Technical failure of the EZ‐blocker™ causing serious adverse events during one lung ventilation: a case series

Abstract

Summary We present a case series of intra‐operative adverse events while using a specific type of bronchial blocker, designed to facilitate device positioning and minimise the risk of dislocation. The Rüsch® EZ‐blocker™ (Teleflex Life Sciences Ltd., Athlone, Ireland) is a Y‐shaped catheter equipped with two separately inflatable cuffs at the tip – one for each bronchial lumen. In this report, we describe four cases where the use of the EZ‐blocker was associated with the development of high airway pressures, hypoxaemia and expansion of the non‐dependent lung. Bronchoscopic evaluation showed spontaneous inflation of the cuff within the dependent (i.e. ventilated) bronchus, causing bronchial obstruction, and volume loss of the cuff within the non‐dependent (i.e. unventilated) bronchus, causing unintended expansion of the non‐dependent lung. After removal of the bronchial blocker, the catheter showed no visible defect, but a bench test revealed a functional connection inside the catheter which allowed air to pass slowly from one bronchial cuff to the other. This technical defect relates to the unique design of the EZ‐blocker as it is the only bronchial blocker equipped with two bronchial cuffs. Clinicians should be aware of this inherent risk since complications may develop insidiously and affect both lungs simultaneously. Early recognition and prompt intervention can prevent life‐threatening intra‐operative deterioration.

Forewarned is forearmed: case reports of device failures and improving patient safety

“…Dillemans et al. highlight in many respects the raison d'être of case reports: that forewarned is forearmed [1]. In this case, the previous experience of one operator facilitated the early suspicion and detection of the same issue in a subsequent patient.…”

“…At the ‘global’ level at the top of Figure 1 is ‘letters or reports to journals’, as these reach the greatest number of clinicians in diverse and widespread locations. Case reports of device failures such as the two included in this issue of Anaesthesia Reports facilitate wide communication to the rest of the profession internationally [1, 2]. We congratulate the authors of the two case reports we have referenced for their diligence in reporting their experiences to the readership of this journal.…”

“…Dillemans et al. describe four separate incidents of the same fault in specific type of bronchial blocker [1]. The second report by Mallam et al.…”

Computed tomography confirmation of an interluminal connection in the Rüsch EZ‐blocker™

“…Dillemans et al. describe a series of unexpected adverse events related to the use of the Rüsch EZ‐blocker™ (Teleflex Life Sciences Ltd., Athlone, Ireland), and deduced the existence of a connection or ‘fistula’ between the two bronchial cuff lines through which air can pass from one cuff to the other [1]. When air passed from the inflated bronchial cuff toward the contralateral deflated cuff, the non‐dependent lung became re‐inflated and the ventilation of the dependent lung was partially obstructed.…”

“…through which air can pass from one cuff to the other [1]. When air passed from the inflated bronchial cuff toward the contralateral deflated cuff, the non-dependent lung became re-inflated and the ventilation of the dependent lung was partially obstructed.…”