Conversion of a single lumen tube to double lumen tube in an anticipated difficult airway: Flexible fiberoptic bronchoscope assisted with intubating introducer-guided technique.

The Editor,

Difficult airway management is a challenging aspect of anesthesia practice and is even more challenging when the surgery demands placement of a double-lumen tube (DLT). Mediastinoscopy is gold standard in staging nonsmall cell lung cancer patients.[1] In an anticipated difficult airway, endotracheal tube can be placed with various techniques,[2] but changeover of the single lumen tube (SLT) to a DLT is a major challenge and needs skill. We report a case where a DLT was placed under the guidance of a Frova intubating introducer with the assistance of flexible fiberoptic bronchoscope (FOB).

A 59-year-old male patient, American Society of Anesthesiology-Physical Status (ASA) II (well-controlled diabetes); body mass index of 25.56 kg/m2, diagnosed case of right lower lobe adenocarcinoma was posted for mediastinoscopy followed by the right lower lobectomy. Airway examination showed adequate mouth opening and modified (Samsoon and Young) Mallampati (MPC) Grade III view.[3] Difficult intubation tray as recommended by ASA task force on difficult airway was made available in the operating room.[2] Injection propofol was given at 1.5 mg/kg body weight and after assessing adequate bag mask ventilation, injection rocuronium 1 mg/kg body weight was given. Direct laryngoscopy revealed only the tip of epiglottis to the view (Cormack and Lehane Grade III).[4] The patient was successfully intubated with 7.5 cuffed SLT with the aid of a 14 Fr intubating introducer [Figure 1] (Cook UK Ltd., Letchworth, UK). After mediastinoscopy, the right lower lobectomy was decided, which needed lung isolation. Cook airway exchange catheter (AEC) was inserted into the SLT and the patient extubated. Bronchial lumen of 37 Fr left-sided DLT was railroaded through the AEC into the trachea. There was an increased resistance to airway reservoir bag, breath sounds were not audible, and no tracing of EtCO2 was seen. DLT was removed and the patient ventilated. A repeat direct laryngoscopy was done and with Frova intubating introducer, DLT was rail roaded. After confirmation of DLT into the trachea by EtCO2 and chest rise, FOB was done to confirm the placement of the left DLT, but it was placed in the right side. We tried to reposition the left DLT, but were unsuccessful. Thus, we decided to put the stylet into the bronchial lumen of left DLT, and guide it to left main bronchus, but again unsuccessful. Since the surgery was of the right side and the right lung isolation was needed, it was imperative to place the left DLT in proper place. We decided to introduce Frova intubating introducer through the bronchial lumen of left DLT and under FOB guidance through tracheal lumen of DLT direct it to the left main bronchus and railroad the left DLT for proper placement which was successful. Oxygen saturation was well maintained throughout the procedure and hemodynamics was stable too. Intraoperative period was uneventful as the isolation was found to be excellent.

Figure 1

Frova intubating intubator

In our case report, we achieved lung isolation by one of the recommended techniques of inserting AEC over the SLT and later inserting the DLT over the AEC.[5] However, we lost the airway while inserting the DLT. In our case, placing an Arndt blocker would have been ideal under FOB guidance, but since the DLT is the gold standard and we routinely insert them, we decided to put a DLT. Placement of a DLT is more complicated than that of a standard tracheal tube because the DLT is larger in diameter, longer, and has a more fixed shape.[6] An AEC can be used to facilitate exchanging from an SLT to a DLT or vice versa. Smith et al.[7] and Chen et al.[8] used videolaryngoscopes to exchange from an SLT to a DLT. Villalonga et al.[9] have reported a case describing the use of 6 mm bronchoscope for left endobronchial SLT and then using a cook airway exchanger to guide a number 39 Fr left DLT through the bronchus. Our experience is unique because we used Frova intubating introducer under FOB guidance to guide the proper placement of left DLT. It can be argued that Arndt bronchial blocker under FOB guidance through a SLT to isolate the right lower lobe could have been a better alternative and could have prevented mishap, but due to common practice of using DLT and inability for suction through the bronchial blocker, we decided to put a DLT. Furthermore, the right lower lobectomy could have been done with either a left- or right-sided DLT, as happened in our case, when the left DLT slipped into the right main bronchus. However, since the airway pressures were high, we are in a teaching institute and since it is a cancer surgery, which can anytime turn into a right pneumonectomy, we sustained with our decision to put a left DLT.

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Conflicts of interest

There are no conflicts of interest.