Single-lung ventilation for right-sleeve pneumonectomy with a modified nasal RAE endotracheal tube.

The patient was a 57-year-old white man (6= 1, 216 lbs) who presented with a dry cough. He had a history of smoking (60 pack years), hypertension, and gastroesophageal reflux disease. A chest computed tomography scan revealed a right mainstem mass (1.25 2.0 cm), nearly obstructing the lumen and extending into the posterior lateral tracheobronchial junction (Fig 1). Biopsy of the lesion confirmed squamous cell carcinoma, but further tests were negative for metastatic disease. After discussing the proposed procedure with the surgeon, it was clear that OLV of the left side would need to be achieved with the narrowest tube possible to facilitate right SP. A modified 6.0-mm NR-ETT (Mallinckrodt Inc, Hazelwood, MO) (Fig 2) was used as an endobronchial tube for lung isolation. To prepare the NR-ETT for the procedure, the authors placed 1-inch adhesive silk tape on the proximal part of the NR-ETT cuff to decrease the cuff-to-tip (C-to-T) distance to 3.5 cm. A silk ligature was tied around the distal end of the adhesive tape. The modified cuff was inflated fully and evenly with 4 to 5 cm of air, and the measured pressure was 25 cmH2O. General anesthesia was induced after placement of a thoracic epidural catheter at the level of the sixth thoracic vertebra. The trachea was then intubated with an 8.0-mm cuffed ETT, and the necessary invasive catheters were placed. Fiberoptic bronchoscopy revealed a right mainstem bronchus mass partially obstructing the lumen at the origin of the right mainstem. Mediastinoscopy was then performed to provide multiple lymph node biopsies, all of which were negative for malignancy. The 8.0-mm ETT was then replaced with the modified NR-ETT. A stylet was placed into the modified NR-ETT to facilitate oral tracheal intubation with direct laryngoscopy. Fiberoptic bronchoscopy (4-mm Olympus Inc, Center Valley, PA) was then used to guide the modified NR-ETT and place its tip 0.5 cm above the most proximal division of the left mainstem bronchus (LMSB). The cuff was inflated with 3 to 4 mL of air, and OLV was successfully achieved as confirmed by chest auscultation and bronchoscopy before and after the patient was placed in the left lateral-dependent position. The tidal volume was set to 500 mL, and the respiratory rate ranged from 12 to 16 breaths/min with an inspiratory-to-expiratory ratio of 1:1.5. Peak airway pressures ranged from 28 to 37 cmH2O, and SpO2 ranged from 96% to 100% throughout the procedure. The chest was entered through the right fourth intercostal space, and, after obtaining the necessary surgical exposure, the stapler (Proximate Linear Stapler 60 mm; Ethicone Endo-Surgery, Inc, Cincinnati, OH) was placed across the right main bronchus at the carina to include the right wall of the distal trachea (Fig 3A). The cuff was deflated, and the modified NR-ETT was withdrawn to the middle of the trachea (Fig 3B). Bronchoscopy confirmed that there was no significant narrowing of the distal trachea into the LMSB. Ventilation was held momentarily until the stapler was deployed; then, ventilation was resumed and the right SP was completed (Fig 3C). At the end of the procedure, the trachea was extubated, and the patient was transferred to the postanesthesia care unit in stable condition. DISCUSSION SP is an uncommon operation in lung cancer surgery. It is a technically demanding procedure that requires careful planning and close communication between the surgeon and the anesthesiologist. In addition to radiologic evaluation of the required resection, bronchoscopy may be necessary to determine the actual anatomy, the extent of the tumor, and the feasibility of the resection. Coordinating OLV and the position of the tube used for ventilation is critical to successful resection while safe and effective ventilation is provided. Although OLV is commonly performed by using a double-lumen endobronchial tube (DLT), it is generally not useful for surgery involving the distal part of the trachea. 3 Several different methods of ventilation and airway management have been proposed. In 1963, Grillo et al 4 advocated intubation of the left mainstem bronchus across the operative field, with sterile tubing passed off to the anesthesiologist. This technique entails a great deal of effort on the part of the surgeon and involves intermittent loss of control of the airway during the switching process. It also adds significant time to the procedure because of the added step of reanastomosis of the trachea to the remaining mainstem bronchus, if required. In the mid-1970s, some anesthesiologists used a standard but uncut long orotracheal tube placed above the tracheal lesion that is merely manipulated by the surgeon past the area of stenosis or mass. 5,6 Although this method is relatively easy to use, the large diameter of a standard tube may traumatize the lesion and cause bleeding or dislodgement of tissue, resulting in further airway obstruction. The technique is also limited to patients with relatively mild stenosis, and the presence of an endotracheal tube may interfere with surgical repair.