Bronchial blocker as an aid in the management of endo-bronchial cuff malfunction of double-lumen tube during one-lung ventilation.

Sir,

A 59-year-old male, weighing 57 kg and 157 cm tall with single vessel coronary artery disease was posted for coronary artery bypass grafting (CABG) through left thoracotomy. After anaesthesia induction, left lung isolation was achieved with 37 F left double-lumen tube (DLT) (Broncho Cath, Mallinckrodt, USA). Tracheal intubation was uneventful. The correct position of DLT was checked with Ambu® aScope™ (Ambu A/S, Ballerup, Denmark) and lung isolation was confirmed clinically by auscultation. During the course of left internal mammary artery (LIMA) harvesting, surgeon deemed the lung isolation inadequate. On troubleshooting for inadequate lung isolation, the pilot balloon of bronchial cuff was partially deflated and it was re-inflated with 3 ml of air to obtain an adequate seal. Repeat bronchoscopic examination revealed the correct position of bronchial cuff in the left bronchus. Within 15 min, lung isolation was again found to be inadequate. A possible diagnosis of bronchial cuff leak/bronchial pilot balloon assembly malfunction was made. A Coopdech endo-bronchial blocker (Daiken Medical Co. Ltd, Japan.) was inserted through the bronchial lumen of the DLT. The DLT was withdrawn under bronchoscopic guidance till the deflated bronchial cuff was visible above the carina to accommodate the cuff of bronchial blocker (BB) in left main bronchus. The insertion depth of the BB required for lung isolation was determined to be 42.5 cm [Figure 1] and the cuff was inflated with 4 ml of air. The ventilating port of BB was connected to bronchial limb of Y connector and the patient end of BB was connected to bronchial lumen of DLT [Figure 2]. With this technique, lung isolation was re-established and maintained. The rest of LIMA harvesting and CABG were uneventful. At the conclusion of surgery, BB was removed and the DLT was exchanged with a single-lumen endotracheal tube. The post-operative course was uneventful and trachea was extubated after 4 h of mechanical ventilation. One of the possible complications during insertion of BB through the bronchial lumen of DLT is that it can offer some resistance with a risk of damage to the BB cuff. A backup plan in the event of failure of combined use of DLT and BB consisted of exchanging the DLT with single-lumen tracheal tube using airway exchange catheter. Subsequently, a BB can be placed under bronchoscopic guidance for lung isolation.

Figure 1

In vitro examination demonstrating the depth of insertion of the BB into the bronchial lumen of left DLT for effective cuff seal. (a)The cuff length of the BB was 2.5 cm. (b)The length of bronchial lumen of DLT from 30 cm mark to the machine end was 10 cm. (c) The final length of BB to be inserted into the bronchial lumen of DLT to provide effective cuff seal was 42.5 cm. BB Bronchial blocker, DLT Double lumen tube

Figure 2

Photograph showing connection of BB to DLT at the conclusion of surgery. The ventilating port of the BB was connected to bronchial limb of Y connector and the patient end of the BB was connected to bronchial lumen of the DLT. BB-Bronchial blocker, DLT-Double-lumen tube

DLTs are the most commonly used method of lung isolation.[1] The cuffs of DLTs are delicate and sometimes stressed by contact with teeth during intubation. Brodsky andLemmens reported tracheal cuff injury 11 times and bronchial cuff injury once out of 1169 left DLT placements.[2] The clinical consequences of cuff injury appear immediately or may be delayed depending on the extent of cuff injured. Bronchial cuff injury manifests as inadequacy/failure to isolate the ipsilateral lung during one-lung ventilation. In our patient, the identification of bronchial cuff malfunction was delayed even though the initial check for lung isolation was satisfactory. Groves et al. also reported significant bronchial cuff leak of DLT only after 15 min of surgical incision.[3]

The best solution for malfunctioning bronchial cuff of DLT is to replace the DLT carefully. However, the anaesthesiologist must consider important issues like surgical stage, patient position, aspiration risk and ventilation/oxygenation compromise. The management of delayed recognition of bronchial cuff leak using a nasal cannula connected to oxygen flowmeter to keep the cuff inflated has been described.[3] The reported disadvantages of this method are need for constant vigilance, complexity, excessive cuff pressure if a leak is eliminated unexpectedly and with large cuff leak, this method would be ineffective. But the use of BB in a situation, as described in our case, is easier and effective over wide ranges of cuff leak since the function of defective endo-bronchial cuff is entirely taken over by the BB. The elective combined use of DLT and BB for selective lobar isolation has been described with successful results.[4] Nino et al. reported the use of BB as a rescue device for an ill-fitting DLT.[5] Therefore, we conclude that the use of BB as a rescue device for DLT cuff leaks should be considered in circumstances where patient repositioning or surgical stage may not be feasible for replacing the DLT.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Nil.

Conflicts of interest

There are no conflicts of interest.