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Failure to Isolate the Right Lung with an EZ-Blocker

Obaidi, Rafee A. MD; O’Hear, Kelley E. MD; Kulkarni, Vivek N. MD; Brodsky, Jay B. MD; Shrager, Joe B. MD

doi: 10.1213/XAA.0000000000000056
Letters to the Editor: Letter to the Editor
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Department of Anesthesiology, Perioperative & Pain Medicine, Stanford University School of Medicine, Stanford, California, Jbrodsky@stanford.edu

Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California

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To the Editor

We previously described the use of a single bronchial blocker (EZ-Blocker, Teleflex, Raleigh, NC) to isolate and collapse both lungs during the same procedure.1 We have since cared for a patient in whom the left lung was successfully collapsed but the right lung was not due to the presence of a tracheal bronchus.

Both written and verbal permission to publish this report have been obtained from the patient.

In a 75-year-old man scheduled for resection of an anterior mediastinal tumor via sternotomy, after the patient’s trachea was intubated with an 8.5-mm internal diameter endotracheal tube, an EZ-Blocker was introduced via a multiport adaptor and slowly advanced until resistance was encountered. Fiberoptic bronchoscopy demonstrated that both blocker extensions were deployed, 1 in each main bronchus. The balloon on left main bronchus extension was inflated under direct vision (Figure 1A). The left lung subsequently collapsed enabling dissection of the left side of the mass. Following deflation of the balloon and reexpansion of the left lung, the balloon on the extension to the right lung was then inflated. However, while the right middle and right lower lobes appeared to collapse, the right upper lobe remained expanded. Bronchoscopy revealed a previously unrecognized bronchial orifice on the lateral wall of the trachea slightly above the carina (Figure 1B). The EZ-Blocker was removed, and the endotracheal tube was exchanged for a 39-F left double-lumen tube. The tracheal lumen was clamped, and only the left lung was ventilated. The right lung completely collapsed, and the operation was completed without further incident.

Figure 1

Figure 1

The EZ-Blocker is a 650-mm-long 7-F polyurethane catheter that separates at its distal end into 2 symmetrical 40-mm-long extensions. When properly positioned, the Y engages the tracheal carina, with 1 extension deployed in each main bronchus. Each extension has an inflatable color-coded balloon so either or both lungs can be blocked with a single EZ-Blocker.1 The proximal edge of each balloon is 6 mm below the Y separation2 (Figure 2).

Figure 2

Figure 2

A tracheal bronchus is a congenital anatomic variant found in 1% to 2% of patients during routine bronchoscopy.3 The right upper lobe bronchus can originate from the right lateral wall of the trachea at the level of the carina to as much as 6 cm above the carina. When the anomalous bronchus is at the carina the condition is termed a trifurcate carina. A trifurcate carina divides into 3 divisions: a left main bronchus, a right bronchus intermedius, and a right upper lobe bronchus. The presence of a tracheal bronchus makes lung isolation with a double-lumen tube or any bronchial blocker difficult.4,5

When properly seated, the inflated blocker balloon on each extension of the EZ-Blocker will be 6 mm below the carina. Although this will not present a problem with the relatively long left main bronchus, right balloon will fail to block the orifice to the right upper lobe when the right main bronchus is very short or absent. We found that the EZ-Blocker cannot be used to isolate the right lung in the presence of a trifurcate carina as occurred in our patient.

Rafee A. Obaidi, MD

Kelley E. O’Hear, MD

Vivek N. Kulkarni, MD

Jay B. Brodsky, MD

Department of Anesthesiology, Perioperative & Pain Medicine

Joe B. Shrager, MD

Department of Cardiothoracic Surgery

Stanford University School of Medicine

Stanford, California

Jbrodsky@stanford.edu

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REFERENCES

1. Brodsky JB, Tzabazis A, Basarab-Tung J, Shrager JB. Sequential bilateral lung isolation with a single bronchial blocker. A & A Case Reports. 2013;1:17–8
2. Mungroop HE, Wai PT, Morei MN, Loef BG, Epema AH. Lung isolation with a new Y-shaped endobronchial blocking device, the EZ-Blocker. Br J Anaesth. 2010;104:119–20
3. Dave MH, Gerber A, Bailey M, Gysin C, Hoeve H, Hammer J, Nicolai T, Weiss M. The prevalence of tracheal bronchus in pediatric patients undergoing rigid bronchoscopy. J Bronchology Interv Pulmonol. 2014;21:26–31
4. Stene R, Rose M, Weinger MB, Benumof JL, Harrell J. Bronchial trifurcation at the carina complicating use of a double-lumen tracheal tube. Anesthesiology. 1994;80:1162–4
5. Peragallo RA, Swenson JD. Congenital tracheal bronchus: the inability to isolate the right lung with a univent bronchial blocker tube. Anesth Analg. 2000;91:300–1
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