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Table of Contents
Year : 2020  |  Volume : 23  |  Issue : 2  |  Page : 249
Preoperative bronchoscopy before lung isolation: Look before you leap

Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India

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Date of Submission03-Aug-2018
Date of Decision07-Oct-2018
Date of Acceptance26-Oct-2018
Date of Web Publication07-Apr-2020

How to cite this article:
Doctor JR, Solanki SL, Kapila SJ. Preoperative bronchoscopy before lung isolation: Look before you leap. Ann Card Anaesth 2020;23:249

How to cite this URL:
Doctor JR, Solanki SL, Kapila SJ. Preoperative bronchoscopy before lung isolation: Look before you leap. Ann Card Anaesth [serial online] 2020 [cited 2022 Aug 8];23:249. Available from:

The Editor,

A 62-year-old man having a carcinoid tumor involving the left main bronchus planned for a left-sided pneumonectomy. The tumor was arising from the left main bronchus approximately 1 cm from carina. Lung perfusion scan of this patient showed 94.3% perfusion on the right side with upper, middle, and lower lobes contributing 17.5%, 49.2%, and 27.7%, respectively. The left lung contributed to only 5.7% of perfusion. The predicted postoperative forced expiratory volume in the 1st s after a left pneumonectomy was 1.74 L.

After placement of a thoracic epidural catheter and attachment of standard American society of Anesthesiologists monitoring, the patient was preoxygenated, and anesthesia was induced with intravenous propofol, fentanyl, and rocuronium. A right-sided 37 F double-lumen tube (DLT) was inserted under direct laryngoscopy. The position of the DLT was then confirmed by conventional auscultation method and using a pediatric fiberoptic bronchoscope. On auscultation, there was no air entry on the left side and also in the right upper lobe area. On fiberoptic bronchoscopic confirmation, DLT was placed in the right main bronchus which bifurcates into middle and lower lobe bronchus. The right upper lobe bronchus was arising directly from the trachea with a view of carinal trifurcation [Figure 1].
Figure 1:Carinal trifurcation with right upper lobe bronchus arising from the trachea

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The presence of a congenital anomaly of the central airway can be of great significance to anesthesiologist. The most common anomaly is a tracheal bronchus that supplies the right upper lobe and which is reported to be present in 0.1%–5% of the population.[1],[2] Three different types (Type I–III) of anomalies have been described with respect to tracheal bronchus.[3] Type III variety with carinal trifurcation presents the maximum challenges when anesthesia with one lung ventilation is contemplated.[3],[4] The anatomical variation prevents the use of DLT for one-lung ventilation.

In our case, the correct placement of DLT was not possible because right upper lobe was not getting ventilated. A bronchial blocker on the left side was also not possible as the mass was too close to the carina in the left main bronchus. We successfully and uneventfully conducted the case after removal of the DLT and reintubating with 8 mm single lumen cuffed endotracheal tube and using low tidal volume ventilation. The soiling of the right lung was prevented by repeated suctioning of the airway, and an attempt was made to clamp the left main bronchus as early as possible.

Our purpose of reporting this case was to highlight the importance of seeing the preoperative bronchoscopy or reconstructing the virtual bronchoscopy images from the preoperative computed tomography scan if the software is available, before planning one lung anesthesia. This can definitely help in the better planning of anesthetic management in such cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed

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Conflicts of interest

There are no conflicts of interest.

   References Top

Barat M, Konrad HR. Tracheal bronchus. Am J Otolaryngol 1987;8:118-22.  Back to cited text no. 1
Lee DK, Kim YM, Kim HZ, Lim SH. Right upper lobe tracheal bronchus: Anesthetic challenge in one-lung ventilated patients – A report of three cases. Korean J Anesthesiol 2013;64:448-50.  Back to cited text no. 2
Conacher ID. Implications of a tracheal bronchus for adult anaesthetic practice. Br J Anaesth 2000;85:317-20.  Back to cited text no. 3
Yoshimura T, Ueda KI, Kakinuma A, Nakata Y. Difficulty in placement of a left-sided double-lumen tube due to aberrant tracheobronchial anatomy. J Clin Anesth 2013;25:413-6.  Back to cited text no. 4

Correspondence Address:
Jeson R Doctor
Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Dr. E. Borges Marg, Parel, Mumbai - 400 012, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aca.ACA_154_18

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  [Figure 1]