Portal de Periódicos da CAPES

Bronchial Rupture by a Double-Lumen Endobronchial Tube During Staging Thoracoscopy

1999; Lippincott Williams & Wilkins; Volume: 88; Issue: 6 Linguagem: Inglês

10.1097/00000539-199906000-00012

1526-7598

Timothy B. Gilbert, Craig W. Goodsell, Mark J. Krasna,

Pleural and Pulmonary Diseases

Single-lung ventilation using a double-lumen endobronchial tube (EBT) is often performed for surgical procedures involving the thorax. The ability to isolate and collapse the nondependent lung is particularly imperative for thoracoscopic procedures, because adequate visualization of most intrathoracic structures depends on near complete atelectasis. Despite proper placement and use of an EBT, severe airway injury by the tube tip or either of its cuffs may occur occasionally. Previous reports seem to be limited to injury during open thoracotomy, in which broad visual exposure of the entire thorax is possible. We report a case of iatrogenic bronchial rupture during the use of an EBT for staging thoracoscopy in which the site of injury was not appreciated initially during the videoscopic examination. Case Report A 53-yr-old, previously healthy patient presented for right-sided thoracoscopic evaluation for staging of biopsyproven esophageal adenocarcinoma. Physical examination was unremarkable; height and weight were 160 cm and 68 kg, respectively. Following the uneventful induction of general anesthesia, a 37F, left-sided, styletted EBT (BronchoCath[registered sign]; Mallinckrodt, Glen Falls, NY) was passed easily through the vocal cords and into the left mainstem bronchus. We performed fiberoptic bronchoscopy (FOB) to confirm proper tube placement and to visualize inflation of the endobronchial balloon cuff; <3 mL of air was required to achieve an adequate seal. Appropriate lung isolation was then confirmed by auscultation. After turning the patient to a left-lateral decubitus position, thoracoscopy commenced with trochar insertion and carbon dioxide insufflation (peak pressure <or=to20 cm H2 O). The initial videoscopic inspection of the pleural cavity revealed poor nondependent lung collapse; therefore, FOB was repeated several times, confirming no significant change in the EBT position. In addition, the patient's positioning on the operative table (i.e., extent of flexion and rotation) was adjusted several times to assist the surgeon's views. Twice, ventilation was discontinued and the EBT advanced slightly with both cuffs deflated, then reinflated. Ultimately, intermittent apneic oxygenation was required to achieve acceptable lung collapse for accessing the retropleural space. No significant change in hemodynamic variables was noted throughout. One hour later, during mobilization of mediastinal and paraesophageal tissues, a dark, spherical, cystic-appearing structure was discovered emanating between the esophagus and trachea in the mediastinum (Figure 1). During dissection in preparation for biopsy of this mass, the surgical team realized that this artifact was the blue-colored endobronchial cuff protruding laterally from a ruptured left mainstem bronchus and into the right pleural space. An urgent open thoracotomy was performed to oversew the bronchial injury and to apply an intercostal muscle flap to enhance the air seal. During repair, the EBT was advanced manually under FOB guidance beyond the site of bronchial injury. A postrepair FOB showed adequate surgical closure of the bronchus with minimal luminal narrowing. The esophageal tumor ultimately was found quite distant from the site of the bronchial injury. After completion of the planned staging procedure, the patient was allowed to emerge from anesthesia and was tracheally extubated without difficulty. No subcutaneous emphysema, pneumomediastinum, or pneumothorax was noted postoperatively, and the patient had an otherwise uneventful recovery. She was discharged on Postoperative Day 4.Figure 1: The dark, spherical, cyst-appearing structure (arrow) emanating laterally from the mediastinum was found to be the tinted endobronchial cuff protruding from the site of the ruptured left mainstem bronchus. The thoracoscopic grasper is seen to the far right. The poorly collapsed nondependent lung is also shown (directly beneath the arrow).Discussion Iatrogenic rupture of airway structures by an indwelling catheter is extremely uncommon [<0.2% in historical series using Carlens tubes [1]]. Although reported after routine endotracheal intubation [2], most tracheobronchial injuries result from the use of more distally placed EBTs. The site of rupture is usually the distal trachea or the posterior membranous wall of the mainstem bronchus with the resultant escape of air into the mediastinum, pleural spaces, or subcutaneous tissues. It was therefore surprising that no air collected outside the airways of this patient. The herniating balloon may have adequately filled the bronchial wall defect and prevented air from escaping into the mediastinum or elsewhere. However, because the cuff protruded beyond the bronchial wall, it may not have been capable of completely sealing the dependent lung bronchus and may have allowed air to pass back into the nondependent lung, causing poor lung isolation. Therefore, the only obvious sign heralding this injury was poor nondependent lung collapse-not hypoxemia, hypotension, or dissection of air beyond the airways. Factors that seem to increase the risk of injury by an EBT include: use of an undersized tube that requires excessive cuff inflation [3]; use of tube too large for a patient's mainstem bronchial lumen [4]; malposition of the tip of the tube [5]; rapid cuff inflation [6]; use of older tubes with low-compliance cuffs (red rubber) or carinal hooks (e.g., Carlens or White tubes) [4]; use of adjuncts such as bronchial blockers [7] or tube-exchangers [8]; the presence of invasive disease of the airways [2,6]; use in patients at the extremes of age [2,7]; and use of N2 O [4,6]. In this particular patient, none of these risk factors were present. The mechanism of injury was undoubtedly either direct injury by the tip of the EBT during its initial placement (or manipulations) or by later injury secondary to inflation of the distal cuff. Unfortunately, there is no way to determine which of these occurred because the poor collapse of the nondependent lung was not noted until the surgeon entered the chest, some time after EBT placement. Tracheobronchial injury during thoracoscopy has not been previously reported. Thoracoscopy could increase the risk of such an injury for several reasons. First, because thoracoscopy requires exquisite lung collapse for good visualization, more manipulations of the EBT (e.g., repositioning, inflations, or deflations of the cuffs, or FOB) may be necessary than with an open thoracotomy. Second, carbon dioxide insufflation [9] could cause more rapid or complete lung collapse and excessive torsion on at-risk airway structures. Third, depending on the area of the thorax being examined, the patient and operative Table oftenrequire readjustment to optimize the surgeon's view. Finally, because of the field of view and variability in quality of the videoscopic image, diagnosis of an injury may be somewhat delayed, as was the case in this patient. Because thoracoscopy is generally performed in a darkened room, recognition of certain physical signs (e.g., cyanosis, subcutaneous emphysema) can be problematic. For these reasons, use of endobronchial intubation and single-lung ventilation should be performed with substantial vigilance during thoracoscopy in order to detect or possibly prevent similar airway injury.