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Management of Congenital Lobar Emphysema with Endobronchial Intubation and Controlled Ventilation

Gupta, Ruchi MD; Singhal, S. K. MD; Rattan, K. N. MS; Chhabra, Balbir MD

doi: 10.1213/00000539-199801000-00014
Case Report

Departments of Anesthesiology and Critical Care (Gupta, Singhal, Chhabra) and Pediatric Surgery (Rattan), Pt. B. D. Sharma Post Graduate Institute of Medical Sciences, Rohtak 124 001, India.

Accepted for publication September 9, 1997.

Address correspondence and reprint requests to Dr. Ruchi Gupta, Department of Anesthesiology and Critical Care, Pt. B.D.S. Post Graduate Institute of Medical Sciences, Rohtak-124 001, India.

Congenital lobar emphysema (CLE) is a rare clinical entity that usually presents as acute respiratory distress. This disease is characterized by hyperinflation of one or more lobes of the lung, leading to compression atelectasis on the ipsilateral or contralateral side and mediastinal shift. These, in turn, produce ventilation perfusion mismatch, resulting in hypoxia. There are few case reports of the anesthetic management of these patients [1,2]. In these reports, anesthesia was maintained with either spontaneous or controlled ventilation via an endotracheal tube. We successfully managed two cases of CLE using endobronchial intubation until the resection of affected lobe and controlled ventilation throughout the surgery.

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Case 1

A 7-mo-old infant weighing 6 kg presented with cough, fever, and respiratory distress. Chest radiographs showed right midzonal hyperinflation, slight mediastinal shift, and right upper zone atelectasis (Figure 1). Computed tomography (CT) scan was also diagnostic of CLE (Figure 2). The infant was scheduled for right-sided lobectomy. Preoperative examination revealed a heart rate of 130 bpm, a respiratory rate of 76 breaths/min, presence of intercostal and sternal recession, and hyperresonant percusion on the right side. On auscultation, there were decreased breath sounds on the right side of the chest. The cardiovascular system was normal. Oxygen saturation (SpO2) was 84% in air, but there was no visible cyanosis. Routine hematological and biochemical investigations were within normal limits. Echocardiography ruled out any associated congenital cardiac anomalies.

Figure 1

Figure 1

Figure 2

Figure 2

Oxygen supplementation was given without premedication. An intravenous (IV) infusion of 5% dextrose in 0.225% saline was started at the rate of 10 mL [center dot] kg-1 [center dot] h-1. General anesthesia was induced with 1.5% isoflurane in 100% oxygen. Atropine sulfate 0.2 mg and succinylcholine 12 mg were given IV. Gentle manual ventilation was performed via the face mask, maintaining preparedness for emergency thoracostomy. Left-sided endobronchial intubation was achieved on the first attempt by turning the head to the right side and rotating the tube to 180[degree sign] [3]. The correct placement of the tube was confirmed by auscultation but not by fiberoptic bronchoscopy because of the size of the smallest available fiberoptic scope. During intubation, SpO2 momentarily decreased to 83% and improved to 96% again when controlled ventilation resumed. There were no further significant changes in SpO2 throughout the intraoperative period. Although there was slight tachycardia, other vital signs varied little.

One-lung anesthesia was maintained in left lateral position using 100% oxygen, 0.4%-0.6% isoflurane, 0.3 mg morphine, and 3 mg atracurium, using a Mapleson F circuit with gentle manual ventilation. Monitoring included noninvasive blood pressure, SpO2, electrocardiogram (EKG), ETCO2, temperature, blood loss, and IV fluids. Vital signs were maintained in normal ranges throughout surgery. After resection of the middle lobe, the endotracheal tube was withdrawn into the trachea. At this stage, bilateral lung ventilation was started, using nitrous oxide and oxygen at a ratio of 50:50. At the end of operation, intercostal block was given with 0.125% bupivacaine, and residual neuromuscular block was reversed with neostigmine 0.3 mg and atropine 0.15 mg IV. The infant was tracheally extubated when spontaneous respiration was sufficient to maintain SpO2 >90% in air. Later, the child was kept in an oxygen-enriched environment in the pediatric intensive care unit under continuous SpO2 and EKG monitoring. After 72 h, the chest drain was removed as the residual lung expanded full. The rest of the postoperative period was uneventful, and the child was discharged after 10 days.

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Case 2

A 2-mo-old male baby weighing 3.5 kg presented with difficulty in breathing and nonacceptance of food. The child was initially treated for bronchopneumonia. A chest radiograph showed emphysema of the left upper zone with mediastinal shift to right and right upper lobe atelectasis (Figure 3). A CT scan confirmed the radiographic findings. The patient was scheduled for left upper lobe lobectomy. The preoperative heart rate and respiratory rate were 138 bpm and 48 breaths/min, respectively. Examination revealed intercostal recession and prominence of left side of the chest. On auscultation, there were decreased breath sounds in the right infraclavicular region, and heart sounds were more audible toward the right side. SpO2 was 86% in air, but there was no visible cyanosis. Routine hematological studies, biochemical investigations and echocardiography were normal.

Figure 3

Figure 3

The infant was not given premedication. Induction was performed with 1.2% isoflurane in 100% oxygen. After giving 0.2 mg atropine and 0.5 mg succinylcholine IV, right-sided endobronchial intubation was performed with a 3-mm inner diameter plain endotracheal tube with Murphy's eye. The tube was withdrawn gently to approximate Murphy's eye with right upper lobe bronchus. This manipulation was performed under continuous auscultation and SpO2 monitoring. The SpO2 decreased to 85%, and the heart rate increased to 156 bpm for a short period during the adjustment of the tube; these variables returned to 96% and 140 bpm, respectively, after establishing right-lung ventilation. During this time, we were prepared for emergency thoracostomy, but the need did not arise. Thereafter, one-lung anesthesia was maintained with 0.4%-0.6% isoflurane in 100% oxygen, 0.1 mg morphine, and 1.5 mg atracuium with gentle manual ventilation using Mapleson's F circuit. Once resection of the affected lobe was completed, bilateral lung ventilation using nitrous oxide was started after respositioning the tube into the trachea. The rest of the perioperative period was uneventful, and the child was discharged on 12th post-operative day.

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Discussion

CLE is a complex spectrum of disease caused by hyperaeration of the affected pulmonary lobe by a checkvalve mechanism. It is more common in male than in female patients [1]. The incidence of left upper lobe involvement is 43%, right middle lobe 32%, right upper lobe 20%, and bilateral involvement 20% [4].

The exact etiology of the disease is not known, but several intrinsic and extrinsic causes have been postulated [5]. Presenting features in these infants can be dyspnea, tachypnea, retraction, wheezing, coughing, cyanosis, and asymmetric breath sounds. In these infants, there is increased intrathoracic pressure because of hyperinflation of one or more pulmonary lobes, leading to mediastinal shift and atelectasis of the ipsilateral or contralateral lobes of the lung. This causes displacement of heart sounds, decreased venous return, and varying degrees of ventilation-perfusion mismatch, which leads to hypoxia. Chest radiographs help to diagnose but is not definitive [5]. A CT scan confirms the diagnosis and may rule out associated anomalous vascular slings.

Associated congenital heart disease or vascular anomalies may occur in 12%-14% of these patients [6]. Thus, all patients should have adequate preoperative cardiac evaluation by echocardiography and CT scan. Cardiac catheterization and angiography are necessary in children with known or suspected congenital cardiovascular lesions.

These children may require bronchoscopy for diagnostic purposes or may have definitive surgical resection, which remains the treatment of choice [7]. Pediatric thoracic anesthesia in these cases requires special technical expertise. In the previously described anesthetic management of CLE, patients were tracheally intubated, and spontaneous respiration was maintained until thoractomy and excision of the affected lobe [5]. In small infants, however, spontaneous respiration in the lateral position may not be justified. Further, during intubation with spontaneous respiration, deeper levels of anesthesia are required, which can aggravate the existing hypoxia and can be catastrophic. The risk of aggravation of the CLE and increased hypoxia during induction and intubation can be overcome by gentle manual ventilation using 100% oxygen. Nitrous oxide is contraindicated until resection of the emphysematous lobe. If overinflation of an emphysematous lobe occurs during the period of gentle manual ventilation, then emergency thoracostomy and allowing the affected lobe to herniate through the thoracostomy incision would alleviate the problem.

Hyperinflation of the emphysematous lobe can further be prevented by endobronchial intubation and one-lung anesthesia, which also provide better surgical exposure. However, because of the lack of doublelumen tubes for this age group, endobronchial intubation can be achieved by using endotracheal tubes with or without a bronchial blocker [9]. Both of our patients were endobronchially intubated without the use of bronchial blocker because the other lung was healthy, and absolute isolation was not desirable. The correct endobronchial placement of the tube should be confirmed by fiberoptic broncoscopy, but the smallest size available to us was a 3.5-mm outer diameter scope, so we could not make use of this modality in our patients.

Our experience suggests that in cases of congenital lobar emphysema, endobronchial intubation with gentle ventilation would be a better alternative to spontaneous bilateral lung ventilation. However, the risk of hyperinflation of the emphysematous lobes should be kept in mind when using this alternative, and one should be prepared for emergency thoracostomy.

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REFERENCES

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