One-Lung ventilation could be done in a programme or emerging way in situations that divert the intra-extrathoracic pressures.
Key words: bronchial injury, ventilation
We describe the case of a 66-year-old male patient, ASA II, scheduled for Esophagectomy due to cancer on distal third of esophagus.
After placing a thoracic catheter (T11-T12), a estandar induction sequence was and patient was intubated with a 7,5mm endotracheal tube. Then prone position for a first surgical time which included thoracoscopy and esophageal detachment was set. After 2 hrs End-tidal CO2 increased from 32 mmHg to 144 mmHg with no change in the wape shape. Additionally, peak and plateau pressures decreased from 20 to 15 and 11 to 8 cmH2o respectively, and expiratory volume dropped from 540 ml to 280m1. The rest of parameters (blood oxygen saturation, heart rate, blood pressure and entropy) were unchanged.
Suddenly patients Sa02 fell to 70% and mean blood pressure decreased a 25%, surgeons warn a section in the left main bronchus and decided to convert surgery into a right thoracotomy.
With patient in left lateral decubitus, we decided to perform an urgent selective right bronchus intubation (fibrobronchoscopy- guided) and to establish one-lung ventilation, during the procedure we observed 1 cm disruption with blood remnants in the left bronchus, being difficult to obtain more information. High oxygen concentration and vasoactive drugs were added. Mechanical ventilator’s parameters were modified, we initiate recruitment maneuvers and PEEP of 8cmH2O.
Patient’s hemodinamic and end-tidal CO2 values progressively normalized but Sa02 remains around 85%. After thoracic surgeons repaired the injury by bronchial suturing, we initiated two-lung ventilation, switching from volumen-controlled mode to a pressure-controlled one, with peak pressure of 12 and respiratory frequency of 14, getting a minute volumen around 6L and normalizing Sa02 parameters. With this we could aimed to reduce the possible damage on the recent bronchial suture. Surgery was completed with no other incidents.
At the Intensive care unit and after gasometric controls proving adequate gas exchange, extubation was achieved 44hrs later without incidents.
High values in the end-tidal CO2 (due to a CO2 movement from thoracoscopic field to the ET lumen) associated with sudden decrease in airway pressure suggested a trachea/bronchial rupture.
In emergency situations like disruption in patient’s airway, the urgent one-lung ventilation is an essential, necessary maneuver to guarantee a better ventilation, surgical conditions and probably generates less damage on the affected bronchus.
During bronchial or tracheal lesions, mechanical ventilation plays an important role, as this will be vital in the first postoperative hours. In an intubated patient with an airway injury, controlling the pressures during mechanical ventilation is mandatory and prevents from generating aggression or recurrence as both early extubation and reducing the time during which the newly sutured bronchus receives a positive pressure are crucial.
Double lumen tubes or endobronchial blockers would have been both valid options. We did not change the one-lumen endotracheal tube given the prone position of the patient and the grade of emergency.
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