A comparison of bronchial blocker under artificial pneumothorax and double-lumen endobronchial tube for lung isolation in thoracoscopic enucleation of oesophageal leiomyoma

Background Oesophageal leiomyomas are one of the most common benign oesophageal tumours. This retrospective, observational study summarized and compared the clinical outcomes of thoracoscopic enucleation of oesophageal leiomyoma between single-lumen endotracheal intubation with a bronchial blocker and double-lumen endotracheal intubation. Methods A total of 36 patients who underwent thoracoscopic enucleation of oesophageal leiomyoma at Peking Union Medical College Hospital between 2014 and 2020 were retrospectively analysed. Fifteen patients received single-lumen endotracheal intubation combined with a right bronchial blocker (SLT-B group), and twenty-one patients received double-lumen endotracheal intubation (DLT group). Clinical data, surgical variables, and postoperative complications were analysed and compared. Results The average tumour size in all patients was 4.3 ± 2.0 cm. The average tumour size among symptomatic patients was significantly larger than that among asymptomatic patients (5.1 ± 2.0 cm vs 3.7 ± 1.7 cm, P < 0.05). Patients in the SLT-B group had a significantly larger average tumour size than patients in the DLT group (5.4 ± 2.1 cm vs 3.5 ± 1.4 cm, P < 0.05). The SLT-B group had a significantly shorter operation time and shorter total hospital stay than the DLT group. No mucosal injury, conversion to thoracotomy, or other operative complications occurred in the SLT-B group. In the follow-up, no recurrence, dysphagia, or regurgitation was found in any of the patients. Conclusions Compared with traditional double-lumen intubation, artificial pneumothorax-assisted single-lumen endotracheal intubation combined with a bronchial blocker for thoracoscopic oesophageal leiomyoma enucleation can achieve complete removal of larger tumours, with fewer complications and shorter hospital stays.

Hypoxemia in Young Children Undergoing One-lung Ventilation: A Retrospective Cohort Study

Background One-lung ventilation in children remains a specialized practice with low case numbers even at tertiary centers, preventing an assessment of best practices. The authors hypothesized that certain case factors may be associated with a higher risk of intraprocedural hypoxemia in children undergoing thoracic surgery and one-lung ventilation. Methods The Multicenter Perioperative Outcomes database and a local quality improvement database were queried for documentation of one-lung ventilation in children 2 months to 3 yr of age inclusive between 2010 and 2020. Patients undergoing vascular or other cardiac procedures were excluded. All records were reviewed electronically for the presence of hypoxemia, oxygen saturation measured by pulse oximetry (Spo2) less than 90% for 3 min or more continuously, and severe hypoxemia, Spo2 less than 90% for 5 min or more continuously during one-lung ventilation. Records were also assessed for hypercarbia, end-tidal CO2 greater than 60 mmHg for 5 min or more or a Paco2 greater than 60 on arterial blood gas. Covariates assessed for association with these outcomes included age, weight, American Society of Anesthesiologists (Schaumburg, Illinois) Physical Status 3 or greater, duration of one-lung ventilation, preoperative Spo2 less than 98%, bronchial blocker versus endobronchial intubation, left operative side, video-assisted thoracoscopic surgery, lower tidal volume ventilation (tidal volume less than or equal to 6 ml/kg plus positive end expiratory pressure greater than or equal to 4 cm H2O for more than 80% of the duration of one-lung ventilation), and type of procedure. Results Three hundred six cases from 15 institutions were included for analysis. Hypoxemia and severe hypoxemia occurred in 81 of 306 (26%) patients and 56 of 306 (18%), respectively. Hypercarbia occurred in 153 of 306 (50%). Factors associated with lower risk of hypoxemia in multivariable analysis included left operative side (odds ratio, 0.45 [95% CI, 0.251 to 0.78]) and bronchial blocker use (odds ratio, 0.351 [95% CI, 0.177 to 0.67]). Additionally, use of a bronchial blocker was associated with a reduced risk of severe hypoxemia (odds ratio, 0.290 [95% CI, 0.125 to 0.62]). Conclusions Use of a bronchial blocker was associated with a lower risk of hypoxemia in young children undergoing one-lung ventilation. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Application of right bronchial blocker under artificial pneumothorax in thoracoscopic enucleation of oesophageal leiomyoma

Background Oesophageal leiomyomas are one of the most common benign oesophageal tumours. This study summarized and analysed the clinical experience of thoracoscopic enucleation of oesophageal leiomyoma. Methods A total of 36 patients who underwent thoracoscopic enucleation of oesophageal leiomyoma at Peking Union Medical College Hospital between 2014 and 2020 were retrospectively analysed. Fifteen patients received single-lumen endotracheal intubation combined with a right bronchial blocker (SLET-B group), and twenty-one patients received double-lumen endotracheal intubation (DLET group). Clinical data, surgical variables, and postoperative complications were analysed and compared. Results The average tumour size in all patients was 4.31 ± 1.96 cm. The average tumour size among symptomatic patients was significantly larger than that among asymptomatic patients (5.08 ± 2.02 vs 3.71 ± 1.72, P < 0.05). Patients in the SLET-B group had a significantly larger average tumour size than patients in the DLET group (5.39 ± 2.13 vs 3.54 ± 1.42, P < 0.05). The SLET-B group had a significantly shorter operation time and shorter total hospital stay than the DLET group. No mucosal injury, conversion to thoracotomy, or other operative complications occurred in the SLET-B group. In the follow-up, no recurrence, dysphagia, or regurgitation was found in any of the patients. Conclusions Compared with traditional double-lumen intubation, artificial pneumothorax-assisted single-lumen endotracheal intubation combined with a bronchial blocker for thoracoscopic oesophageal leiomyoma enucleation can achieve complete removal of larger tumours, with fewer complications and shorter hospital stays.

One Lung Ventilation in a Patient with Central Airway Obstruction: Fluoroscopic Guided Bronchial Blocker Placement

Thyroidectomy is the most common endocrine surgical treatment performed worldwide. Medullary thyroid carcinoma which accounts for less than 1.5 percent of these cases is different from other types of thyroid cancers in a way that it is a neuroendocrine malignancy that originates from the parafollicular C cells of the thyroid gland secreting calcitonin and it frequently spreads to lymph nodes and other organs. Anesthetic management in a case of a large thyroid mass with central airway obstruction is a task cut out for an anesthesiologist and the need to provide one-lung ventilation in these patients for thoracoscopic dissection of mediastinal lymph nodes adds to the challenges. In this case report, we describe fluoroscopic guided bronchial blocker placement as a novel technique for delivering one-lung ventilation in such patients, when the traditional approach of bronchial blocker placement with concomitant use of a fiber optic bronchoscope was not practicable due to the small size of the endotracheal tube in the presence of central airway obstruction.

Difficulty Intubating a Double-Lumen Tube due to a Tracheal Bronchus: A Case Report

Background: Intubation difficulties, hypoxemia, inability to perform a one-lung ventilation, and high airway pressure often occur during double-lumen tube intubation. Tracheal bronchus is a very rare and difficult to find reason. We present a case of tracheal bronchus accidentally discovered during double-lumen tube intubation in a patient undergoing thoracic surgery. We are the first one to summarize the one-lung ventilation strategy for patients with tracheal bronchus. Case Presentation: A 53-year-old man underwent a scheduled thoracoscopic left upper lobectomy. After two unsuccessful attempts to pass the right-sided double-lumen tube through the right mainstem bronchus, fiberoptic bronchoscopy revealed an aberrant tracheal bronchus with an incidence of 0.1%–3%. Finally we used a left-sided DLT to ventilate the right lung. The patient had no airway complications and was discharged 7 days after the operation.Conclusions: This case serves to remind us that preoperative visits must be thorough and careful. Although a computed tomography chest examination was performed before surgery, we just looked at the inspection report and did not look at the images. We also reviewed relevant literature and summarized the one-lung ventilation strategies for patients with tracheal bronchus. For left-lung ventilation, either a left-sided double-lumen tube or a combination of a bronchial blocker and Fogarty artery embolization catheter can be used. For right-lung ventilation, a bronchial blocker or a left-sided double-lumen tube is a good choice.