chest wall involvement [2], there may also be a role for induction therapy in patients that are considered marginal resection candidates based on T3 or T4 status. In these cases, induction chemotherapy may be used to test the biology of the tumor. Patients with locally advanced disease who progress through therapy are clearly not going to benefit from resection and should be considered inoperable.
CASE REPORT TORRANCE ET AL EMERGENCY SURGICAL BRONCHOTOMY
688
CASE REPORT TORRANCE ET AL EMERGENCY SURGICAL BRONCHOTOMY
FEATURE ARTICLES
nent cardiac arrest. The surgeon, therefore, asked for a size 7 mm ETT and threaded it into the right main bronchus through a longitudinal cut in the membranous part of the left main bronchus after instructing the anesthesiologist to remove the double-lumen tube altogether. Digital examination of the left main bronchus provided a mental picture of the pathway the ETT would have to follow. This permitted passage of the ETT into the right main bronchus and resumption of ventilation. The anesthesiologist then placed a new per oral ETT to gain stability while wet swabs were applied to the bronchotomy incision to facilitate ventilation. After a period of stability, a new right-sided DLT was placed. With the airway stabilized, the surgical procedure could then be completed. As a consequence of the transbronchial intubation, the initial longitudinal incision in the membranous part of the left main bronchus became extended. The left lateral wall of the trachea (at the junction between its membranous and cartilaginous parts) was torn open for 2 cm to 3 cm above the carina. To reach this area, the aortic arch and left subclavian artery were mobilized on tapes and retracted anteriorly using a method that we have described previously [1]. The surgeon then had good access to the distal half of the trachea. This allowed the placement of eight 4-0 polydioxanone sutures, which incorporated a buttressing bite of the adjacent esophageal musculature. The left main bronchus was then divided after being stapled with the TA60 staple gun (Covidien, Mansfield, MA). At the end of the procedure, the SaO2 levels were 90% on fraction of inspired oxygen of 0.6. It was considered best to transfer the patient to the general intensive care unit after carrying out a formal tracheostomy to assist early ventilator weaning. He was extubated from the ventilator the next day and made an uncomplicated recovery. Histology of the resected specimen revealed a T2N0 adenocarcinoma. He remains well 4 years after the operation with no evidence of disease recurrence.
Comment Although most experienced thoracic surgeons have heard of this type of complication, there is a surprising paucity of published accounts in the literature. That may be because many of these cases had a fatal outcome. The surgeon who carried out the operation that is the subject of this case report has known of two similar cases in his 20-year experience in cardiothoracic surgery, both of which had a fatal outcome. It is undoubtedly because of the reflections on those deaths that a prompt plan for managing the situation described in this report was possible. We have been able to find only one previous case report dealing with this situation [2]. In that case, a right middle lobectomy was being undertaken when failure of ventilation through a DLT arose. The surgeon opened the right main bronchus and placed an ETT into the left main bronchus, but that did not provide satisfactory ventilation. A supplementary ETT was placed in the right upper
Ann Thorac Surg 2013;96:687– 8
lobe bronchus, and this combination provided adequate ventilation until a new DLT could be secured. Their patient also made a good recovery. In discussions with a senior UK anesthesiologist who has been involved in assessing such adverse events, the view was expressed that another equally viable way of managing this situation is for the anesthesiologist to tear off the surgical drapes, firmly take charge of the entire theater team, then turn the patient onto his back so as to facilitate removal of the DLT and insertion of a singlelumen ETT. In this scenario, no provision would be made for maintenance of sterility. Such an approach would need to have been formed in the mind of the anesthesiologist before getting into such a situation and would need to be enacted with minimal discussion with the surgeon (personal communication from Dr Ralph Vaughan, former vice-president, Royal College of Anaesthetists, London, UK, 2000). Some thoracic anesthesiologists have a strong preference for a left-sided DLT in all thoracic operations, even for left pneumonectomy. In such a situation, the DLT has to be repositioned to a more proximal location in the trachea before dividing the left main bronchus, and this may be associated with transient return of ventilation to the left lung unless the maneuver can be carried out swiftly. The use of such a strategy is mandatory where there is an abnormally high takeoff of the right upper lobe bronchus with a short right main bronchus. It is possible that had we used this airway management plan in our case, we would not have run into the problems described. We have no testable theory as to why it should suddenly not be possible to ventilate through a doublelumen endotracheal tube but surmise that the tube must have become kinked in such cases. When performing a carinal pneumonectomy, it is possible to experience sudden loss of the DLT due to the balloon cuff being punctured by a needle when closing the lateral tracheal wall. In this situation, direct placement of a single-lumen tube through the surgical wound is a simple and intuitive reaction that will provide a secure airway until a new DLT has been passed. When the airway has not already been opened, it is not so intuitive to incise the airway so as to intubate the contralateral lung for ventilation in the event of failure of a DLT. For this reason, we wish to draw attention to our experience for dealing with this rare and not necessarily catastrophic situation.
The authors would like to thank the patient for giving permission to disseminate his case.
References 1. Chaudhri BB, Lo ST, Kerr K, Buchan K. Repair of iatrogenic distal tracheal rupture by left thoracotomy. Ann Thorac Surg 2007;84:1382–3. 2. Ng YT, Chung PC, Hsieh YR, Yu CC, Lau WM, Liu YH. Failure to provide adequate one-lung ventilation with a conventional endotracheal tube using a transbronchial approach: a case report. Can J Anaesth 2003;50:603– 6.
References 1. Spaggiari L, D’Aiuto M, Veronesi G, et al. Extended pneumonectomy with partial resection of the left atrium, without cardiopulmonary bypass, for lung cancer. Ann Thorac Surg 2005;79:234 – 40. 2. Ettinger DS, Akerly W, Bepler G, et al. National Comprehensive Cancer Network (NCCN). Non-small cell lung cancer clinical practice guidelines in oncology. J Natl Comprehensive Cancer Network 2010;8:740 – 801. 3. Bobbio A, Carbognani P, Grapeggia M, et al. Surgical outcome of combined pulmonary and atrial resection for lung cancer. Thorac Cardiovasc Surg 2004;52:180 –2.
Sudden Loss of Ventilation Through a Double-Lumen Endotracheal Tube Requiring a Surgical Bronchotomy
687
A left completion pneumonectomy for primary lung cancer (left lower lobectomy) was complicated by sudden loss of ability to ventilate the patient through the doublelumen endotracheal tube. The problem could not be overcome by the anesthesiologist. In the face of impending cardiorespiratory arrest, a single-lumen tube was introduced through an incision in the left main bronchus through to the right main bronchus. This life-saving maneuver safeguarded the airway and permitted a successful outcome to the operation. (Ann Thorac Surg 2013;96:687– 8) © 2013 by The Society of Thoracic Surgeons
T
he sudden inability to ventilate a patient through a double-lumen endotracheal tube (DLT) is a wellrecognized event although rare. It is well recognized because of its fatal potential. In some instances, it is not possible to reventilate the patient through the same endotracheal tube (ETT). During a pneumonectomy or lobectomy procedure, this complication could be managed by making an incision in the main bronchus of the diseased lung and passing an ETT through to the unventilated lung. That may allow the patient’s oxygen saturation (SaO2) to return to a level sufficient to facilitate the replacement of the DLT. Given the speed with which such a maneuver must be accomplished, it behooves all thoracic surgeons to have given thought to the matter before actually finding themselves in this situation. A 76-year-old man was admitted for excision of a suspected left lower lobe primary lung cancer. The patient previously underwent left upper lobectomy for a T1N0 primary lung adenocarcinoma 2 years before admission. The new mass was found in the upper part of the residual left lower lobe, which at computed tomography and positron emission tomography scan appeared to be a localized tumor recurrence. Given that no preoperative tissue diagnosis was available, the plan was to conduct a frozen section examination intraoperatively and proceed to completion pneumonectomy if the lesion was found to be malignant. At operation, a right-sided Rusch Bronchopart 39F endotracheal tube (Teleflex Medical Europe Ltd, Garrycastle, Ireland) was placed so as to be able to isolate the residual left lung. At thoracotomy, the mass in the residual left lower lobe was approximately 5 cm in diameter. It was soon realized that wedge excision of this mass would not leave a functional portion of lung tissue behind, and so we proceeded directly to completion pneumonectomy. During dissection around the left main bronchus, there was a sudden loss of ability to ventilate the patient. The situation did not respond to simple anesthetic maneuvers—the patient’s SaO2 soon fell to 18% and the blood pressure fell to 50/20 mm Hg with bradycardia. The situation appeared to be one of immi-
Robert Torrance, BSc, Alan Dawson, MBChB, BSc (Hons), Jared M. Wohlgemut, BSc, and Keith Buchan, MBChB
Accepted for publication Dec 18, 2012.
School of Medicine and Dentistry, University of Aberdeen, and Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, United Kingdom
Address correspondence to Dr Buchan, Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, United Kingdom; e-mail: [email protected].
© 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2012.12.045
FEATURE ARTICLES
The decision regarding operability is complex, and it must take into account the risks and benefits of resection as well as the risks and benefits of nonoperative therapy. In this case, the risks of surgery are well defined and not insubstantial. However, the risks of nonoperative therapy would have included tumor embolization into systemic circulation causing stroke or other end-organ dysfunction. Moreover, treatment with radiation therapy could have resulted in cardiac perforation. In this case, the surgical option was chosen based on the relative risks and benefits of operative and nonoperative therapy, after careful deliberation in multidisciplinary tumor board and careful informed consent of the patient. Of note, the evaluation included CT scan, positron emission tomography scan, echocardiogram, mediastinoscopy, aspiration of the pleural fluid to exclude M1a disease, and complete mediastinal lymph node dissection to ascertain N0 status. The benefits of complete resection and the risks of unresectable disease were explained to this patient and his relatives in the “informed consent.” The patient and his relatives decided to receive the operation and signed the informed consent after careful consideration. The surgery was uncomplicated and resulted in excellent local control of the disease and improved the patient’s quality of life regarding hemoptysis. Ultimately, the patient died of metastatic disease. Although the use of induction chemotherapy is usually reserved for patients with N2 or chest wall involvement [2], there may also be a role for induction therapy in patients that are considered marginal resection candidates based on T3 or T4 status. In these cases, induction chemotherapy may be used to test the biology of the tumor. Patients with locally advanced disease who progress through therapy are clearly not going to benefit from resection and should be considered inoperable.
CASE REPORT TORRANCE ET AL EMERGENCY SURGICAL BRONCHOTOMY
688
CASE REPORT TORRANCE ET AL EMERGENCY SURGICAL BRONCHOTOMY
FEATURE ARTICLES
nent cardiac arrest. The surgeon, therefore, asked for a size 7 mm ETT and threaded it into the right main bronchus through a longitudinal cut in the membranous part of the left main bronchus after instructing the anesthesiologist to remove the double-lumen tube altogether. Digital examination of the left main bronchus provided a mental picture of the pathway the ETT would have to follow. This permitted passage of the ETT into the right main bronchus and resumption of ventilation. The anesthesiologist then placed a new per oral ETT to gain stability while wet swabs were applied to the bronchotomy incision to facilitate ventilation. After a period of stability, a new right-sided DLT was placed. With the airway stabilized, the surgical procedure could then be completed. As a consequence of the transbronchial intubation, the initial longitudinal incision in the membranous part of the left main bronchus became extended. The left lateral wall of the trachea (at the junction between its membranous and cartilaginous parts) was torn open for 2 cm to 3 cm above the carina. To reach this area, the aortic arch and left subclavian artery were mobilized on tapes and retracted anteriorly using a method that we have described previously [1]. The surgeon then had good access to the distal half of the trachea. This allowed the placement of eight 4-0 polydioxanone sutures, which incorporated a buttressing bite of the adjacent esophageal musculature. The left main bronchus was then divided after being stapled with the TA60 staple gun (Covidien, Mansfield, MA). At the end of the procedure, the SaO2 levels were 90% on fraction of inspired oxygen of 0.6. It was considered best to transfer the patient to the general intensive care unit after carrying out a formal tracheostomy to assist early ventilator weaning. He was extubated from the ventilator the next day and made an uncomplicated recovery. Histology of the resected specimen revealed a T2N0 adenocarcinoma. He remains well 4 years after the operation with no evidence of disease recurrence.
Comment Although most experienced thoracic surgeons have heard of this type of complication, there is a surprising paucity of published accounts in the literature. That may be because many of these cases had a fatal outcome. The surgeon who carried out the operation that is the subject of this case report has known of two similar cases in his 20-year experience in cardiothoracic surgery, both of which had a fatal outcome. It is undoubtedly because of the reflections on those deaths that a prompt plan for managing the situation described in this report was possible. We have been able to find only one previous case report dealing with this situation [2]. In that case, a right middle lobectomy was being undertaken when failure of ventilation through a DLT arose. The surgeon opened the right main bronchus and placed an ETT into the left main bronchus, but that did not provide satisfactory ventilation. A supplementary ETT was placed in the right upper
Ann Thorac Surg 2013;96:687– 8
lobe bronchus, and this combination provided adequate ventilation until a new DLT could be secured. Their patient also made a good recovery. In discussions with a senior UK anesthesiologist who has been involved in assessing such adverse events, the view was expressed that another equally viable way of managing this situation is for the anesthesiologist to tear off the surgical drapes, firmly take charge of the entire theater team, then turn the patient onto his back so as to facilitate removal of the DLT and insertion of a singlelumen ETT. In this scenario, no provision would be made for maintenance of sterility. Such an approach would need to have been formed in the mind of the anesthesiologist before getting into such a situation and would need to be enacted with minimal discussion with the surgeon (personal communication from Dr Ralph Vaughan, former vice-president, Royal College of Anaesthetists, London, UK, 2000). Some thoracic anesthesiologists have a strong preference for a left-sided DLT in all thoracic operations, even for left pneumonectomy. In such a situation, the DLT has to be repositioned to a more proximal location in the trachea before dividing the left main bronchus, and this may be associated with transient return of ventilation to the left lung unless the maneuver can be carried out swiftly. The use of such a strategy is mandatory where there is an abnormally high takeoff of the right upper lobe bronchus with a short right main bronchus. It is possible that had we used this airway management plan in our case, we would not have run into the problems described. We have no testable theory as to why it should suddenly not be possible to ventilate through a doublelumen endotracheal tube but surmise that the tube must have become kinked in such cases. When performing a carinal pneumonectomy, it is possible to experience sudden loss of the DLT due to the balloon cuff being punctured by a needle when closing the lateral tracheal wall. In this situation, direct placement of a single-lumen tube through the surgical wound is a simple and intuitive reaction that will provide a secure airway until a new DLT has been passed. When the airway has not already been opened, it is not so intuitive to incise the airway so as to intubate the contralateral lung for ventilation in the event of failure of a DLT. For this reason, we wish to draw attention to our experience for dealing with this rare and not necessarily catastrophic situation.
The authors would like to thank the patient for giving permission to disseminate his case.
References 1. Chaudhri BB, Lo ST, Kerr K, Buchan K. Repair of iatrogenic distal tracheal rupture by left thoracotomy. Ann Thorac Surg 2007;84:1382–3. 2. Ng YT, Chung PC, Hsieh YR, Yu CC, Lau WM, Liu YH. Failure to provide adequate one-lung ventilation with a conventional endotracheal tube using a transbronchial approach: a case report. Can J Anaesth 2003;50:603– 6.