Airway Management a Single-Lumen Mark S. Scheller,

During Anesthesia for Double-Lung Endotracheal Tube With an Enclosed

MD, Jolene M. Kriett, MD, Cecilia M. Smith, DO, and Stuart W. Jamieson,

T

HE APPROACH TO airway management in patients undergoing lung transplantation is dependent on the type of transplant procedure (combined heart-lung, singlelung, or double-lung technique), the site of the airway anastomosis (trachea or mainstem bronchus), and whether cardiopulmonary bypass (CPB) will be used. Modifications of the original operative technique for double-lung transplantation’.’ have been introduced recently including the use of bilateral bronchial anastomoses’ and sequential single-lung transplantation.” The respective advantages of these techniques include the improved collateral blood supply at the donor bronchial anastomotic sites, thereby decreasing the risk of ischemic airway complications, and the potential elimination of the need for CPB. Specific strategies for airway management during double-lung transplantation have not been previously addressed. This report describes recent experience with a patient who underwent double-lung transplantation without CPB using a singlelumen endotracheal tube with enclosed bronchial blocker (Univent tube, Fuji Systems Corporation, Tokyo, Japan).

the cndotracheal

tracheal distance

carina and the right uppet- lobe bronchus measured. This was found to be approximately 2 cm and was felt to he

adequate

CASE REPORT A 31.year-old, 121.lb, 5-ft, 4-in woman with cystic fibrosis diagnosed during infancy, was referred for consideration of lung transplantation. The patient had markedly restricted exercise tolerance and recurrent hospitalizations for pseudomonas pulmonary infections, control of pulmonary secretions, and respiratory failure. Right heart catheterization demonstrated normal pulmonary artery (PA) pressures and cardiac function. As part of this protocol for candidates with cystic fibrosis, endoscopic sinus surgery was performed in preparation for transplantation. During that procedure, a single-lumen no. 8 oral endotracheal tube was placed without difficulty. When suitable donor organs were located, the patient was readmitted to the hospital. Physical examination showed mild wheezing bilaterally, dyspnea, and a productive cough. The patient was afebrile and preoperative laboratory studies, including chest radiograph, were within normal limits. Arterial blood gas (ABG) analysis performed during room air breathing disclosed a pH of 7.49. PaO, of 82 mm Hg, PaCO, of 36 mm Hg, and a base excess of 4 mEq/L (Table I). Radial arterial and left internal jugular central venous pressure catheters were inserted. Additional monitoring included an electrocardiogram, pulse oximeter (SpOJ, and endtidal carbon dioxide (P, .,CO,). Anesthesia was induced with fentanyl and thiamylal and the patient was paralyzed with pancuronium. Because the patient had eaten a full dinner only 2 hours before surgery, cricoid pressure was maintained at all times during induction, laryngoscopy, and intubation. Using direct laryngoscopy, a no. 8 Univent tube (Fig 1) was positioned in the trachea. A fiberoptic bronchoscope was passed

From the Departments of Anesthesiology, Medicine, and Surgery, Universityof California, San Diego, La Jolla, CA. Address reprint requests to Mark S. Scheller, MD, Depar?ment of Anesthesiology, 0629, University of California, San Diego, 9500 Gilman Dr, La Jolla, CA 92093.0629. Copyright 0 I992 by W B. Saunders Company 10%0770192/0602-0017$03.00l0

tube

for acceptance

.mil the

MB, FRCS

through

of the balloon

distance

between

of the Univent

the

bronchial

blocker. After the initial examination, directing

the concavity

enclosed

bronchial

under fiberoptic

the endotracheal

ventilation

blocker

of the Univent

vision into the left mainstem

(OLV).

an air/oxygen

at all times. Anesthesia and isoflurane

left side. The

tube

was advanced

bronchus.

Inflation

ol

adequate occlusion of the bronchus oxygen saturation during one-lung

Two-lung

mixture

tube was rotated.

of the tube to the patient’s

the cuff of the blocker affirmed and maintenance of adequate

ventilation

in an attempt

(TLV) was resumed

to maintain

was maintained

with

the SpOz > 90r,;

with fentanyl,

midazolam.

( < I’% inspired).

A bilateral anterior thoracotomy incision with sternal transrction in the fourth intercostal space was performed. Pleural adhesions and inferior pulmonary ligaments were divided using electrclcautery. The hilar dissection was completed on each side with encirclement of the main PAS and pulmonary veins. The pericardium was incised necessary.

204

Transplantation Using Bronchial Blocker

anteriorly

Pericardial

to facilitate

incisions

were

cannulation

also made

for 60 mm Hg (personal observation) and, as such, may function as a high-pressure low-volume balloon with attendant risks of mucosal damage, particularly if used for extended periods. Overall, the authors were pleased with the ease and

SCHELLER

ET

AL

Fig 1. Univenttube. The bronchial blocker has been extended and pilot bailoon inflated. Note that the proximal shaft of the bronchial Mocker is attached to the endotracheal tube to prevent movement of the blocker, and that the proximal orifice of the bronchial blocker lumen is uncapped. This lumen may be used to deflate the lung for suctioning, or for the application of continuous posithre ah-way pressure.

effectiveness of this option for airway management during double-lung transplantation in this patient with cystic fibrosis. However, the importance of fiberoptic bronchoscopy should be emphasized for verification of the correct position of the endobronchial blocker, as previously described by Inoue et al.” The major reason for this is to ensure that the balloon lies as far cephalad as possible while still adequately occluding the bronchus of the lung to be transplanted, so as not to interfere with the surgical bronchial anastomosis. Secondly, but of equal importance,

is that in using the blocker for right lung transplantation, the bronchus of the right upper lobe may be occluded by the blocker. Measuring the distance between the tracheal carina and the orifice of the right upper lobe bronchus with fiberoptic bronchoscopy may be helpful in determining the acceptability of the Univent tube for use in the right mainstem bronchus. Therefore, it is essential that personnel experienced in the use of fiberoptic bronchoscopy be available during the surgical procedure if this method of airway management is selected.

REFERENCES

1. Patterson GA, Cooper JD, Goldman B, et al: Technique of successful clinical double-lung transplantation. Ann Thorac Surg 45:626-633,1988

2. Bonser RS, Fragomeni LS, Kriett JM, et al: Technique of clinical double-lung transplantation. J Heart Transplant 7:298-303, 1988

AIRWAY

MANAGEMENT

IN DOUBLE LUNG TRANSPLANT

3. Metras D, Noirclerc M, Brunet CH, et al: Double-lung transplant: The role of bilateral bronchial suture. Transplant Proc 22:1477-1478,199O 4. Pasque MK, Cooper JD, Kaiser LR, et al: Improved technique for bilateral lung transplantation: Rationale and initial clinical experience. Ann Thorac Surg 49:785-791,199O 5. Gaynes JM, Giron L, Nissen MD, et al: Anesthetic considerations for patients undergoing double-lung transplantation. J Cardiothorac Anes 4:486-498,199O 6. Inoue H, Shotsu A, Ogawa J, et al: New device for one-lung

207

anesthesia: Endotracheal tube with movable blocker. .J Thorac Cardiovasc Surg 83:940-941,1982 7. Inoue H, Shotsu A, Ogawa J, et al: Endotracheal tube with movable blocker to prevent aspiration of intratracheal bleeding. Ann Thorac Surg 37:497-499,1984 8. Kamaya H, Krishna PR: New endotracheal tube (Univents) for selective blockade of one lung. Anesthesiology 63:342-343,1985 9. Herenstein R, Russo JR, Moonka N, et al: Management of one-lung anesthesia in an anticoagulated patient. Anesth Analg 67:1120-1122,1988