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Bronchial Blocker Versus Double-Lumen Tube for Lung Isolation With Massive Hemoptysis During Cardiac Surgery

2013; Elsevier BV; Volume: 27; Issue: 3 Linguagem: Inglês

10.1053/j.jvca.2012.11.018

1532-8422

Hamdy Awad, Obaid Malik, Kevin Hollis, Michelle Santiago, Shaheen Islam, Juan A. Crestanello,

Tracheal and airway disorders

Airway management in life-threatening massive hemoptysis is a critical first step. The threshold for blood loss to define massive hemoptysis is not well established, and the values in the literature vary from 100 to 1,000 mL.1Giannoni S. Buti G. Allori O. et al.Bilateral concurrent massive hemoptysis successfully controlled with double endobronchial tamponade. A case report.Minerva Anestesiol. 2006; 72: 665-674PubMed Google Scholar In a survey by the American College of Chest Physicians in 2000, 28% of respondents had a patient die from massive hemoptysis in the previous year, and nearly half of the respondents favored using a double-lumen tube (DLT).2Haponik E.F. Fein A. Chin R. Managing life-threatening hemoptysis: Has anything really changed?.Chest. 2000; 118: 1431-1435Crossref PubMed Scopus (108) Google Scholar The authors present a case in which both available devices were used for lung isolation. First, they used an endobronchial blocker (EBB) to prevent spillage of blood as a temporary measure, and then they used a DLT to identify and control the source of bleeding and long-term ventilation. A 5-ft 3-in. 152-lb 87-year-old woman underwent a ministernotomy for aortic valve replacement. Her platelets and coagulation lab values were within normal limits. A pulmonary artery catheter (PAC) was placed, which was 50 cm at the hub, and it was not locked. She was intubated with a size 8 single-lumen endotracheal tube (ETT). Transesophageal echocardiogram showed that the tip of the PAC was in the right PA. While the patient was on cardiopulmonary bypass, bright red blood began pouring out of the ETT. The PAC then was pulled out. A flexible fiberoptic bronchoscopy was performed and it revealed bleeding from the right mainstem bronchus, but the exact source of bleeding could not be identified. Three attending cardiothoracic anesthesiologists arrived for assistance. Under the recommendation of 1 anesthesiologist, a size 9-French Cohen EBB was passed into the right mainstem bronchus with good lung isolation. Later, a recommendation was made by another anesthesiologist to replace the EBB with a DLT. This resulted in a debate (Table 1) and the team decided to exchange the single-lumen ETT for a size 35-French left-sided DLT using a tube exchanger. Good lung isolation was established again, and 700 mL of blood were suctioned out of the right tracheal side of the DLT. Bleeding from the right lower lobe was identified with flexible bronchoscopy, and 30 mL of 1:1000 epinephrine was instilled through the tracheal lumen of the DLT. Later, protamine was administered and the bleeding subsided. The patient was transported to an intensive care unit with 2-lung ventilation through the original DLT. The DLT was exchanged for a single-lumen ETT the next day. The patient was extubated on postoperative day 4 with minor transient hemoptysis. She was discharged on postoperative day 11 with home health care.Table 1Advantages and Disadvantages of Bronchial blockers versus Double-Lumen Tubes During Lung Isolation in Patients With Massive HemoptysisBronchial BlockersDouble-lumen TubesAdvantagesAdvantagesBleeding controlled by tamponadeCan be used for selective lobar isolation for source of bleeding2Haponik E.F. Fein A. Chin R. Managing life-threatening hemoptysis: Has anything really changed?.Chest. 2000; 118: 1431-1435Crossref PubMed Scopus (108) Google ScholarMultiple bronchial blockers can be used simultaneously for more than 1 source of bleeding1Giannoni S. Buti G. Allori O. et al.Bilateral concurrent massive hemoptysis successfully controlled with double endobronchial tamponade. A case report.Minerva Anestesiol. 2006; 72: 665-674PubMed Google ScholarAllow direct visualization of source of bleeding and suction of bloodProvide more appropriate seal than EBBs11Kalra A, Heitner S, Topalian S: Iatrogenic pulmonary artery rupture during Swan-Ganz catheter placement—A novel therapeutic approach. Catheter Cardiovasc Interv [Internet] 2012. Available at: 〈http://www.ncbi.nlm.nih.gov/pubmed/22615240〉. Cited August 12, 2012Google ScholarTake less time for insertion than bronchial blockers12Cohen E. Pro: The new bronchial blockers are preferable to double-lumen tubes for lung isolation.J Cardiothorac Vasc Anesth. 2008; 22: 920-924Abstract Full Text Full Text PDF PubMed Scopus (31) Google ScholarEBBs can be inserted through DLTs if necessaryAfter stabilization, patients can be moved safely to intensive care unit and undergo safe prolonged ventilation with DLTs13Anantham D. Jagadesan R. Tiew P.E. Clinical review: Independent lung ventilation in critical care.Crit Care. 2005; 9 ([Epub 2005 Oct 10. Review]): 594-600Crossref PubMed Scopus (53) Google Scholar, 14Glass D.D. Tonnesen A.S. Gabel J.C. et al.Therapy of unilateral pulmonary insufficiency with a double lumen endotracheal tube.Crit Care Med. 1976; 4: 323-326Crossref PubMed Scopus (45) Google ScholarDisadvantagesDisadvantagesCannot be used to suction blood4Sidery M. Cahir J. Screaton N.J. et al.Computed tomography reveals an unusual complication in a patient having undergone coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2004; 18: 668-670Abstract Full Text Full Text PDF PubMed Scopus (5) Google ScholarMore prone to dislodgement and proximal migrationBlood stagnation in the lung has long-term side effectsNo guidelines exist on whether right or left or which size DLT should be used in this emergency situationDLT placement requires that clinicians remove the single-lumen endotracheal tube and risk losing the airwayRight-sided DLTs require more time to position and they have a smaller margin of safety with regard to right upper lobe collapse and obstruction4Sidery M. Cahir J. Screaton N.J. et al.Computed tomography reveals an unusual complication in a patient having undergone coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2004; 18: 668-670Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 6Poplausky M.R. Rozenblit G. Rundback J.H. et al.Swan-Ganz catheter-induced pulmonary artery pseudoaneurysm formation: Three case reports and a review of the literature.Chest. 2001; 120: 2105-2111Crossref PubMed Scopus (82) Google Scholar, 15Benumof J.L. Partridge B.L. Salvatierra C. et al.Margin of safety in positioning modern double-lumen endotracheal tubes.Anesthesiology. 1987; 67: 729-738Crossref PubMed Scopus (252) Google ScholarAfter stabilization, DLTs may need to be exchanged for a single-lumen tube if patients require postoperative ventilatory support4Sidery M. Cahir J. Screaton N.J. et al.Computed tomography reveals an unusual complication in a patient having undergone coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2004; 18: 668-670Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Open table in a new tab PA rupture (PAR) is a rare but devastating complication of PAC use. PAR can be asymptomatic or present with massive hemoptysis with and without hemodynamic instability.3Ruiz P. Sequential lobar-lung-lobar isolation using a deflecting tip bronchial blocker.J Clin Anesth. 2006; 18: 620-623Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar Iatrogenic PAR may be caused by any of the following mechanisms: flushing of a wedged balloon, retraction of a wedged balloon, migration of the catheter tip into a smaller arteriole, eccentric balloon inflation with inadvertent insertion of the catheter tip into the vascular wall, lodging of the catheter tip in the arterial wall, and transmission of cardiac forces to the arterial walls through the catheter tip, causing rupture.4Sidery M. Cahir J. Screaton N.J. et al.Computed tomography reveals an unusual complication in a patient having undergone coronary artery bypass surgery.J Cardiothorac Vasc Anesth. 2004; 18: 668-670Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar The authors believe that the PA in their patient may have ruptured due to migration of the unlocked PAC tip into a smaller arteriole. Generally, securing the airway is a critical first step in managing patients with massive hemoptysis. However, there is a case report in which a perioperative team elected to not secure the airway with 50 to 100 mL of hemoptysis.5Fortin M. Turcotte R. Gleeton O. et al.Catheter-induced pulmonary artery rupture: Using occlusion balloon to avoid lung isolation.J Cardiothorac Vasc Anesth. 2006; 20 ([Epub 2006 May 4]): 376-378Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar This approach is risky with larger volumes of hemoptysis, and the authors believe that it is important to secure the airway first and then to isolate the lung. This can be achieved with either EBBs or DLTs (Table 1). EBBs may be used as temporary devices, but DLTs offer more definitive treatment for patients with massive hemoptysis. Lung isolation can prevent asphyxia, which may be caused by lung spillage and blood clots.6Poplausky M.R. Rozenblit G. Rundback J.H. et al.Swan-Ganz catheter-induced pulmonary artery pseudoaneurysm formation: Three case reports and a review of the literature.Chest. 2001; 120: 2105-2111Crossref PubMed Scopus (82) Google Scholar An intraoperative bronchial clot recently was described in which the ETT had to be removed and the clot had to be taken out with a rigid bronchoscope.7Neuburger P.J. Galloway A.C. Zervos M.D. et al.Case report: Separation from cardiopulmonary bypass with a rigid bronchoscope airway after hemoptysis and bronchial impaction with clot.Anesth Analg. 2012; 114: 89-92Crossref PubMed Scopus (4) Google Scholar In addition, PAR may lead to hemothorax, which can make management more difficult.8Armstrong E.J. McCabe J.M. Cheitlin M.D. Pulmonary artery rupture from invasive hemodynamic monitoring.Arch Intern Med. 2011; 171: 1109Crossref PubMed Scopus (3) Google Scholar, 9Kearney T.J. Shabot M.M. Pulmonary artery rupture associated with the Swan-Ganz catheter.Chest. 1995; 108: 1349-1352Crossref PubMed Scopus (133) Google Scholar One study noted that all 7 patients with PAR and hemothorax who did not have a thoracotomy died.9Kearney T.J. Shabot M.M. Pulmonary artery rupture associated with the Swan-Ganz catheter.Chest. 1995; 108: 1349-1352Crossref PubMed Scopus (133) Google Scholar Hemothorax may result in empyema in as many as 33% of patients.10Karmy-Jones R. Holevar M. Sullivan R.J. et al.Residual hemothorax after chest tube placement correlates with increased risk of empyema following traumatic injury.Can Respir J. 2008; 15: 255-258PubMed Google Scholar In this case, the surgeon was reluctant to perform a full sternotomy to explore the pleural space for evidence of a hemothorax. The authors believe that by controlling the bleeding as quickly as possible, the above-mentioned complications can be avoided. A pulmonary angiogram is a definitive test for the localization of bleeder vessels, and the authors believe that a pulmonary angiogram should be performed in patients with PAR to exclude the long-term complication of PA pseudoaneurysm formation. However, the patient in the present case did not have an angiogram performed before discharge. A novel therapeutic approach by interventional cardiology using vascular plugs also has been described.11Kalra A, Heitner S, Topalian S: Iatrogenic pulmonary artery rupture during Swan-Ganz catheter placement—A novel therapeutic approach. Catheter Cardiovasc Interv [Internet] 2012. Available at: 〈http://www.ncbi.nlm.nih.gov/pubmed/22615240〉. Cited August 12, 2012Google Scholar Extracorporeal membrane oxygenation also has been used to manage patients with massive hemoptysis. A recent case was described in which bleeding could not be controlled with a bronchial blocker, epinephrine lavage or an angiogram, and massive hemoptysis was managed by clamping of the ETT to tamponade the bleeding while the patient was placed on extracorporeal membrane oxygenation.1Giannoni S. Buti G. Allori O. et al.Bilateral concurrent massive hemoptysis successfully controlled with double endobronchial tamponade. A case report.Minerva Anestesiol. 2006; 72: 665-674PubMed Google Scholar Massive hemoptysis is an urgent and difficult problem to deal with, and there is no clear algorithm or guidelines for managing this rare and unpredictable clinical scenario. In the present case the authors used the EBB as a temporary measure and then the DLT for more definitive airway management.