SINGLE-LUNG isolation is commonly utilized to facilitate surgical access for various thoracic procedures. In postpneumonectomy patients requiring surgery in the remaining lung, selective isolation of a lobe may afford enhanced surgical access and may minimize injury to the lung tissue during surgical manipulation. We report two patients who had undergone left pneumonectomy—one who was scheduled for a partial sternotomy and exploration of a right neck mass, and another who was scheduled for right-sided pleurectomy—and the methods used for selective lobar blockade.
Case Report
Case 1
A 62-yr-old woman (162.5 cm, 44.5 kg) was diagnosed with recurrent cervicothoracic sarcoma. She had undergone a left pneumonectomy in 1989, followed by chemotherapy and radiotherapy; sternotomy with resection of mediastinal sarcoma in 1996; and distal pancreatectomy, splenectomy, left hemicolectomy, and left nephrectomy in 2000. She had developed stridor of 1 week's duration, and magnetic resonance imaging showed a 5 × 4 × 5 cm mass lying to the right of the esophagus, displacing and narrowing the trachea to the left, and 50% of its normal caliber just below the level of the clavicular heads. The surgeon requested selective right upper lobe collapse to aid exploration and dissection of the right neck mass. Preoperative pulmonary function tests showed a forced vital capacity of 1.84 l and a forced expiratory volume in 1 s (FEV1) of 1.48 l.
After induction of anesthesia, an 8.5-mm ID endotracheal tube (ETT) was inserted into the trachea without difficulty. Bronchoscopy showed a short left main bronchial stump, and both the right main bronchus and the bronchus intermedius were estimated to be 20 mm long.
The single-lumen ETT was removed; a 37-French left-sided double-lumen tube (DLT; Bronchopart®; Rüsch Inc., Duluth, GA) was inserted into the trachea during direct laryngoscopy and guided into the bronchus intermedius with a fiberoptic bronchoscope. The DLT was rotated 180° in the process. The bronchial orifice of the DLT was positioned just above the right middle and lower lobe orifices, with the proximal end of the inflated bronchial cuff at the upper lobe take off. With both cuffs inflated, the right middle and lower lobes were ventilated through the bronchial lumen, and the right upper lobe was allowed to collapse. Partial sternotomy was performed, with the incision extended to the right chest. The right upper lobe was well deflated, and good surgical access was obtained. Pressure control ventilation with a fraction of inspired oxygen (Fio2) of 1.0 was utilized (peak inspiratory pressures kept < 30 cm H2O, with adjustment of respiratory rate to maintain normocapnia), and oxygen saturation remained at 98–100%. Right neck exploration was performed. Prior to closure, the right upper lobe was reinflated by ventilating the tracheal lumen.
Case 2
A 65-yr-old woman (178 cm, 97 kg) had undergone a left extrapleural pneumonectomy for malignant mesothelioma 20 months earlier. She developed a recurrent right pleural effusion and underwent right pleuroscopy. Pleural biopsy showed recurrent malignant mesothelioma.
After induction of anesthesia with easy mask ventilation, direct laryngoscopy with a Macintosh blade revealed a Cormack and Lehane Grade 3 larynx. An 8/22-French bronchial blocker (Fogarty Occlusion Catheter model #62080822F; Baxter Healthcare Corp., Irvine, CA) was inserted into the trachea, utilizing a 45° bend at its tip, and an 8.5-mm ETT was advanced over a fiberoptic bronchoscope and placed alongside the blocker. The blocker was guided into the bronchus intermedius fiberoptically, with its tip at the right middle and lower lobe orifices.
During stripping of the pleura from the upper lobe, the ETT was guided into the bronchus intermedius fiberoptically, and the cuff was inflated to occlude the right upper lobe orifice. Despite incomplete deflation of the right upper lobe, surgery proceeded easily, utilizing ventilation with small tidal volumes (300–350 ml) and adjusting the respiratory rate to maintain adequate minute ventilation. Fio2was 1.0 throughout. End-tidal carbon dioxide levels were between 38 and 45 mmHg, and oxygen saturation was maintained between 96 and 98%. The ETT was withdrawn into the trachea during surgery involving the lower half of the lung. During stripping of the pleura from the lower lobe and diaphragm, the Fogarty catheter could not be maneuvered into the right lower lobe bronchus to selectively collapse the lower lobe. It was therefore removed, and a wire-guided endobronchial blocker (WEB; Cook Inc., Bloomington, IN), coupled to a bronchoscope through a guide loop, was advanced until it exited the bronchoscope and entered the right lower lobe bronchus. Under direct visualization, the balloon was inflated with 6 ml of air to occlude the lower lobe bronchus. Airway pressures were kept below 30 cm H2O, and oxygen saturation was maintained between 95 and 98%.
Discussion
The fine balance between providing satisfactory surgical exposure and maintaining adequate oxygenation is a challenge in postpneumonectomy patients presenting for surgery involving the contralateral hemithorax. Selective lobar bronchial blockade offers an attractive solution for targeted surgical access with preservation of ventilation of as much lung as possible. 1However, not all postpneumonectomy patients will tolerate selective lobar bronchial blockade, and alternative solutions include low–tidal volume ventilation or high-frequency jet ventilation. 2
Selective lobar bronchial blockade can be provided by endobronchial intubation with a single-lumen tube, DLTs, bronchial blockers, or a single-lumen endotracheal tube with an enclosed bronchial blocker (Univent® tube; Vitaid, New York, NY). The choice depends on the anatomy of the patient's tracheobronchial tree, airway pathology, and the physician's familiarity with the equipment and planned surgery. Selective lobar bronchial blocking with a bronchial blocker has been used in pediatric video-assisted thoracic surgery, 3,4to improve arterial oxygen saturation during hemorrhage in a patient who has undergone a previous contralateral lobectomy, 5in the management of bronchopleural fistula, 6and in emergency pulmonary hemorrhage. 7An intentionally malpositioned right-sided DLT has been used to selectively block the right upper lobe bronchus in life-threatening hemoptysis. 8
The use of a left-sided DLT on the right side has been used to occlude the right upper lobe orifice in hemorrhage 9,10and during bilateral sequential lung transplantation, after transplantation of the right lung. 11This is the first report of the use of a left-sided DLT on the right side to selectively occlude the right upper lobe bronchus during thoracic surgery in a patient who had undergone a left pneumonectomy.
To collapse the right upper lobe, a DLT was chosen over a bronchial blocker, as we felt that it might be difficult to guide the blocker into the right upper lobe bronchus due to the acute angle of the bronchus to the right main stem and the risk of dislodgement from this short upper lobe bronchus during surgical manipulation. Endobronchial intubation with a single-lumen ETT would necessitate repositioning if the right upper lobe needed to be reinflated emergently or at the end of surgery, and it also will not allow application of continuous positive airway pressure (CPAP) if required. A malpositioned right-sided DLT can be used to occlude the right upper lobe orifice, 8and the upper lobe can be reinflated by deflating the bronchial cuff, but CPAP cannot be applied to the right upper lobe.
Although problems with the use of a left-sided DLT on the right side may arise, 11we did not experience any difficulty in placing the left-sided DLT into the bronchus intermedius, and the DLT did not kink in the oropharynx. With the bronchial lumen just above the middle and lower lobe orifices and the tracheal lumen above the carina, selective ventilation of the right upper lobe (via the tracheal lumen) and both the middle and lower lobes through the bronchial lumen was achievable without having to reposition the tube. The distance from the bronchial orifice to the proximal end of the bronchial cuff of the 37-French DLT (selected according to the patient's height) used was 21 mm, and that was ideal in our patient whose bronchus intermedius was estimated to be 20 mm long. This method worked well to give good deflation of the right upper lobe during surgery, and the lobe reinflated readily before chest closure on ventilation through the tracheal lumen. If the length of the bronchus intermedius is shorter than the distance from the bronchial tip to the proximal end of the bronchial cuff in the particular DLT used, the cuff itself occludes the right upper lobe orifice. Although this may give good deflation of the right upper lobe, more precise positioning of this small bronchial cuff may be required, and, similar to a malpositioned right-sided DLT, CPAP cannot be applied.
A Fogarty occlusion catheter was utilized in the second patient primarily for right lower lobe collapse to gain better surgical access to the diaphragm. Surgery involving the right upper lobe was assisted by partial collapse of the right upper lobe, with the single-lumen ETT advanced into the bronchus intermedius. No attempt was made to selectively block the right upper lobe orifice with the catheter due to the reasons previously mentioned. Although placement of the Fogarty catheter into the right lower lobe bronchus was achieved easily, 4we had problems directing the unguided catheter into the specific lobar bronchus. We therefore switched to the WEB, and placed the blocker in the lower lobe bronchus without difficulty. Although the upper end of the 3-cm elliptical balloon was visible above the lower lobe bronchus, the seal was tight, and ventilation of the middle lobe was not impeded.
Compared to the Fogarty occlusion catheter, placement of the WEB into the lower lobe bronchus was easy, and the multiport adaptor allowed simultaneous ventilation and bronchoscopy while providing an effective seal and locking device for the catheter. Upon removal of the guide loop, the lumen of the WEB allows for CPAP when required, which can be especially important in patients with limited pulmonary reserve. Maximum contact of the balloon with the bronchial wall provided a tight seal, which might not have been as good with the spherical balloon of the Fogarty catheter.
We have described the methods used to selectively occlude the right lobar bronchi according to the site of surgery in order to maintain adequate ventilation in patients with previous left pneumonectomy. The use of a left-sided DLT on the right side is presented, and some practical problems associated with bronchial blocking devices are discussed.
