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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
   Acknowledgment
    References
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Table of Contents
CASE REPORT  
Year : 2014  |  Volume : 17  |  Issue : 2  |  Page : 164-166
A novel technique to prevent endobronchial spillage during video assisted thoracoscopic lobectomy


1 Medanta Institute of Critical Care and Anaesthesia, Medanta The Medicity, Gurgaon, Haryana, India
2 Department of Minimally Invasive Thoracic Surgery, Medanta The Medicity, Gurgaon, Haryana, India

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Date of Submission06-May-2013
Date of Acceptance29-Oct-2013
Date of Web Publication1-Apr-2014
 

   Abstract 

Endobronchial spillage of fungal material into normal lung can infect it and the spillage of fungal material should be prevented during surgery. We report our experience of a patient who presented for right upper lobectomy with bronchiectasis, tubercular destruction and subsequent aspergilloma. A 4F Fogarty catheter was introduced through the tracheal lumen of the left sided endobronchial double lumen tube (DLT) to occlude the bronchus intermedius to prevent spillage of aspergilloma into the non-infected lower and middle lobes of the right lung. The Fogarty catheter was pulled into the trachea just before stapling the bronchus; thereafter, right upper lobectomy was completed successfully. The patient was extubated uneventfully and transferred to post-operative recovery ward. The endobronchial blockage of the intermediate bronchus of the operative lung by the Fogarty catheter and isolation of the left lung by the DLT prevented spillage of aspergilloma in both the operative right lung and the left lung.

Keywords: Aspergilloma; Fogarty catheter; Lung isolation

How to cite this article:
Sharma A, Sinha S, Khanna S, Mehta Y, Khandelwal S, Khan AZ. A novel technique to prevent endobronchial spillage during video assisted thoracoscopic lobectomy. Ann Card Anaesth 2014;17:164-6

How to cite this URL:
Sharma A, Sinha S, Khanna S, Mehta Y, Khandelwal S, Khan AZ. A novel technique to prevent endobronchial spillage during video assisted thoracoscopic lobectomy. Ann Card Anaesth [serial online] 2014 [cited 2020 Apr 10];17:164-6. Available from: http://www.annals.in/text.asp?2014/17/2/164/129880



   Introduction Top


Lung isolation techniques permit better surgical exposure during thoracic, esophageal, mediastinal and vascular surgery. [1] Proper lung isolation prevents contamination of the contralateral lung by infective secretions. However, with lesions localized to broncho pulmonary segments, there is a risk of spillage to the ipsilateral lung lobe, even when it is collapsed. [2] We describe selective isolation of the right upper lobe by a Fogarty catheter in a patient with pulmonary aspergilloma scheduled for right upper lobectomy.


   Case Report Top


A 28-year-old female of African origin presented with a history of recent onset hemoptysis. She was diagnosed with tuberculosis as a teenager and had received full anti tubercular therapy. She was not dyspneic and her room air blood gases were within normal limits. Pulmonary function tests showed mild obstruction with a significant reversibility. Computed tomography (CT) scan of the chest revealed a partially collapsed right upper lobe with suspected aspergilloma formation in extensive fibro-cavitary tubercular destruction [Figure 1]. The lesion appeared to communicate with the airways. A video assisted thoracoscopic surgical (VATS) right upper lobectomy was scheduled and the patient commenced on intravenous voriconazole, which continued for 4 months. An added possibility of endobronchial spillage of the aspergilloma was considered in the perioperative period due to the cavity's connection with the ipsilateral airways. To reduce the risk, selective isolation of the right upper lobe was planned.
Figure 1: Computed tomography scan image of the aspergilloma

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Following adequate pre-oxygenation, anesthesia was induced with propofol. Atracurium was used to provide neuromuscular blockade and fentanyl for analgesia. A 35 French left sided endobronchial double lumen tube (DLT) was inserted and the lungs ventilated on a mixture of air, oxygen and isoflurane. Fiberoptic bronchoscopy (Olympus BF 3C40) was performed through both the lumens of the DLT to ensure its correct placement. Following confirmation of the DLT position, the right lung was collapsed by clamping the tracheal lumen and limiting ventilation. Separate suction catheters were introduced down each lumen and minimal secretions aspirated. To reduce spillage further in the right lung, a 4F Fogarty catheter was introduced under direct fiberoptic vision in the right main stem bronchus and positioned distal to the opening of the right upper lobe bronchus [Figure 2] and [Figure 3]. Its cuff was inflated with 2 ml of air and an apparent good seal (a snug fit) was observed through the fiberoptic bronchoscope. After positioning of DLT, a large bore intravenous cannula, a central venous line through right internal jugular vein and a left radial arterial line were inserted. Thereafter, the patient was positioned left lateral. The right upper lobectomy was started and prior to bronchial clamping, both right and left lumens were suctioned using separate catheters. This time, copious muco-purulent secretions were aspirated from the right main bronchus above the Fogarty balloon. The latter was then withdrawn under fiberoptic bronchoscopic vision and surgical clamps applied to the right upper lobe bronchus, the right upper lobe bronchus was cut between the clamps and the specimen was delivered. At the end of the surgical procedure, the trachea was extubated. Post-operative analgesia was provided with regular acetaminophen and tramadol was prescribed as rescue analgesic for 48 h. The patient recovered well and was discharged home 5 days after surgery.
Figure 2: The fogarty in position, introduced through the tracheal lumen. Tapes secure the catheter to prevent displacement of the catheter and the inflation syringe to prevent any accidental movement of the plunger

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Figure 3: Final positions of the double lumen tube and fogarty catheter

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   Discussion Top


In infective lesions, lung separation prevents contamination of the contralateral lung. [1] DLTs are the technique of choice in most cases, due to their ease of use and simplicity for alternating between one and two lung ventilation. [3] However, variations in the already asymmetric nature [4] of the airway may hamper satisfactory positioning. Bronchial blockers are useful in conditions of difficult intubation, lung isolation through tracheostomy tubes, selective lobar isolation in bronchopleural fistulae and as rescue devices in poorly positioned DLTs. [1],[3],[5] However, in such situations lung movements continue in the surgical hemithorax, and the positive pressure ventilation in the operative lung can hamper surgery. [6] Blockers also need longer time for placement and have a higher chance of dislodgement. The subsequent lung collapse after blocker positioning is also slow. [1] The Fogarty embolectomy catheter is primarily a vascular tool. However, reports abound of its use in bronchial blockade. [1] It is economic [7] and widely available in our setup and can be positioned under direct vision through a fiberoptic bronchoscope.

The Fogarty catheter has inherent limitations. The high pressure, low volume occlusion balloon cuff and the presence of a stylet increase the risk of airway trauma. To guard against possible injury, we advanced the Fogarty catheter and inflated the cuff under direct vision. The absence of a communicating channel slows lung deflation and does not allow suctioning or oxygen insufflation. Therefore, we commenced lung deflation soon after DLT insertion and introduced the Fogarty prior to surgical positioning to give time for the lung to collapse. There is a constant risk of dislodgement of bronchial blockers and DLTs. Hence, their position was reconfirmed following lateral positioning. Our patient had no history of latex allergy, which would have been a contraindication to Fogarty use.

An aspergilloma is a fungal ball developing in a preexisting lung cavity. [8] Spillage of the aspergilloma in the surrounding healthy lung can disseminate the infection and lead to severe pneumonia, empyema, sepsis and respiratory failure. The patient's CT scan suggested a possible communication between the lesion and the airways. Contamination of the healthy lung under anesthesia and during surgical manipulation was a concern. Although a DLT would have protected the contralateral (left) lung, the ipsilateral middle and lower right lobes needed to be isolated against contamination by the fungal ball in the right upper lobe. Therefore, we decided to place a left sided DLT to isolate both lungs. Once its position was confirmed, we introduced a Fogarty catheter under vision through the tracheal lumen to isolate the right upper lobe bronchus from the rest of the right lung. The combination of a properly positioned DLT with selective bronchial blockade provided flexibility and stability. [6]


   Conclusion Top


A Fogarty catheter can be positioned through a DLT for targeted isolation of lung lobes to limit endobronchial spill of infective secretions. This can reduce the risk of sepsis and promote better post-operative recovery.


   Acknowledgment Top


We would like to thank the patient for consenting to publish this report.

 
   References Top

1.Campos JH. An update on bronchial blockers during lung separation techniques in adults. Anesth Analg 2003;97:1266-74.  Back to cited text no. 1
    
2.Pfitzner J, Peacock MJ, Tsirgiotis E, Walkley IH. Lobectomy for cavitating lung abscess with haemoptysis: Strategy for protecting the contralateral lung and also the non-involved lobe of the ipsilateral lung. Br J Anaesth 2000;85:791-4.  Back to cited text no. 2
    
3.Vretzakis G, Dragoumanis C, Papaziogas B, Mikroulis D. Improved oxygenation during one-lung ventilation achieved with an embolectomy catheter acting as a selective lobar endobronchial blocker. J Cardiothorac Vasc Anesth 2005;19:270-2.  Back to cited text no. 3
    
4.Brodsky JB. Lung separation and the difficult airway. Br J Anaesth 2009;103 Suppl 1:i66-75.  Back to cited text no. 4
    
5.Nino M, Body SC, Hartigan PM. The use of a bronchial blocker to rescue an ill-fitting double-lumen endotracheal tube. Anesth Analg 2000;91:1370-1.  Back to cited text no. 5
    
6.McGlade DP, Slinger PD. The elective combined use of a double lumen tube and endobronchial blocker to provide selective lobar isolation for lung resection following contralateral lobectomy. Anesthesiology 2003;99:1021-2.  Back to cited text no. 6
    
7.Munir MA, Albataineh JI, Jaffar M, Campos JH. An alternative way to use Fogarty balloon catheter for perioperative lung isolation. Anesthesiology 2003;99:240.  Back to cited text no. 7
    
8.Kousha M, Tadi R, Soubani AO. Pulmonary aspergillosis: A clinical review. Eur Respir Rev 2011;20:156-74.  Back to cited text no. 8
    

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Correspondence Address:
Anand Sharma
Medanta Institute of Critical Care and Anaesthesia, Medanta The Medicity, Sector 38, Gurgaon - 122 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.129880

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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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