P044: OVERCOMING AIRWAY LIMITATIONS TO ACHIEVE LUNG ISOLATION
Nicole Fares, MD; Nuan Song, MD
University of Miami/Jackson Memorial Hospital
Introduction/Background: One lung ventilation is commonly used when performing robotic thorascopic surgeries for resecting pulmonary lesions. To achieve this, a double lumen tube or flexible bronchoscope is needed. If using a flexible bronchoscope, traditionally a size 7.5 or 8.0 minimum cuffed endotracheal tube is required to accommodate both the bronchial blocker and flexible bronchoscope, however this case details a method used to provide one lung ventilation when only a 6.0 endotracheal tube could be used.
Case Description: This challenging case describes the airway management of a 50 year old female with a medical history including previous salivary carcinoma with resection and radiation therapy in 2009 for the purposes of a left lower lobe wedge resection and right lower lobe wedge resection. Due to the patient’s severely limited mouth opening of one fingerbreath and trismus, an awake fiberoptic intubation was planned through the nares with a 7.5 ETT to fit a bronchial blocker and flexible bronchoscope. Patient preoperatively received glycopyrrolate, as well as nebulized 4% lidocaine, and was made to gargle and swallow viscous lidocaine prior to attempting. Sedation was attempted with midazolam, dexmedetomidine, and ketamine. Patient’s nares was sprayed with oxymetolozone, and was dilated with 28 french and 30 french nasal trumpets to prepare for passage of the bronchoscope and tube. Despite successful passage of the bronchoscope past the vocal cords, a 7.5 endotracheal tube was attempted but could not pass the patient’s nares and caused bleeding. Therefore, a 6.0 cuffed endotracheal tube was passed successfully and anesthesia was induced with 100 mg propofol and sevoflurane, paralysis with rocuronium was also given. The bronchial blocker was passed through the endotracheal tube, and the flexible bronchoscope was passed through the opposite nares and past the vocal cords as well, outside of the tracheal tube, until carina was visualized. The bronchial blocker was able to be seated using the visuals from the flexible bronchoscope. Upon extubation, bougie was placed through endotracheal tube and patient was made sure to be with consistent appropriate tidal volumes and following commands prior to tube removal.
Discussion: This case presentation describes the successful placement of a bronchial blocker using a smaller endotracheal tube than is traditionally required to place. This method is useful because often times pulmonary lesions are metastatic, and patient’s have head and neck cancers which can affect obtaining an airway. However, there are drawbacks to this method. During movement from right lateral decubitus to left lateral decubitus, the endotracheal tube came removed from the top plastic piece which connected the tube to the circuit, and tidal volumes sharply decreased. Using clamps, the tube was able to be lifted from the patient’s nares slightly and reattached to the circuit. This is a known drawback of using a smaller endotracheal tube size, and should be on the immediate differential if smaller tidal volumes or loss of end tidal CO2 is seen.