One-lung ventilation (OLV) for lung surgery remains challenging in patients with difficult airways. Conventionally, OLV is provided with the double-lumen tube (DLT), Univent tube, or bronchial blocker through the oral approach1–3; however, in patients with permanent tracheostomy (such as in cases of total laryngectomy), the conventional airway management technique for OLV becomes limited.4 The available OLV techniques and equipment are described for the oral approach. No dedicated airway management equipment is available specifically for its use through the tracheostomy stoma. Here, we report a successful airway management for OLV in a patient of total laryngectomy by using an endobronchial blocker inserted through adult silicone hyperflex adjustable flange tracheostomy tube (SHATT). This technique has not been described previously in the literature.
A 55-year-old female patient weighing 50 kg and 153 cm tall was diagnosed with lung metastasis and scheduled for lung lobectomy. She underwent total laryngectomy and permanent tracheostomy 4 years previously when she was diagnosed with squamous cell carcinoma of larynx stage T3N1M0. After the surgery, she received radiation therapy. She was on routine follow-up, and 3 months previously, she complained of persistent cough. Chest x-ray revealed a coin-sized lesion in left upper lobe. Findings on positron emission tomography–computed tomography revealed a metastatic mass lesion 1.5 × 1.3 cm in size in the left upper apicoposterior lobe of lung. She was planned for left upper lobectomy and mediastinal lymph node dissection. Patient written consent and authorization were obtained for the publication of the case.
She had a known hypothyroid condition for previous last 4 years and was taking oral thyroxine (50 μg). The results of her laboratory investigations, including hemogram, liver function test, and kidney function test, were normal. On examination, the tracheostomy stoma was healthy. Computed tomography scan revealed no stricture or narrowing at stoma site or in the trachea. She was given oral pantoprazole 40 mg on the morning of surgery. In the operating room, a 5-lead electrocardiogram, noninvasive blood pressure cuff, and pulse oximeter were attached. An 18-G peripheral IV access line was secured. An epidural catheter was placed at T8 to T9 level in left lateral position, and the catheter was secured at 10 cm to the skin. The patient was administered IV fentanyl (50 μg). Lignocaine solution (4%) was applied by an atomizer at the site of the stoma and in the trachea through stoma for topicalization. The SHATT (Portex Bivona® Silicone Tracheostomy tube, size 8-mm internal diameter, Smiths Medical ASD, Inc, Dublin, OH; Figure 1) was inserted gently after lubrication with 2% lignocaine jelly. The patient was preoxygenated with 100% oxygen through the tracheostomy tube.
Anaesthesia was induced with incremental sevoflurane (starting with 1% and increased incrementally to 3%) in oxygen. Once anesthesia was induced, ventilation was ensured by the use of gentle bag ventilation. By using a special 3-part swivel adaptor (Arndt Multi-port Airway Adaptor®, Cook Critical Care, Cook Medical, Bloomington, IN), we performed a fiberoptic bronchoscopy through the tracheostomy tube and positioned it approximately 3 cm above the carina after instilling another 4 mL of 2% lignocaine solution through the scope port. The tracheostomy tube flange was adjusted at stoma and secured tightly. Thereafter, IV propofol (50 mg), fentanyl (50 μg), and vecuronium (5 mg) were administered.
After lung ventilation with 2% sevoflurane in oxygen for 3 minutes, an Arndt Endobronchial Blocker (Cook Medical) was inserted under bronchoscopic guidance by the use of its swivel adaptor and placed in left main bronchus. Its position was confirmed so as to observe the blocker balloon just beyond the carina and blocker fixed and tightened with the connector. The ventilation was continued with 1.5% sevoflurane in oxygen. The ventilator was adjusted on volume-controlled mode with tidal volume of 420 mL, respiratory rate of 12 breaths/min, and inspired fraction of oxygen of 0.5. The patient was positioned in lateral position, and bronchial blocker position was reconfirmed with the use of a flexible fiberscope.
The surgery was started. Before we entered on the thoracic cavity, we initiated OLV by inflating the blocker cuff. The ventilator setting was changed to pressure-controlled mode with inspiratory pressure of 22 mm Hg and respiratory rate of 15 breaths/min. Suction was connected to the bronchial blocker for faster deflation of the lung. Oxygen saturation maintained between 95% and 98% with an inspired fraction of oxygen of 0.6. IV fentanyl and vecuronium boluses were administered as required. Patient remained hemodynamically stable.
After completion of surgery, blocker was removed and 2-lung ventilation was initiated. Total duration of surgery was approximately 250 minutes, with OLV used for approximately 170 minutes. At the end of surgery, patient was turned supine and sevoflurane was discontinued. The bronchial blocker was removed, and ventilatory support was continued through the SHATT. The residual neuromuscular blockade was reversed with IV neostigmine (2.5 mg) and glycopyrrolate (0.4 mg). Once the respiratory effort was adequate, oxygenation was continued with a T-Piece with oxygen flow of 4 L/min through the SHATT. The patient was transferred to the intensive care unit for further management.
Postoperative analgesia was maintained with IV paracetamol (1 g) every 6 hours and epidural morphine (3 mg) every 8 hours for first 2 days and then every 12 hours for next 3 days. The patient remained hemodynamically stable and maintained oxygen saturation. Next day, the patient was transferred to the ward. The SHATT was removed after 3 days, and patient was advised to continue deep breathing exercises along with steam inhalation. The patient was discharged home uneventfully on the fifth postoperative day.
Our patient underwent total laryngectomy and permanent tracheostomy for laryngeal cancer previously. The surgery was followed by radiation therapy, and presently the patient presented with lung metastasis requiring lung lobectomy. Radiation therapy leads to fibrosis of the underlying tissues and thus lesser mobility of tissues, including difficulty in airway manipulation. In the absence of dedicated airway device for providing OLV through tracheostomy stoma, the case was challenging and mandated the assessment of the patient airway clinically and through imaging as well. A proper planning was required for not only airway management technique but also airway device selection.
In thoracic surgeries, DLT remains the gold standard for OLV. In tracheostomized patients, airway management via the use of DLT will be prone to malposition because of its longer size and shortened upper airway because of laryngectomy.1,5 Also, an unusual angle at the site of tracheostomy stoma can make insertion of the DLT difficult and prone for tracheal injury. This will be more of concern for patients who had received radiation therapy. Although a shorter DLT is commercially manufactured, it may not be easily available.6 OLV can be provided with the Univent tube, but its use in tracheostomized patient is related to risk of airway injury (bronchial tearing leading to pneumothorax), difficult placement, and possibility of blocker trapped during surgery.7 The outer diameter of Univent tube is oval shaped and relatively larger and may not fit through the tracheostomy stoma, which increases the possibility of airway morbidity in patients who had received radiation exposure for cancer. The other option is use of single-lumen tracheal tube, which is advanced further to make it endobronchial. This technique remains limited because of risk of kinking, trachea or bronchial trauma, and difficulty in providing effective OLV. These difficulties are related to relatively larger cuff of endotracheal tube, longer length of tube beyond the cuff, and thus difficulty in placement and achieving optimal OLV. Other concerns are risk of right upper lobe obstruction, incomplete collapse of surgical lung, and possibility of lung contamination.
The use of single-lumen tracheal tube or tracheostomy tube along with blocker is an option for OLV through tracheostomy stoma.8,9 Compared with a DLT or Univent tube of the same internal diameter, the endobronchial blocker through the single-lumen endotracheal tube has a smaller external diameter and more flexibility and thus more convenient to fix and reduces the risk of airway morbidity. The use of a conventional endotracheal tube has a risk of kinking because a larger portion of the tube remains outside the airway. The availability of the armoured tube may be alternative to prevent kinking. In both these tubes, however, dislodgement as major portion remains outside the lumen and also difficulty in fixation remains. The longer length of tracheal tube beyond the cuff make narrow margin of safety for endobronchial intubation when cuff is attempted to be kept beyond the tracheostomy stoma.10 This is of more concern if the stoma is lower on the trachea, as may happen in oncology laryngeal surgery. The use of a conventional tracheostomy tube is not suitable for controlled ventilation, and its length cannot be adjusted. This will create difficulty in placement of bronchial blocker. Unlike conventional tracheostomy tubes, SHATT is designed to be adjusted to fit unusual anatomy and is ideal for thick or bull necks and obese and trauma patients. The adjustable neck flange allows for horizontal and vertical modification to obtain the best fit. The adjustable nature of the tube provides a secure airway until a proper length, fixed neck flange tube can be obtained. The long and flexible, wire-reinforced silicone shaft is designed to accommodate difficult airway anatomy, providing a secure airway, intended for improved kink and crush resistance. The silicone tube construction allows the tube to remain flexible in the trachea. These features would be of benefit in preventing airway morbidity in patients who had radiation exposure for cancer management. It has clip-in obturator with hollow tip, allowing for changing of the tube over a guidewire, if tube exchange is required.
We conclude that the use of SHATT may be used along with a bronchial blocker for the provision of OLV in patients with permanent tracheostomy who require OLV for thoracic surgery.
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