CJA
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
This Article
Right arrow Full Text (PDF)
Right arrow Submit a scholarly reply
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Govindarajan, R.
Right arrow Articles by Sathyamoorthy, M. K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Govindarajan, R.
Right arrow Articles by Sathyamoorthy, M. K.
Canadian Journal of Anesthesia 52:993 (2005)
© Canadian Anesthesiologists' Society, 2005

Correspondence

Anesthetic management of bronchopleurocutaneous fistula – an alternate approach

Ramasamy Govindarajan, MD, Ambarish Mathur, MD, Judith Aransohn, MD, Wagih Saweris, MD, Biswajit Ghosh, MD and Madhan Kumar Sathyamoorthy, MD

The Brookdale University Hospital and Medical Center, Brooklyn, USA, E-mail: gbiswajit{at}yahoo.com

To the Editor:

A 48-yr-old man with a persistent left bronchopleurocutaneous fistula (BPCF) and empyema thoracis following pneumonectomy presented for bronchial stump closure and left thoracoplasty. The patient refused any attempts at awake intubation.

He was placed in semi-recumbent position with the left side down after topicalization and mask induction. Right-sided double-lumen tube (DLT) placement was attempted while the patient was breathing spontaneously, but was unsuccessful in the absence of adequate muscle relaxation. Attempts to position a left bronchial blocker under fibreoptic guidance resulted in the balloon either slipping into the fistulous opening or backing up into the trachea. Advancing a single-lumen tube into the right main stem bronchus resulted in right upper lobe obstruction and attempted DLT insertion over a tube exchanger was also unsuccessful.

When rescheduled, he was positioned and induced in the same manner as before and intubated with an 8.5 size endotracheal tube. Anesthesia was maintained with air, oxygen and sevoflurane using a Bain circuit, the patient breathing spontaneously. A triple-lumen central line and a transesopheal echocardiograph (TEE) were added to standard monitoring. The patient was positioned in the sitting position and stabilized in the appropriate frame, with his hands abducted and flexed forwards. The surgeon approached the BPCF through a left thoracotomy by transaxillary approach.

Transtracheal jet-ventilation was delivered through the tip of a catheter placed above the level of fistula, to lessen the possibility of barotrauma. Anesthesia was maintained with an infusion of ketamine. During jet-ventilation PaO2 values were 80 to 90 mmHg while PaCO2 increased to 60 mmHg. The fistula was repaired and leak tested while purulent material from the left chest cavity was suctioned clean. Controlled ventilation restored blood gas levels towards normal. Left thoracoplasty was completed and the patient was extubated in the operating room. Postoperative pain control was achieved by a thoracic epidural catheter with continuous infusion of bupivacaine and fentanyl.

While anesthetizing the patient with BPCF in the sitting position, oxygenation can be assured with jet-ventilation, and gravity aids in draining away purulent secretions from the trachea.1 CO2 accumulation can be managed by limiting the surgical time and establishing controlled ventilation at the earliest opportunity. Hypotension can be corrected with crystalloid infusion. The hazard of air embolism can be monitored with TEE and treated with a triple lumen central venous catheter.2

When conventional methods of pulmonary isolation fail, anesthesia and surgery pose unusual challenges during the operative management of BPCF.3,4 Careful planning and meticulous anesthetic management can transform a difficult case into a manageable one.

References

1 Bishop MJ, Benson MS, Sato P, Pierson DJ. Comparison of high-frequency jet ventilation with conventional mechanical ventilation for bronchopleural fistula. Anesth Analg 1987; 66: 833–8.[Abstract/Free Full Text]

2 Porter JM, Pidgeon C, Cunningham AJ. The sitting position in neurosurgery: a critical appraisal. Br J Anaesth 1999; 82: 117–28.[Abstract/Free Full Text]

3 Hollaus PH, Lax F, el-Nashef BB, Hauck HH, Lucciarini P, Pridun NS. Natural history of bronchopleural fistula after pneumonectomy: a review of 96 cases. Ann Thorac Surg 1997; 63: 1391–7.[Abstract/Free Full Text]

4 James BE, Edmond C, Steven MN. Anesthesia for thoracic surgery. In: Barash PG, Cullen BF, Stoelting RK (Eds). Clinical Anesthesia. Philadelphia Lippincott-Raven; 1997: 669–97.




This article has been cited by other articles:


Home page
 Canadian J. AnesthesiaHome page
R. Morse and A. Schirge
The "critical airway": too complex for a management algorithm?
Can J Anesth, August 1, 2006; 53(8): 851 - 852.
[Full Text] [PDF]

This Article
Right arrow Full Text (PDF)
Right arrow Submit a scholarly reply
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Govindarajan, R.
Right arrow Articles by Sathyamoorthy, M. K.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Govindarajan, R.
Right arrow Articles by Sathyamoorthy, M. K.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS