July 2005 - The Hong Kong College of Anaesthesiologists

Bull HK Coll Anaesthesiol Volume 14, Number 2 July 2005Novel Use of Endobronchial Tube in Management ofa Patient with Giant Lung BullaLance S.K. Chua, T.Y. Chan, W.M. Chan, Richard G.B. OoiDepartment of Anaesthesia, Intensive Care and Operating Theatre Services, Yan Chai HospitalSUMMARYThe management of a patient with anticipated difficult airway and a giant lung bulla in the right upper lobe,presenting with respiratory failure is described. Ventilation of the patient’s lungs was facilitated by isolation ofthe right‐upper lobe using a left sided double‐lumen endobronchial tube.Keywords: Giant lung bulla; Anesthetic equipment; Intubating laryngeal mask airway; Double lumentubes; Selective ventilation.Bull HK Coll Anaesthesiol 2005;14:101‐5Double lumen endobronchial tracheal tube(DLT) placement is a technique employedfor isolation or independent ventilation ofthe lungs. These tubes are designed to minimizeoccluding the upper lobe of the endobronchial side.Anatomically, the right upper lobe is particularlysusceptible and consequently right sided DLT’shave an additional opening in the endobronchialcuff to ensure right upper lobe ventilation.However, we encounter a situation where it wastherapeutic to occlude the right upper lobe, whileallowing the middle and lower lobes to beventilated, using a DLT designed for leftendobronchial placement.1MBBS, HKCA, FHKAM (Anaesthesiology), MedicalOfficer, 2 MB BS, FHKCA, FHKAM (Anaesthesiology),FANZCA, Consultant. 3MBBS, FHKCP,MRCP,FHKAM (Medicine), Senior Medical Officer,4MBBS, FRCA, FHKCA, FHKAM (Anaesthesiology),Senior Medical Officer. Department of AnaesthesiaIntensive Care and Operating Theatre Services, YanChai Hospital, Tsuen Wan.Address correspondence to: Dr Lance Chua, PrivatePractice, E‐mail: lordelk@gmail.comCase PresentationA 65 year old male (60 kg) presented to theIntensive Care Unit (ICU) with respiratory failuresecondary to pneumonia. He suffered fromnasopharyngeal carcinoma ten years previouslyand had been treated with nasopharyngectomyand radiotherapy. He also had a history ofprevious pulmonary tuberculosis and chronicobstructive pulmonary disease (COPD),complicated by a giant bulla in the right upper lobezone.On admission to ICU, he was obtunded and inrespiratory distress. His respiratory rate was 38min ‐1 , arterial blood pressure was 100/70 and heartrate was 100 min ‐1 . His electrocardiogram showedsinus rhythm without cor pulmonale or evidence ofacute ischemia. His arterial blood gas resultsshowed type II respiratory failure with carbondioxide tension of 13 kPa. His chest radiograph(CXR) revealed a right giant bulla occupying half ofthe hemithorax and dense haziness in the left lungfield and remaining right lung, in addition tounderlying COPD changes (Figure 1).A decision was made to initiate mechanicalventilation and assessment of his airway suggested101