Intrathoracic bronchial intubation: A feasible option to manage life-threatening hypoxia in a neonate.

Sir,

One day, 1600 g, preterm baby with type C tracheoesophageal fistula (TEF) was scheduled for emergency TEF repair. In the operating room, pulse oximetry, electrocardiography, noninvasive blood pressure and temperature monitoring was established. Anesthesia was induced using 100% oxygen and sevoflurane titrated to effect. Intravenous fluid consisted of balanced crystalloids (Isolyte P; 4 ml/kg/hr), injection Atracurium 0.8 mg), fentanyl 4 mcg was administered intravenously. Trachea was intubated with 3.0 mm ID uncuffed polyvinyl chloride endotracheal tube (ETT). Manual positive-pressure ventilation was commenced. Correct ETT placement confirmed by end-tidal CO2(EtCO2) and bilaterally equal air entry without undue distention of the stomach on auscultation. ETT was fixed at 9.0 cm. Extra-length of ETT was cut to minimize dead space and prevent kinking. Posterio-lateral thoracotomy position was made and neonate put on pressure controlled ventilation (peak airway pressure 15–20 cmH2O; respiratory rate, 25/min; inspiratory: Expiratory ratio [1:1.5]) using retropleural approach, surgeon identified and exposed a low lying fistula. Soon thereafter, sudden fall in airway pressures and EtCO2 occurred. Manual ventilation did not improve respiratory parameters. Surgeon noticed accidental knick in main stem trachea near the right tracheo-bronchial junction. Tip of ETT was visible through the severed carina, but it could not be advanced as ETT was cut at the oral end and then fixed. Surgeon's attempt to ventilate with the thumb over the rent failed. Neonate desaturated rapidly, SpO230%; heart rate 40/min. At this moment, another 3.0 mm ETT was given to surgeon for intrathoracic endobronchial insertion vi the rent and manual ventilation of the right lung was initiated through this ETT [Figure 1]. SpO2 and heart rate improved. Three-fourths of the rent was repaired around intrathoracic ETT. Thereafter, oral ETT was replaced in the lateral position and advanced just above the carina. Surgeon removed intrathoracic ETT and directed oral ETT into the bronchial lumen to complete the repair. Subsequently, oral ETT was withdrawn back to carina and breathing circuit again connected at the oral end. In the postoperative period, mechanical ventilation and supportive. therapy continued in Intensive Care Unit (ICU). Rest of ICU stay was uneventful.

Figure 1

Intra-operative image showing severed end of right tracheobronchial junction at carina and right bronchus with endotracheal tube in situ

Limited data are available on the iatrogenic tracheal injuries in neonates. Previously, trauma during delivery endotracheal intubation or foreign body removal has been reported,[1] Di Gaetano et al.[2] reported cautery induced carinal perforation in an adult. Managed using selective bilateral main stem bronchial intubation. There is a case report of left main stem bronchial tear with EtCO2 upsurge during thoracoscopic TEF repair.[3] Dango et al.[4] reported subtotal posttraumatic rupture of distal tracheobronchial tree in a toddler. Patient required abridgment with a pericardial patch. In the present neonate, large accidental knick lead to complete loss of ventilation. Prompt intrathoracic endobrochial ETT placement restored hemodynamics and acted as a bridge for surgical repair. Therefore, it is suggested that ETT should not be cut at the oral end to allow easy manipulation during surgery. De Gabriele et al.[5] recommend use of fiberoptic bronchoscope to correctly identify TEF before surgical incision. To conclude, early recognition and prompt intervention tailored according to the situation averted peri-operative mortality in a neonatal TEF surgery.