Management of bronchopleural fistula using a modified single lumen tube

provided the original work is properly cited. CC Bronchopleural fistula (BPF) is defined as a pathologic connection between the tracheobronchial tree and the pleural space with persistent air leak for more than 24 hours. It is associated with poor prognosis after pneumonectomy [1], which mainly contributes to the occurrence among elective lung resections despite the outstanding advances in surgical techniques. Mechanical ventilation is always problematic for balancing the actual ventilation and the leakage in patients who present a BPF after pulmonary resections. High airway pressure to achieve sufficient minute ventilation may aggravate air leakage and interfere the healing process [2]. We describe a case in which a modified single-lumen endobronchial tube was used in a patient who developed BPF after right lower lung lobectomy in order to improve ventilation and allow adequate suctioning. A 71-year-old man (159 cm, 48.4 kg) underwent a videoassisted right lower lung lobectomy with mediastinal lymph node dissection for surgical resection of non-small-cell lung cancer. The patient had a previous history of hypertension, diabetes mellitus, chronic renal failure and hepatitis B virus-related cryptogenic liver cirrhosis. His postoperative course was complicated by persistent air leak through the chest tube. After pleurodesis failed to seal the air leak, serial radiographs had been worsened despite the trial of both antibacterial agents and percutaneous catheter drainage (PCD). A large air leak continued during both inspiration and expiration, combined with dyspnea and producing yellowish sputum. Bronchoscopy and computed tomography (CT) scan showed a definite BPF on the right lower lobar bronchus. Due to recurrent desaturation and failed interventions (PCD repositioning), open window thoracostomy (Eloesser operation) was performed under one-lung ventilation. On POD 1 after the Eloesser operation, he could not maintain the extubated state and developed aggravating dyspnea and worsening hypoxemia. A 35 French (Fr) left sided double-lumen endotracheal tube was placed and its position was confirmed by bronchoscopy. The left lung was ventilated with nitrous oxide (NO) mixed with air using the synchronized intermittent mandatory ventilation mode with a tidal volume of 270 ml. Continuous oxygen flow at 8 L/min was applied to the right lung. The patient required frequent tube suctioning. Intravenous midazolam and cisatracurium were infused continuously. Arterial blood gases analysis showed slight improvement afterwards, but worsened over the following 3 days. On POD 4, the patient showed progressive hypoxemia (SpO2 91%). Suctioning or manual ventilation with self-inflating resuscitation bag was ineffective. We assessed that the double lumen tube was too narrow to remove the discharges because bronchoscopy showed a thick purulent plug blocking the whole lumen. The tube was changed to a 7.5 mm single-lumen tube. A thin and long catheter was placed for oxygen supply (5 L/ min) and frequent suctioning (Fig. 1A). The next day, massive air leaks were evident, severely impairing effective ventilation: delivered tidal volumes were 200 ml. Bronchoscopy showed that the stump site fistula was exposed and a purulent discharge was flowing over from the right to the left main bronchus. Lung separation was definitely needed, but double lumen tube was not suitable due to productive discharges. Advancing the singlelumen tube would provide both successful lung separation and deep site accessibility (Fig. 1B). Commercial ready-made tubes did not satisfy the purpose; thus, we made a specially devised