Temporary solution for one lung ventilation with isolated bronchial blocker of Univent® tube

Corresponding author: Junyong In, M.D., Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, 814, Siksadong, Ilsandong-gu, Goyang 410-773, Korea. Tel: 82-31-961-7875, Fax: 82-31-961-7864, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC One lung ventilation (OLV) is a commonly used technique to accomplish surgical visualization during thoracic surgical procedures, and is often required unexpectedly during surgery. In most cases, OLV is done with through intraoperative tube change, or with various bronchial blockers (BBs) [1,2]. However, if changing the tube is not possible (e.g. active oral bleeding, or severe intraoral edema), or, even worse, if the BBs are not prepared (less prepared conditions, or emergency situations), intermittent two lung ventilation (TLV) or high frequency jet ventilation (HFJV) is the last choice [3]. A 48-year-old (178 cm, 68 kg) man was scheduled for emergency surgical drainage of a deep neck infection. For the postoperative airway management, awake nasal intubation was selected. The oropharyngeal mucous membranes were topically anaesthetized with 4% lidocaine. This was supplemented with shallow sedation using intravenous infusion of dexmedetomidine 1 mcg/kg for 10 minutes. Fiberoptic intubation through the nose was performed with a 7.0 wirereinforced endotracheal tube (ETT). Anesthesia was induced with propofol and vecuronium, maintained with a mixture of desflurane and oxygen (FiO2 0.4) and remifentanil infusion. TLV was started with tidal volume of 10 ml/kg at 12 rates/min. Initial body temperature was 39.0C and peak airway pressure was 18 cmH2O. Because the abscess drainage was not adequate, it was decided to do further drainage through a thoracoscopy. But changing to a double lumen tube (DLT) or a Univent tube (Fuji system corp., Tokyo, Japan) was impossible due to severe intraoral edema. BBs and Fogarty catheter were not prepared. Intermittent TLV was applied initially, but because of the inadequate visualization of the operative field, we tried to use a BB housed in the Univent tube, extracted by cutting the main tube. The BB and the fiberoptic bronchoscopy (FB) were too bulky to enter the ETT together, so after measuring the approximate distance from the orifice of the ETT to the carina and to the left main bronchus with the FB, the BB was inserted blindly. The balloon was inflated incrementally until adequate OLV was confirmed with auscultation. A short corrugated tube was connected to the ETT because the BB was longer than the ETT (Fig. 1). The short corrugated tube was semitransparent