Carinal resection with two high-frequency jet ventilation delivery systems

Abstract

Case report A 76-yr-old man was admitted for investigation of progressive hoarseness and shortness of breath on moderate exertion. Laryngoscopy, bronchoscopy and mediastinoscopy revealed a squamous cell carcinoma of the right vocal cord as well as a squamous cell carcinoma of the carina adjacent to the origin of the left main bronchus. There was a history of cigarette smoking and exposure to coal and gold dust, as well as mild hypertension treated with enalapril 5 mg od. He had undergone abdominal aortic aneurysm repair one year previously.Physical examination was unremarkable. Blood pressure was 130/60 mmHg. Haemoglobin, electrolyte and creatinine concentrations, liver function tests, chest x-ray and ECG were all within normal limits. His preoperative arterial blood gas analysis breathing room air showed: pH 7.44; PCO2 5.06 kPa (38 mmHg); PO2 I0.8 kPa (81 mmHg); HCO3 26 mmol-L -I, 02 sat 96%. Pulmonary function tests revealed a mild to moderate airflow limitation with hyperinflation and also moderate impairment of lung diffusion.It was decided to resect the carinal tumour first, and subsequently to irradiate the laryngeal lesion. The patient was scheduled for excision and reconstruction of the carina through a right posterolateral thoracotomy. Conduct of anaesthesiaThe patient received premedication with glycopyrrolate 0.2 mg ira. Following placement of a lumbar epidural catheter for postoperative analgesia, general anaesthesia was induced with propofol 100 mg and tracheal intubation was facilitated with succinylcholine 120 mg. A #14 F Fogarty occlusion catheter, used as a bronchial blocker, was inserted into the right main bronchus followed by intubation of the trachea with a 9.0 mm endotracheal tube. The position of both was confumed by fibreoptic bronchoscopy.Initally, anaesthesia was maintained with oxygen 40%, N20, halothane, fentanyl 100 Isg and muscle relaxation

High Frequency Jet Ventilation of One Lung using a Bronchial Blocker of Univent during Carinal Resection

“…Bronchial lumen of double lumen tube is used during anastomoses instead of single lumen tube. The second and third one have some disadvantages that the tube may interfere the surgical field and repeated insertion and removal of tube may cause stump injury (2). Fourth, the HFJV can be applied.…”

“…HFJV has been shown to be appropriate in patients with disrupted major airways, including patients with tracheal and bronchial problems (3, 6-8). Because of the continuous high frequency outflow of gases, HFJV provides the surgeon with an uninterrupted surgical field and lessens the risk of aspiration of blood into the airways distal to the resection (2). However, air trapping and barotraumas are potential risks of HFJV (9, 10).…”

“…An attempt to ventilate one lung with high frequency positive pressure ventilator with a single plastic catheter was made by El-Baz et al (11) And simultaneous ventilation of both lungs using two separate catheters, one inserted into each main bronchus, and two ventilators, has been reported by Perera et al (2) However, they pointed out the flexibility of a plastic catheter could cause the difficulty with manipulation.…”

“…It is essential to provide adequate ventilation and oxygenation during airway manipulation without disturbing the surgical field. This may be accomplished using high frequency jet ventilation (HFJV) with a suction catheter (2). This case report describes the successful use of a bronchial blocker of a Univent tube (Fuji Systems Corporation, Japan) for HFJV of one lung in a patient undergoing carinal resection.…”

Resection of Distal Tracheal and Carinal Tumours With the Aid of Cardiopulmonary Bypass

“…It offers distinct advantages to the surgeon, as tubal obstruction is unnecessary and ventilation can be continuous. Moreover, mediastinal motion and risk of aspirating blood into the airways distal to the resection are reduced due to the continuous outflow of gases with the use of HFJV (15). The very high concentration of oxygen insufflated into the airways ensures good oxygenation, but it is not reliably known how carbon dioxide is removed from the airways and whether there may be dangerous periods of hyperapnoea.…”