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Oo S, Chia RHX, Li Y, Sampath HK, Ang SBL, Paranjothy S, Tam JKC, Lee CCM. Bronchial rupture following endobronchial blocker placement: a case report of a rare, unfortunate complication. BMC Anesthesiol 2021; 21:208. [PMID: 34461826 PMCID: PMC8404020 DOI: 10.1186/s12871-021-01430-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/20/2021] [Indexed: 11/23/2022] Open
Abstract
Background Lung separation may be achieved through the use of double lumen tubes or endobronchial blockers. The use of lung separation techniques carries the risk of airway injuries which range from minor complications like postoperative hoarseness and sore throat to rare and potentially devastating tracheobronchial mucosal injuries like bronchus perforation or rupture. With few case reports to date, bronchial rupture with the use of endobronchial blockers is indeed an overlooked complication. Case presentation A 78-year-old male patient with a left upper lobe lung adenocarcinoma underwent a left upper lobectomy with a Fuji Uniblocker® as the lung separation device. Despite an atraumatic insertion and endobronchial blocker balloon volume within manufacturer specifications, an intraoperative air leak developed, and the patient was found to have sustained a left mainstem bronchus rupture which was successfully repaired and the patient extubated uneventfully. Unfortunately, the patient passed on in-hospital from sepsis and other complications. Conclusion Bronchial rupture is a serious complication of endobronchial blocker use that can carry significant morbidity, and due care should be exercised in its use and placement. Bronchoscopy should be used during insertion, and the volume and pressure of the balloon kept to the minimum required to prevent air leak. Bronchial injury should be considered as a differential in the presence of an unexplained air leak. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01430-6.
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Affiliation(s)
- Shuwen Oo
- Department of Anaesthesia, National University Health System, Singapore, Singapore.
| | - Rachel Hui Xuan Chia
- Department of Anaesthesia, National University Health System, Singapore, Singapore
| | - Yue Li
- Department of Cardiothoracic and Vascular Surgery, National University Health System, Singapore, Singapore.,Department of Cardiothoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Hari Kumar Sampath
- Department of Cardiothoracic and Vascular Surgery, National University Health System, Singapore, Singapore.,Department of Cardiothoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Sophia Bee Leng Ang
- Department of Anaesthesia, National University Health System, Singapore, Singapore
| | - Suresh Paranjothy
- Department of Anaesthesia, National University Health System, Singapore, Singapore
| | - John Kit Chung Tam
- Department of Cardiothoracic and Vascular Surgery, National University Health System, Singapore, Singapore.,Department of Cardiothoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
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Goetschi M, Kemper M, Kleine-Brueggeney M, Dave MH, Weiss M. Inflation volume-balloon diameter and inflation pressure-balloon diameter characteristics of commonly used bronchial blocker balloons for single-lung ventilation in children. Paediatr Anaesth 2021; 31:474-481. [PMID: 33406307 DOI: 10.1111/pan.14123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Balloon-tipped bronchial blocker catheters are widely used in pediatric thoracic anesthesia to establish single-lung ventilation. In clinical practice, their balloons demonstrate sudden expansion when inflated with air. In addition, there are concerns related to the high inflation pressures required to expand the balloons. METHODS This in vitro study assessed inflation volume- and inflation pressure-balloon diameter characteristics of the Fogarty arterial embolectomy catheters and Arndt endobronchial blockers. Balloon diameters were photographically assessed during unrestricted volume- and pressure-guided inflation, using air up to the maximum allowed inflation volume as indicated by the manufacturers. Inflation pressures required to open the blocker balloons and inflation pressures needed to expand them to maximum indicated diameter were measured. RESULTS Volume-guided inflation demonstrated a late acute rise in diameter in Fogarty blocker balloons, whereas in the Arndt endobronchial blocker balloons almost linear inflation volume-to-diameter characteristics were observed. Pressure-guided inflation on the other hand demonstrated low-volume, high-pressure characteristics in the Fogarty blocker balloons, with inflation pressures required to expand the balloons to maximum diameters ranging from (mean (SD)) 636 (75) to 947 (152) cmH2 O. The inflation pressures required to open the Fogarty blocker balloons were even >1000 cmH2 O. Inflation pressures required to expand the 5 F, 7 F, and 9 F Arndt endobronchial blocker balloons to maximum indicated diameter were much lower, namely at 218 (15), 252 (28), and 163 (8) cmH2 O. CONCLUSION Based on these study findings, the balloons of Fogarty arterial embolectomy catheters represent high-pressure devices and do not permit stepwise controlled bronchial blockage. The Arndt endobronchial blockers have some advantages over the Fogarty blocker devices, but also represent high-pressure equipment and must be used with caution and limited duration. Manufacturers are asked to design pediatric endobronchial blocker catheters with truly high-volume, low-pressure balloons in accordance to age-related pediatric airway dimensions.
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Affiliation(s)
- Markus Goetschi
- Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
| | - Michael Kemper
- Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland.,Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | | | - Mital H Dave
- Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
| | - Markus Weiss
- Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
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Goetschi M, Kemper M, Dave MH, Kleine-Brueggeney M, Henze G, Weiss M. Dimensional compatibility of balloon-tipped bronchial blockers with the pediatric airway anatomy using different recommendations for age-related size selection. Paediatr Anaesth 2020; 30:1245-1253. [PMID: 32688433 DOI: 10.1111/pan.13973] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 07/08/2020] [Accepted: 07/13/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Age-related recommendations for size selection of bronchial blocker devices are based on a few dated anatomical autopsy and radiological studies determining lower airway dimensions in children. These recommendations are based on anterior-posterior internal bronchial diameters, which are smaller than the more relevant lateral internal bronchial diameters. METHODS Outer diameters of bronchial blocker balloons inflated with the maximum recommended volume of air were compared to age-related lateral internal bronchial diameters of left and right proximal mainstem bronchi using five different recommendations for age-related size selection of bronchial blocker equipment in children published in the literature. RESULTS The ratio of outer bronchial blocker diameters inflated with the maximal recommended volume of air to the median lateral internal diameters of the proximal mainstem bronchus ranged from 71.4% to 181.8% for the left side and from 61.7% to 162.6% for the right side. There were many settings where the blocker diameters did not reach the median lateral internal diameters of the proximal mainstem bronchus. This was more often observed for the right than for the left side (37 vs 22 settings). CONCLUSION This analysis demonstrates that irrespective of the recommendation for size selection used, neither the two balloon-tipped vascular catheters included nor the Arndt endobronchial blockers are ideal for lung isolation in children are compared with the age-related relevant dimensions of pediatric airway anatomy. A redesign of bronchial blocker equipment with age-related anatomically based high-volume, low-pressure blocker balloons made from ultrathin membranes and with smaller catheters would be desirable.
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Affiliation(s)
- Markus Goetschi
- Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
| | - Michael Kemper
- Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
| | - Mital H Dave
- Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
| | | | - Georg Henze
- Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
| | - Markus Weiss
- Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
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Carassiti M, Cataldo R, Formica D, Massaroni C, De Filippis A, Palermo P, Di Tocco J, Setola R, Valenti C, Schena E. A new pressure guided management tool for epidural space detection: feasibility assessment in a clinical scenario. Minerva Anestesiol 2020; 86. [DOI: 10.23736/s0375-9393.20.14031-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Affiliation(s)
- T Asai
- Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, 2-1-50 Minamikoshigaya, Koshigaya, Saitama 343-8555, Japan
| | - E P O'Sullivan
- Department of Anaesthesia, St James's Hospital, Dublin, Ireland
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Carassiti M, Quarta R, Mattei A, Tesei M, Saccomandi P, Massaroni C, Setola R, Schena E. Ex vivo animal-model assessment of a non-invasive system for loss of resistance detection during epidural blockade. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2018; 2017:759-762. [PMID: 29059983 DOI: 10.1109/embc.2017.8036935] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
During recent decades epidural analgesia has gained widespread recognition in many applications. In this complex procedure, anaesthetist uses a specific needle to inject anesthetic into the epidural space. It is crucial the appropriate insertion of the needle through inhomogeneous tissues placed between the skin and the epidural space to minimize anesthetic-related complications (e.g., nausea, headache, and dural puncture). Usually, anaesthetists perform the procedure without any supporting tools, and stop pushing the syringe when they sense a loss of resistance (LOR). This phenomenon is caused by the physical properties of the epidural space: the needle breaks the ligamentum flavum and reaches the epidural space, in this stage the anaesthetist perceives a LOR because the epidural space is much softer than the ligamentum flavum. To support the clinician in this maneuver we designed a non-invasive system able to detect the LOR by measuring the pressure exerted on the syringe plunger to push the needle up to the epidural space. In a previous work we described the system and its assessment during in vitro tests. This work aims at assessing the feasibility of the system for LOR detection on a more realistic model (ex vivo pig model). The system was assessed by analyzing: its ability to hold a constant value (saturation condition) during the insertion of the needle, and its ability to detect the entrance within the epidural space by a decrease of the system's output. Lastly, the anaesthetist was asked to assess how the ex vivo procedure mimics a clinical scenario. The system reached the saturation condition during the needle insertion; this feature is critical to avoid false positive during the procedure. However, it was not easy to detect the entrance within the epidural space due to its small volume in the animal model. Lastly, the practitioner found real the model, and performed the procedures in a conventional manner because the system did not influence his actions.
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Rispoli M, Zani G, Bizzarri F, Nespoli MR, Mattiacci DM, Agnoletti V, Fiorelli A, Corcione A, Buono S. Bronchial blocker positioning: learning curve and confidence in its use. Minerva Anestesiol 2018; 84:1254-1260. [PMID: 29343044 DOI: 10.23736/s0375-9393.18.12390-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite being simple and safe to use and cheap, EZ blocker (EZB) remains underused probably because it requires particular skills in recognizing airway and in using fiber-bronchoscopy to check the exact position of their cuffs. Thus, we planned an education training program on the use of EZB for novices in anesthesia and evaluated the number of procedures required for the acquisition of the skills of this technique. METHODS The educational training program included three different phases as follows. The first phase included a lecture on the utility of one-lung ventilation in thoracic surgery, on the use of the fiber- bronchoscopy and on the characteristics of EZB. The second phase consisted in a practical teaching course performed on a manikin model to acquire the skills in EZB. The third phase was a clinical training where each participant performed a defined number in patients scheduled for thoracic surgery procedures. The acquisition of dexterity and satisfaction were then statistically valuated. RESULTS The dexterity in placing EZB significantly increased after six attempts (P<0.1). Participants acquired skills in correcting position EZB after 15 attempts. Participants increased their level of confidence with EZB (score 5.7±1.3) and were highly satisfied with the training received (score 5.8±1.6). CONCLUSIONS EZB is a valid strategy for obtaining one lung ventilation. Thus, it should be included in the armamentarium of all anesthetists interested in the field of thoracic surgery. Our teaching course seems to be a valuable method to instill easily and speedily in training novices in anesthesia the skills in placing EZB.
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Affiliation(s)
- Marco Rispoli
- Anesthesia and Intensive Care, Vincenzo Monaldi Hospital, Naples, Italy -
| | - Gianluca Zani
- Anesthesia and Intensive Care, Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Federico Bizzarri
- Anesthesia and Intensive Care, Arcispedale S. Maria Nuova Hospital, Reggio Emilia, Italy
| | - Moana R Nespoli
- Anesthesia and Intensive Care, Vincenzo Monaldi Hospital, Naples, Italy
| | - Dario M Mattiacci
- Anesthesia and Intensive Care, Vincenzo Monaldi Hospital, Naples, Italy
| | - Vanni Agnoletti
- Anesthesia and Intensive Care, Arcispedale S. Maria Nuova Hospital, Reggio Emilia, Italy
| | - Alfonso Fiorelli
- Unit of Thoracic Surgery, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio Corcione
- Anesthesia and Intensive Care, Vincenzo Monaldi Hospital, Naples, Italy
| | - Salvatore Buono
- Anesthesia and Intensive Care, Vincenzo Monaldi Hospital, Naples, Italy
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Carassiti M, Mattei A, Quarta R, Massaroni C, Saccomandi P, Tesei M, Setola R, Schena E. A New Pressure Guided Management Tool for Epidural Space Detection: Feasibility Assessment on a Simulator. Artif Organs 2017; 41:E320-E325. [DOI: 10.1111/aor.13007] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 07/07/2017] [Accepted: 07/10/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Massimiliano Carassiti
- Unit of Anesthesia, Intensive Care, and Pain Management, Department of Medicine; Università Campus Bio-Medico di Roma; Rome Italy
| | - Alessia Mattei
- Unit of Anesthesia, Intensive Care, and Pain Management, Department of Medicine; Università Campus Bio-Medico di Roma; Rome Italy
| | - Rossella Quarta
- Unit of Anesthesia, Intensive Care, and Pain Management, Department of Medicine; Università Campus Bio-Medico di Roma; Rome Italy
| | - Carlo Massaroni
- Unit of Measurements and Biomedical Instrumentation; Università Campus Bio-Medico di Roma; Rome Italy
| | - Paola Saccomandi
- Unit of Measurements and Biomedical Instrumentation; Università Campus Bio-Medico di Roma; Rome Italy
| | - Marco Tesei
- Unit of Automatics, Center for Integrated Research; Università Campus Bio-Medico di Roma; Rome Italy
| | - Roberto Setola
- Unit of Automatics, Center for Integrated Research; Università Campus Bio-Medico di Roma; Rome Italy
| | - Emiliano Schena
- Unit of Measurements and Biomedical Instrumentation; Università Campus Bio-Medico di Roma; Rome Italy
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