(Chest. 2001;120:1399-1402.)
© 2001
American College of Chest Physicians
First Experience With Fiberoptically Directed Wire-Guided Endobronchial Blockade in Severe Pulmonary Bleeding in an Emergency Setting*
Barbara Kabon, MD;
Barbara Waltl, MD;
Johannes Leitgeb, MD;
Stephan Kapral, MD and
Michael Zimpfer, MD
*
From the Department of Anesthesiology and General Intensive Care (Drs. Kabon, Waltl, Kapral, and Zimpfer) and the Department of Traumatology (Dr. Leitgeb), University of Vienna, Austria.
Correspondence to: Barbara Kabon, MD, Department of Anesthesiology and General Intensive Care, University Hospital of Vienna, 18–20 Waehringer Guertel, A-1090 Vienna, Austria; e-mail: barbara.kabon{at}univie.ac.at
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Abstract
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We report the first use of a new wire-guided endobronchial blocker
in a critical respiratory situation caused by localized pulmonary
bleeding. During emergency management, it became increasingly difficult
to ventilate a multiple-trauma patient with a conventional single-lumen
tube because of massive bleeding through the bronchus of the left lower
lobe. Using the Arndt endobronchial blocker set (William Cook Europe
A/S; Bjaeverskor, Denmark), we were able to prevent the spread of
hemorrhaging and achieved effective ventilation and marked improvement
in gas exchange. This new device allows the effective blockade of an
isolated lobe under direct bronchoscopy to buy time for further
intervention.
Key Words: blockade of segmental bronchus • blunt thoracic trauma • intrabronchial hemorrhage • wire-guided endobronchial blocker
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Introduction
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Thoracic
injuries contribute importantly to the morbidity and mortality of
trauma patients1
2
; in Europe, the overall mortality rate
following blunt thoracic trauma is about 25%.1
There, the
majority of thoracic injuries are not penetrating injuries but rather
predominantly are caused by rapid deceleration and most often affect
young individuals.3
Blunt thoracic trauma is rarely an
isolated occurrence; most frequently, it is accompanied by severe
extrathoracic damage.
Massive blunt chest trauma may cause fractures of the thoracic
skeleton, pneumothorax and hemothorax, contusions or lacerations of the
pulmonary parenchyma, damage to the tracheobronchial tree,
diaphragmatic rupture, or cardiac contusion. Severe hemorrhage into the
tracheobronchial system and concomitant progressive failure of
mechanical ventilation with elevated peak airway pressure is a
life-threatening complication following blunt thoracic trauma. Only
immediate diagnosis and repair can avert mortality due to
asphyxia.1
At present, the management of tracheobronchial hemorrhage includes
suctioning through an endotracheal tube and fiberoptic bronchoscopy
with aspiration of tracheal secretions and blood. However, severe
bleeding in the airway can soil the entire lung, leading to hypoxemia.
In these cases lung isolation is indicated. This usually is undertaken
with double-lumen endotracheal tubes inserted selectively into the
mainstem bronchus, although Fogarty embolectomy catheters also have
been used as blockers.2
4
The control of major bleeding
may require emergency thoracotomy, and immediate lobectomy or
crossclamp resections may be indicated to isolate the injured areas of
the lung. For all of these interventions, adequate mechanical
ventilation and sufficient oxygenation are essential.
We report on the occlusion of the damaged bronchus and containment of
localized pulmonary bleeding using a new device designed to perform
single-lung ventilation without needing to use a double-lumen tube, as
described by Arndt et al.5
6
7
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Case Report
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After a deceleration injury caused by a fall from a building of
15 m, a 45-year-old man (body weight, 85 kg) was admitted to the
emergency department. Emergency orotracheal intubation with a
conventional 8.5-mm single-lumen tube had been performed at the site of
the accident. Cardiopulmonary resuscitation was underway when the
patient was admitted to the hospital. The patient was in shock
secondary to the chest trauma, was hemodynamically unstable, and was
pulseless; the ECG showed wide complex bradycardia. During controlled
mechanical ventilation with elevated peak pressure, the patient
experienced severe respiratory failure. Clinical investigation and a
frontal supine chest radiograph revealed multiple rib fractures and
traumatic left tension hemopneumothorax. A left chest tube was
immediately inserted, and the patient’s clinical situation improved at
once. Routine monitoring showed a rise in arterial BP and oxygen
saturation and sinus tachycardia of about 160 beats/min. The initial
arterial blood gas sample showed the following (Table 1
): pH, 7.138; PO2, 218 mm Hg;
PCO2, 49 mm Hg; and hematocrit, 31%.
A severe pelvic fracture exposed during clinical examination was
confirmed by radiograph. Clinical signs of abdominal bleeding prompted
an ultrasound investigation, but no evidence of pathology was found.
The patient received midazolam, sufentanil, and vecuronium infusions.
After placement of a 12-F central venous catheter via the left
subclavian vein, rapid restoration of circulating volume was started
with crystalloid and colloid solutions, hypertonic hydroxyethyl starch,
and packed O-negative erythrocytes by means of a rapid infusion system
(Level 1; SIMS Smith Industries; Rockland, MA).
Coagulopathy necessitated the transfusion of fresh-frozen
plasma, and, because of hypocoagulation, balanced treatment with single
components was administered after the correction of antithrombin III
levels. The hemodynamic parameters improved, and adequate oxygen
saturation was achieved by maintaining the fraction of inspired oxygen
at > 0.75. Peak airway pressures were limited to normal ranges with
a positive end-expiratory pressure of 8 cm
H2O and a 1:1 inspiration/expiration ratio (Table 1)
. Direct suction through an endotracheal tube yielded a negligible
amount of hemorrhagic mucus.
After the initial stabilization and adequate resuscitation of the
patient, thoracic (Fig 1
) and abdominal spiral CT scans were performed and the following
conditions were revealed: a residual intrathoracal hemorrhage on the
left side dorsally; laceration of the left kidney and the spleen; and
major retroperitoneal bleeding. During the CT scan, the scanner for
which is located in our emergency department area, the cardiopulmonary
condition of the patient deteriorated. A second chest tube was
inserted, and 1,500 mL sanguineous fluid was drained. Simultaneously,
there was massive bleeding through the endotracheal tube. The patient
was started on dopamine and adrenaline infusions to maintain a mean BP
at 70 mm Hg and was given aggressive ventilation support with a peak
airway pressure of > 45 mm H2O. Frequent
arterial blood gas measurements recorded a much increased carbon
dioxide tension (about 70 mm Hg) and a continuous fall in arterial
oxygenation to < 50% saturation (Table 1)
. Suction through a
conventional tube did not yield any improvement. Fiberoptic
bronchoscopy showed the cause of the raised airway pressure to be
hemorrhaging through the bronchus of the left lower lobe into the
entire tracheobronchial system. Endobronchial blockade was indicated to
isolate the affected lobe.
We decided to use the Arndt endobronchial blocker set (AEBS) [William
Cook Europe A/S; Bjaeverskor, Denmark], which consists of a special
endobronchial blocker (a 9F, 70-cm catheter with a 3-cm elliptical,
low-pressure, high-volume balloon at the distal end and a wire-guided
loop) that is employed in conjunction with a conventional endotracheal
tube, a fiberoptic bronchoscope, and a multiport airway adapter. The
ports and their configuration allow the blocker and bronchoscope to be
inserted while simultaneously maintaining uninterrupted ventilation.
The wire-guided loop links the blocker to the fiberoptic bronchoscope
to visually guide the placement of the balloon. We coupled a 3.5-mm
pediatric fiberoptic bronchoscope (model BF, type 3 C 30; Olympus;
Tokyo, Japan) to the blocker through the guide loop and inserted them
through the left mainstem bronchus into the left lower segmental
bronchus. The blocker was advanced until it exited the bronchoscope,
which then was retracted into the trachea (Fig 2
). The balloon was inflated with 7 mL air to totally occlude the
segmental bronchus, and lavage of the remaining airway was performed.
After this procedure, tidal volumes increased significantly, gas
exchange improved markedly (Table 1)
, oxygen saturation returned to
92%, and further emergency management was possible.
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Figure 2.. With the help of the multiport adapter, the
endobronchial blocker was inserted into the left inferior bronchus
through a single-lumen tube. After the elliptical balloon at the distal
end was inflated, the further spread of the hemorrhage was prevented.
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Continued abdominal bleeding and the results of the CT scan indicated
the need for an emergency laparotomy. During surgery, the patient once
again bled through the left mainstem bronchus. As evidenced by
bronchoscopy, this bleeding was triggered by another focus of
parenchymal contusion located in the left upper lobe. The blocker was
pulled back into the left mainstem bronchus under direct vision, and,
as opposed to the previous approach, one-lung ventilation was
successfully performed yielding an oxygen saturation level of about
90%. At the same time, however, sustained hemorrhagic shock occurred
as a result of the massive abdominal and retroperitoneal bleeding.
Thus, the patient died intraoperatively due to circulatory arrest
despite the fact that continued resuscitation was maintained and every
effort to assure adequate perfusion with ventilation was made.
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Discussion
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A new device described by Arndt et al5
6
7
for use in
single-lung ventilation with single-lumen intubation proved to be an
appropriate tool in an emergency situation brought about by severe
pulmonary bleeding after blunt thoracic trauma. Originally, the AEBS
was intended for endobronchial blockade of either lung in procedures
requiring one-lung ventilation when placement of double-lumen
endotracheal tubes or Inoue tubes (Univent; VITAID Medical Products;
Lewiston, NY) was reported to be technically impractical or connected
with high risk.5
6
7
The AEBS is used in conjunction with a
pediatric bronchoscope or intubating fiberoptic laryngoscope, allowing
for visualization to aid the timely and precise placement of the
endobronchial blocker.
To our knowledge, this case report deals with the first successful
application of this device in isolating a localized intrabronchial
hemorrhage during the emergency management of a multiple-trauma patient
who had suffered critical respiratory failure while conventionally
ventilated with a single-lumen tube.
The patient developed an elevation in airway pressure with subsequent
life-threatening hypoxemia due to bleeding through the left lower lobe
bronchus, which spread throughout the entire tracheobronchial tree. As
all attempts at endotracheal suction and bronchoscopic lavage failed, a
lung-isolating procedure was indicated. The aim was to select a safe
and rapid technique for securing the airway and isolating the bleeding
parts of the lung. For this purpose, it is common to use a double-lumen
endobronchial tube (eg, a Univent tube or an 8–14 Fogarty
occlusion catheter) to achieve endobronchial
blockade.2
4
8
9
10
There are drawbacks to these procedures. The application of a
double-lumen tube under direct laryngoscopy can be hazardous in
emergency cases because of the concomitant cardiopulmonary instability
and the high risk of aspiration. In addition, trauma cases frequently
are associated with cervical spine injuries, maxillofacial fractures,
or intracranial hemorrhaging, which can complicate airway management
because of immobilization in the occipitoatlantoaxial complex, the
traumatized airway, and elevated intracranial pressure. In order to
avoid hazardous and demanding airway manipulation, an endobronchial
blockade using the single-lumen endotracheal tube already in place must
be considered the procedure of first choice. The drawback to the
Univent tube is that it significantly reduces the inner diameter of the
tracheal tube, resulting in increased airway pressure.11
Positioning an 8–14 Fogarty occlusion catheter, even if the technique
has been modified to place the catheter coaxially with a fiberoptic
bronchoscope, can be considerably more difficult than placing a
wire-guided blocker catheter.9
10
Furthermore, the
spherical balloon was designed for vascular embolectomy, not for airway
blockade, and, consequently, its contact with the bronchial wall is
suboptimal. Finally, current bronchoscopy ports have proved to be an
imperfect means of securing the blocker in place, and dislocation
during surgical manipulation is likely.
The AEBS was designed to overcome these drawbacks of the current
endobronchial blocker technology5
6
7
(Figs 3
,
4
). For the indication of intrabronchial hemorrhage, the fiberoptically
wire-guided direction of the blocker allows it to be placed visually in
any part of the bronchial system or near the ostium of a single lung
segment. Removal of the wire after placement provides a lumen for
manipulation within the blocked area. After selective isolation of a
single lobe, the remaining parts of the lung are endoscopically cleared
and suctioned. Finally, because a single lobe can be targeted, the
improvements in gas exchange can be greater than if an entire lung is
isolated.
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Figure 3.. The multiport airway adapter, which consists of a
connector to lock the blocker in place and maintain an air-tight seal
(1) and allows introduction of the bronchoscope (2) and the blocker
while simultaneously maintaining ventilation (3). The endobronchial
blocker uses a guide loop assembly to fiberoptically guide the
placement of the balloon (4).
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It must be emphasized that the emergency airway management that we have
reported on here does not represent a curative method but should be
understood as an appropriate procedure to gain time to perform or
complete urgent interventions. Thus, it may serve as a bridge to
emergency surgery, such as laparotomy or thoracotomy and lobectomy.
In the present case, we gained 45 min after the blockade of the lower
lobe and another 20 min after blockade of the left mainstem bronchus,
during which we ensured sufficient ventilation. There are no studies at
present on the use of this technique in similar emergency situations,
but our experience prompts us to recommend it as an alternative that is
well-suited to be performed with the currently used methods of airway
management in the presence of severe pulmonary hemorrhage.
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Figure 4.. The 3-cm elliptical, low-pressure, high-volume
balloon is designed for adequate contact with the bronchial wall. The
wire loop for the fiberoptic guidance of the endobronchial blocker also
is shown.
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Acknowledgements
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We thank Jane Neuda for editorial assistance.
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Footnotes
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Abbreviation: AEBS = Arndt endobronchial blocker set
Received for publication November 11, 2000.
Accepted for publication March 19, 2001.
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References
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Castelli, I, Schläpfer, R, Stulz, P (1995) Das Thoraxtrauma. Anaesthesist 44,513-530[CrossRef][ISI][Medline]
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Devitt, JH, McLean, RF, Koch, JP (1991) Anesthetic management of acute blunt thoracic trauma. Can J Anaesth 38,506-510
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Kapral, S, Mauritz, W (1999) Polytrauma: definition und pathopysiologie. VanAken, H Reinhart, K Zimpfer, M eds. Ains Band 2 Intensivmedizin ,1194-1214 Thieme Stuttgard, Germany.
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Glinz, W (1990) Evaluation of thoracic injuries. Border, JR eds. Blunt multiple trauma: comprehensive pathophysiology and care ,391-408 Marcel Dekker New York, NY.
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Arndt, GA, Kranner, PW, Rusy, DA, et al (1999) Single-lung ventilation in a critically ill patient using a fiberoptically directed wire-guided endobronchial blocker. Anesthesiology 90,1484-1486[CrossRef][ISI][Medline]
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Arndt, GA, Buchika, S, Kranner, PW, et al (1999) Wire-guided endobronchial blockade in a patient with a limited mouth opening. Can J Anaesth 46,87-89[Abstract/Free Full Text]
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Arndt, GA, DeLessio, ST, Kranner, PW, et al (1999) One-lung ventilation when intubation is difficult: presentation of a new endobronchial blocker Acta Anaesthesiol Scand 43,356-358[CrossRef][ISI][Medline]
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Inoue, H, Shohtsu, A, Ogawa, J, et al (1984) Endotracheal tube with movable blocker to prevent aspiration of intratracheal bleeding. Ann Thorac Surg 37,497-499[Abstract]
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Larson, CE (1990) A device for endobronchial blocker placement during one-lung anesthesia [letter] Anesth Analg 71,311-312[Free Full Text]
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Arndt, GA, Kranner, PW, Lorenz, DC (1994) Axial placement of an endobronchial blocker [letter] Can J Anaesth 41,1126-1127[Free Full Text]
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Slinger, PD, Lesiuk, L (1998) Flow resistances of disposable double-lumen, single-lumen, and Univent tubes. J Cardiothorac Vasc Anesth 12,142-144[CrossRef][ISI][Medline]
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Abstract
Introduction
