S004: IATROGENIC BRONCHOPULMONARY FISTULA RECOGNITION AND MANAGEMENT DURING PEDIATRIC LUNG MALFORMATION REPAIR
Lindsey J Laux, MD1; Catalina Coppola, MD1; Rafeal E Gonzalez, MD2; 1Jackson Memorial Hospital / Nicklaus Children's Hospital; 2Nicklaus Children's Hospital
Background: CPAM (congenital pulmonary airway malformation) is a unilateral benign growth of abnormal lung tissue. This is the most common cause of a fetal lung lesion and is typically diagnosed via fetal ultrasound. Timing of surgical removal of the lesion is determined by size, location, and the degree of compression of the heart, and optimally occurs within the first year of life.
This case report details the anesthetic management of a 4 month old patient who developed a bronchopulmonary fistula during video assisted thoracoscopic repair of CPAM.
Case Description: The patient is a 4 month old, 9 kg infant, who presented for excision of abnormal lung tissue via thoracoscopic left lower lung lobectomy. The lesion was diagnosed on prenatal ultrasound at 20 weeks gestation. At the time of surgery, CT scan revealed the lesion to be 2.3 x 4.0 x 1.5 cm located in the posterior basilar segment of the left lower lobe.
After inhalational induction with Sevoflurane, IV access was obtained, and intubation proceeded with Miller 1 blade and 3.5 cuffed endotracheal tube. The endotracheal tube was advanced into the right mainstem bronchus for left sided lung isolation. The patient, however, did not tolerate lung isolation and two-lung ventilation was reinstated. After discussion with the surgeon, a decision was made to proceed utilizing two-lung ventilation and utilize higher insufflation pressures to partially collapse the left lung.
During resection, insufflation pressure was intermittently alarming for pressures > 50 PSI when the patient suddenly developed an increasing end tidal CO2 that rapidly rose to read as “undetectable”. Point of care arterial blood gas demonstrated a pH: 6.882 and pCO2: >130. Patient then developed desaturation and decreased exhaled sevoflurane. An endobronchial leak identified with subsequent resolution of symptoms with clamping. The leak was repaired by the surgeon and lobectomy proceeded without further complications.
Upon completion of the surgery, the patient was unable to be weaned from the ventilator and was brought to the PICU intubated and sedated. He was extubated on postoperative day 1 without complications and discharged home four days later.
Discussion: CPAM is a commonly repaired lung lesion in neonates. In small pediatric patients, one-lung ventilation is not always tolerated so higher insufflation pressures may be used to partially collapse the operative lung during two-lung ventilation. While endobronchial leaks can occur during surgical resection and change the expected airway mechanics, it is commonly identified due to decreased ventilation and tidal volumes caused by air escaping from the bronchial tree into the surgical field. However, high insufflation pressures can create a pressure gradient that instead drives insufflation gas (CO2) into the bronchial tree, thus washing out the gasses delivered by the ventilator. This can lead to potentially dangerous levels of hypercarbia, loss of oxygenation, and reduction in anesthetic gas concentrations. Prompt recognition and adequate management of intraoperative complications is key to patient stability and recovery.