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Case report: Endotracheal tube malposition in a patient with a tracheal bronchus

[Présentation de cas : malposition du tube endotrachéal chez une patiente qui présente une bronche trachéale]

From the Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.

Address correspondence to: Dr. David T. Wong, Department of Anesthesiology, MC 2-405, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada. Phone: 416-603-5118; Fax: 416-603-6494; E-mail: david.wong{at}uhn.on.ca

Purpose: A tracheal bronchus is a congenital abnormality of the tracheobronchial tree, in which a displaced or accessory bronchus arises from the trachea superior to its bifurcation. We report a patient with a tracheal bronchus that was found incidentally during surgery in the prone position, and the potential airway management problems which may have ensued.

Clinical features: A 70-yr-old female underwent posterior spinal decompression and fusion in the prone position. Intraoperatively, end-tidal CO₂ and airway pressure increased. Fibreoptic bronchoscopy revealed that the endotracheal tube (ETT) was kinked at the 16 cm mark, which was corrected by rotating the patient’s head and ETT. When the bronchoscope was advanced beyond the tip of the ETT, a tracheal-bronchial tree trifurcation was identified. Endobronchial intubation was suspected. As the ETT was withdrawn, the endoluminal view remained unchanged. During bronchoscopy, the patient’s trachea was nearly extubated in the prone position. Subsequent bronchoscopy of the major bronchial divisions showed that the trifurcation represented left main stem bronchus, bronchus intermedius and right upper lobe bronchus. Once the tracheal bronchus was recognized, the tip of the ETT was repositioned 3 cm above the tracheal trifurcation, and the rest of the case was uneventful.

Conclusion: This case highlights the diagnostic challenge and airway management implications of one variant of a tracheal bronchus when airway problems are encountered intraoperatively. This knowledge should be applied in the differential diagnosis and management of intraoperative hypoxemia; and in the proper positioning of the ETT.