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Failure to provide adequate one-lung ventilation with a conventional endotracheal tube using a transbronchial approach: a case report

[Ventilation unilatérale inadéquate avec un tube endotrachéal traditionnel et l’utilisation d’une approche transbronchique : une étude de cas]

Yuet Tong Ng, MD^*, Peter Chi Ho Chung, MD^*, Jing Ru Hsieh, MD^*, Chun Cheung Yu, MD^*, Wai Meng Lau, MD^* and Yun Hen Liu, MD

^* From the Departments of Anesthesiology,
and Cardiothoracic Surgery, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan.

Address correspondence to: Dr. Peter Chi-Ho Chung, Department of Anesthesiology, Chang Gung Memorial Hospital at Keelung, 222, Mai-Chin Road, Keelung, Taiwan, R.O.C. Phone: +886-2-24313131-2777; Fax: +886-2-24313161; E-mail: p654084{at}cgmh.org.tw

Purpose: To report a case where failure to provide adequate one-lung ventilation during transbronchial intubation resulted in a potentially fatal mishap.

Clinical features: A 61-yr-old male was scheduled for right lung lobectomy. Induction of general anesthesia was smooth, and subsequent resection of the right middle lobe was uneventful. Difficult ventilation with high airway pressure and poor right lung re-expansion prompted repositioning of the double-lumen tube after the resection. The removal of the right middle bronchial clamp and associated right mainstem manipulation caused flooding of blood into the double-lumen tube.

Mindful of the risk of fatal desaturation, the surgeon immediately opened the right mainstem bronchus and cleared the airway. Confirmation of a displaced double-lumen tube prompted the surgeon to insert an endotracheal tube (internal diameter 5.5 mm) from the opened right mainstem bronchus to the left main bronchus to maintain oxygenation. Although bronchoscopic examination confirmed proper location of the reinserted tube, oxygen saturation was not sufficiently (60%) improved. Another 5.5-mm endotracheal tube was inserted, with its tip inside the right upper bronchiole, for further ventilatory support. Finally, a rise in SpO₂ to around 95% allowed completion of surgery.

Conclusions: Displacement of the double-lumen endobronchial tube and flooding with clotted blood will result in potentially fatal ventilation difficulties. Repositioning and cleaning of the tube must be prompt to reduce the risk of hypoxemia. Where emergency single-lung ventilation is required, we suggest the utilization of a modified single-lumen endotracheal tube with a shortened cuff-tip length to ensure an adequate margin of safety for mainstem bronchus intubation.

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