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From the Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong, SAR, PRC.
Address correspondence to: Dr. Anthony Ho, Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR. Phone: 852 2632 2735; Fax: 852 2637 2422; E-mail: hoamh{at}cuhk.edu.hk
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Abstract |
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Clinical features: A full-term neonate with a type C TEF presented for thoracoscopic repair. The fistula was at the level of the carina, making its isolation from positive pressure ventilation using traditional techniques difficult. In addition, non-ventilation of the right lung was required. The use of two Fogarty type balloon-tipped embolectomy catheters placed alongside the endotracheal tube successfully achieved the goal of blocking ventilation of the fistula and the right lung. The use of fibreoptic bronchoscopy greatly facilitated placement of the blockers. The patient made an uneventful recovery.
Conclusion: Placing two balloon-tipped blockers, one in the TEF and the other in the right mainstem bronchus, is a viable technique for thoracoscopic fistula repair when the fistula is at or very close to the level of the carina.
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Introduction |
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Case report |
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Corrective surgery was undertaken on day two. Preoperatively, SpO2 was 94% on room air, she was tachypneic with a mild fever for which she received antibiotics, but vital signs were otherwise stable. Relevant blood work was unremarkable. Routine intraoperative monitors were attached; however, attempts to establish an arterial line failed. The in situ Replogle tube was placed on gentle continuous suction. Prior to induction, atropine 0.1 mg iv was given. General anesthesia was induced with up to 4% sevoflurane (end-tidal) in 100% O2 with the child in a slight reverse Trendelenberg position. Spontaneous respiration was maintained. After spraying the larynx and trachea with lidocaine 10% (total approximately 15 mg), fibreoptic bronchoscopy (Olympus LF-P 1.8 mm, Tokyo, Japan) was performed to discover that the TEF was at the carina (Figure
). The fibrescope was withdrawn and the trachea was intubated with a 4 Fr Fogarty arterial embolectomy catheter (Applied Medical Technology, Inc, Cleveland, OH, USA) with its tip slightly bent so that the balloon was facing posteriorly. Next inserted was an uncuffed internal diameter 3 mm ETT. Under fibreoptic bronchoscopy through the ETT lumen, the TEF was intubated successfully with the Fogarty catheter tip on the first attempt (Figure), and the balloon was inflated just enough so that it appeared to completely occlude the fistula. The approximate inflation volume was 0.2 mL of saline. The ETT was then removed, and another 4 Fr Fogarty catheter with the tip slightly bent towards the right was passed into the trachea followed by reintubation with the same ETT. The second Fogarty catheter tip was then positioned in the right mainstem bronchus with the aid of fibreoptic bronchoscopy, again through the ETT lumen (Figure). Inflation of the second catheter balloon with approximately 0.2 mL of saline resulted in satisfactory isolation of the right lung. The child was then paralyzed and controlled ventilation was started. The balloon pressures were not measured. There was no gas leak around the in situ ETT and the catheters at a peak ventilatory pressure of 20 cm H2O.
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Postoperatively, the child was treated with antibiotics for pneumonia and intermittent iv boluses of fentanyl for analgesia and sedation. Her trachea was extubated on postoperative day six upon resolution of the pneumonia. She was discharged to a peripheral hospital on postoperative day 12. Subsequent recovery was uneventful, as evaluated during multiple visits to clinic up to one year later.
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Discussion |
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Formulation of the airway management plan was possible after the airway anatomy was delineated with fibreoptic bronchoscopy. Once a two-blocker technique was chosen, the TEF blocker was the first to be inserted. As reported by others,7 and due to the downward direction of the tracheo-distal esophageal/ gastric fistula, this task was not time-consuming. Because the ETT was too small to accommodate a Fogarty catheter and a fibrescope, both blockers had to be outside of the ETT. The ETT thus was inserted twice: after the fistula blocker was placed, and after the endobronchial blocker was inserted. The accurate positioning of both blockers required bronchoscopy through the ETT lumen. One concern which arose was whether the presence of two blockers and an ETT would create excessive pressure on the tracheal mucosa. We were unable to objectively investigate this aspect, but noted that the child had no clinical evidence of tracheo-malacia or stenosis on multiple follow-up visits. Bearing in mind that the cross-section of the neonatal trachea has a partial oval shape, it was thought that the stems of the blockers would migrate into the gaps between the tracheal mucosa and the ETT. Others have not reported this potential problem with the use of a single blocker and an ETT.7,8
The disadvantages of bronchial blockers include the possibility of retrograde migration of either blocker into the tracheal lumen, resulting in partial or complete airway obstruction; and insufficient blockade of the mainstem bronchus leading to partial ventilation of the collapsed lung; and bronchial rupture.10
One alternative technique of blocking the TEF and the right mainstem bronchus simultaneously is to deliberately slide the ETT into the left mainstem bronchus.11,12 This simple approach is sometimes effective.13 However, differences in the diameters of either mainstem bronchus and the trachea may result in an ETT that fits a mainstem bronchus well but is too small for the trachea, or one that fits the latter but is too large for the former. This might predispose to left bronchial edema. In one report, left upper lobe collapse also highlighted the low margin of safety in deliberate endobronchial ETT placement in neonates to achieve one-lung ventilation.11 Another disadvantage stems from the not uncommon occurrence of desaturation during one-lung ventilation in TEF repair.14 As such, intraoperatively, the ETT may need to be retracted several times to ventilate both lungs. Subsequent repositioning of the ETT tip back into the left mainstem bronchus requires fibreoptic bronchoscopy, which may be hazardous and cumbersome in a semiprone neonate, made even more difficult by the clutter of sterile drapes separating the small distance between the operative field and the patient’s mouth.
Use of a specially designed bifurcated tracheal tube for TEF repair has also been described.15 This is not a double-lumen tube, and is therefore not suitable for differential lung ventilation. Intubating the TEF with a balloon-tipped catheter pulled through a gastrostomy has also been described16 but has been criticized for its complexity.8
In summary, the need to avoid communication between the stomach and the lungs and the importance of collapsing the right lung during thoracoscopic TEF repair led to the use of two balloon-tipped embolectomy catheters placed alongside the ETT in a neonate. This appears to be a viable technique and may be considered when the TEF is too proximal to the carina to be easily blocked with an ETT.
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Footnotes |
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This work is attributable to the Chinese University of Hong Kong and the Prince of Wales Hospital, Shatin, NT, Hong Kong SAR.
Conflict of interest: None to declare.
Accepted for publication September 11, 2006. Revision accepted November 27, 2006.
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References |
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