Case Report

Successful anesthetic management in a child after traumatic rupture of left main bronchus by a single‑lumen cuffed‑endotracheal tube Hamed Elgendy1,2, Tariq Jilani1 Departments of Anesthesia, 1King Abdullah Medical City, Makkah, Kingdom Saudi Arabia, 2Assiut University Hospital, Assiut, Egypt

ABSTRACT

Received: 11‑01‑14 Accepted: 24‑04‑14

Tracheobronchial injury (TBI) may lead to catastrophe if remains undetected or managed improperly. The incidence of TBI is less in children as compared with adults due to their pliable chest wall. Its clinical manifestations include persistent pneumothorax, cervical subcutaneous emphysema, pneumomediastinum, cyanosis, and respiratory insufficiency. The recommended airway management is to intubate the healthy bronchus with a single‑lumen or double‑lumen endotracheal tube (ET) and bypassing the injured side. We report successful anesthetic management of traumatic rupture of the left main bronchus in a child by using a single‑lumen cuffed‑ET. Many factors affect the outcome of such injuries and include the extent of the lesion, the resulting pulmonary status, the adequacy of surgical reconstruction. More severe injury may require lobectomy or pneumonectomy. Early diagnosis and proper management result in good functional outcome. Key words: Airway injury; Child; Anesthesia; Bronchial rupture

INTRODUCTION

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Tracheobronchial rupture is rare in clinical practice, especially in pediatric patients. There are a few case reports of complete or incomplete rupture of the bronchi.[1,2] It may result from a complicating emergent endotracheal intubation,[1] following the use of endotracheal tube (ET) introducers or as a result of blunt chest trauma.[2] Incidence of tracheobronchial injuries (TBI) due to road traffic accidents constitutes 59% of the cases. Because of the hard bone contour in adults as compared with pliable chest wall in children, these injuries are 10 times more common in adults than in children.[3] 40-80% of TBI occur within 2.5 cm of the carina. It was reported that the right main bronchus is affected more often than the left (26% and 17.5%, respectively).[4] This has been attributed to the fact that the left main bronchus is relatively protected by the aorta. Anatomically, the

distal trachea and the right main bronchus overlie the vertebral bodies, which increases its chance of rupture, as the later becomes the anvil at the time of impact. Although the incidence of tracheobronchial ruptures is low, it is a potentially fatal injury and should be diagnosed and treated promptly to avoid complications and maintain pulmonary function. [5] Most patients of TBI present with cervical subcutaneous emphysema, pneumothorax, cyanosis, pneumomediastinum, and respiratory insufficiency.[2] A continuing pneumothorax despite chest drainage on initiation of positive pressure ventilation should alert the physician to the underlying airway injury[6] or massive lung parenchymal injury. There are few reports of airway management by single‑lumen ET in young pediatric patients because of the nonavailability of pediatric size double‑lumen tube (DLT).[7] To our knowledge, a few case reports of bronchial injury caused by thoracostomy tube (TT) have

Address for correspondence: Dr. Hamed Elgendy, Department of Anesthesia, King Abdullah Medical City, Muzdalifa Road, P.O. Box 57657, Makkah 21955, Kingdom Saudi Arabia. E‑mail: [email protected]

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Elgendy and Jilani: Anesthetic management of ruptured left main bronchus

been published,[1,2,8] but little information is available about their anesthetic management. CASE REPORT Local Institutional Review Board approval and patient consent was obtained. A 14‑year‑old boy developed left‑sided tension pneumothorax, left lung collapse, and atelectasis following motor vehicle accident. Even after insertion of a TT, the left lung remained collapsed, which was revealed on the follow‑up chest X‑rays. In addition, moderate air‑leak persisted in the TT underwater seal system. After resuscitation of the patient in an emergency room, the patient was intubated with a single‑lumen ET tube and transferred to Intensive Care Unit (ICU) where fiberoptic bronchoscopy (FOB) revealed a ruptured distal left main bronchus. The patient was transferred to our center for surgical intervention. Radiological findings showed persistent collapse of the left lung and a deeply inserted TT [Figure 1]. The computed tomography (CT) showed TT closely located to aorta, left pulmonary artery and vein [Figure 2], fracture of the left 5th rib was also noted (not shown in CT). After careful examination of the preoperative radiology findings and discussion with the thoracic surgeons; the cardiopulmonary bypass (CPB) and the cardiac surgical team were alerted and put on standby to intervene if any accidental bleeding occurred during the removal of the TT. The patient was sedated with fentanyl 50  µg/h and midazolam infusion 0.06 mg/kg/h and transferred from ICU to the operating room. A central venous cannula was placed in left internal jugular vein under ultrasound guidance. Patient was monitored with invasive arterial and central venous pressures. Two 14 gauge cannulae were inserted in left and right

Figure 1: Preoperative chest X-ray shows left lung atelectasis and deeply inserted thoracostomy tube (black arrows)

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saphenous veins for rapid volume infusion if massive bleeding occurs during removal of TT. Preoperative arterial blood‑gas (ABG) analysis, with the patient receiving 100% oxygen (FIO2 1.0) by mask, confirmed hypoxic status of the patient PaO 2  (60 mmHg), pH (7.35), PaCO2 (51 mmHg). Anesthesia was induced with propofol 150 mg, and maintained with sevoflurane 1-1.5% and rocuronium 35 mg was administered for muscle relaxation. The intravenous (IV) fluids were restricted, and blood products were avoided; in addition, IV furosemide 40 mg was administered to reduce pulmonary congestion. Reintubation of the trachea with a DLT was guided by FOB (Olympus LF‑2; Olympus Optical Co., Tokyo, Japan), but DLT could not be inserted due to bleeding and excessive secretions. After careful bronchial lavage, a 7‑mm cuffed‑ET was inserted into the right main stem bronchus guided by FOB; this confirmed the patency of the right upper main bronchus; the repeat ABG was acceptable. Left thoracotomy showed the presence of the (TT) inside the left main bronchus [Figure 3]. Initial repair of left main bronchus failed due to severe injury and the operating surgeon decided for left pneumonectomy. After pneumonectomy, the ET was withdrawn above the carina under FOB guidance. Adequacy of left bronchial stump repair was confirmed by FOB. The patient was transferred to the ICU and pressure controlled ventilation was used until extubation after 48 h. Patient was discharged from ICU following acceptable ABGs and follow‑up chest X‑rays. DISCUSSION Early diagnosis of TBI and proper management reduce the morbidity and improve patient’s outcome. Hewett in 1876 first described continuous drainage of the chest

Figure 2: Preoperative computed tomography shows thoracostomy tube lodged between aorta (1), left pulmonary artery (2) and vein (3 and 4) (white arrows)

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Elgendy and Jilani: Anesthetic management of ruptured left main bronchus

Figure 3: Intra-operative surgical exposure left thoracostomy showing the thoracostomy tube inside the let main stem bronchus (black arrow)

through an intercostal tube, numerous techniques of insertion of TT, associated complications and their management have been described.[9] Clinical assessment of tracheobronchial rupture is followed by conservative measures[10] before bronchoscopy and include antibiotic administration, symptoms relief with subcutaneous needle or chest tube to release pneumothorax and avoiding vigorous cough.[1] Fiberoptic bronchoscopy is the best method to confirm the diagnosis and to determine the exact location and extent of the lesion. [8] Anesthetic management should be planned to protect airway, ensure ventilation and to ensure patient’s safety.[11] Anesthetic agents may include opioid, inhalational agent and muscle relaxant. Conventional ventilation using regular ET and positive pressure ventilation will result in air‑leak, inadequate ventilation or total loss of tidal volume including anesthetic gases through the ruptured airway and can potentially result in catastrophic outcome. The airway and ventilation management of patients of TBI is similar to patients with bronchopleural fistula. The injured airway must be bypassed, and the intact airway should be intubated for ventilation. The intact airway can be intubated with a DLT, or an ET; isolation and ventilation using a DLT is the preferred choice. The DLT ensures adequate ventilation, facilitates surgical procedure and avoids high‑pressure on suture lines.[12] The patient should be paralyzed only after confirming isolation and adequate ventilation of the lung associated with the uninjured intact bronchus. The tube position should be confirmed by FOB and by clinical confirmation of isolation of the airway and ventilation of the lung connected to 294

intact airway. Absence of air‑leak from the TT tube and absence of breath sounds during auscultation on the side of injured airway suggests malpositioning of TT tube. In case of failure to secure airway isolation, spontaneous ventilation should be maintained using a single-lumen ET until surgical control of the injured airway is obtained and the airway is isolated. In addition, after thoracotomy, the operating surgeon can guide the placement of single-lumen ET tube in the intact bronchus. Transbronchial approach has been described to provide ventilation during surgery, the surgeon cannulated the left main bronchus through the surgically exposed right main bronchus (internal diameter 5.5‑mm) to maintain oxygenation. [13] High‑frequency jet ventilation has been described in a full‑thickness tear in the tracheal wall with complete disruption of both bronchi. Insertion of two intrabronchial catheters through emergency thoracotomy improved the saturation and provided acceptable oxygenation. This type of ventilation was used during both intra‑and post‑operative settings to avoid high‑positive airway pressures and the need for a cuffed‑ET, which could damage the tracheal suture line.[2] The proper assessment of the patient regarding both clinical and investigational points is a key point in our case. CT demonstrated the severity of the injury, hence cardiac surgical team was alerted, and full preparation of CPB was made as a backup during the removal of the TT. Complex lesions in which both trachea and bronchi are injured pose a great challenge to clinicians, whether or not there is associated great vessel injury. In addition to the technical difficulty in repairing the lesion, inadequate gas exchange and unstable hemodynamics are potential major problems. CPB may be necessary in such situations to provide adequate oxygenation, carbon dioxide removal and circulatory support;[12] however, full anticoagulation for CPB carries additional risk. To summarize, the insertion of a DLT is challenging in the presence of flooding of airway with secretions and clotted blood; use of single‑lumen ET is the option available, the ET tube tip should be placed in the uninjured bronchus under FOB guidance. For adequate management of TBI, early diagnosis and proper management are the keys for good functional recovery. ACKNOWLEDGMENTS We thank Dr. Aser Farghal for critical reading of the manuscript and Dr. Medhat Rashwan for skilled technical assistance Annals of Cardiac Anaesthesia    Vol. 17:4    Sep-Dec-2014

Elgendy and Jilani: Anesthetic management of ruptured left main bronchus

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Cite this article as: Elgendy H, Jilani T. Successful anesthetic management in a child after traumatic rupture of left main bronchus by a single-lumen cuffedendotracheal tube. Ann Card Anaesth 2014;17:292-5. Source of Support: Nil, Conflict of Interest: None declared.

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