Nowadays the BBs has become more and more popular for OLV because of advantages over DLT in procedures, such as tracheostomy, intubation for pediatric patients, patients requiring postoperative ventilation, et al [1]. It also possessed some advantages when compared with DLT, including minor airway trauma, less possibility for airway rupture, and lower rate of complications [3, 4]. However, there are a few disadvantages of the BBs tube. The BBs tube requires longer time to intubate and collapse lungs. Malposition, contamination of the healthy lobes, and sewn by stapler are more prone to happen with BBs than DLT. [5–7].
Bronchial obstruction is not a new situation in intubation, which is mostly caused by secretions, pus, mucus plugs, blood clots, malposition of BBs cuff or twist of the tube by oral biting [8, 9]. A small portion of obstructions are caused by tumor embolus, variant bronchus, cuff hyperinflation or malfunction of ET [10–13]. Occlusion caused by the detached balloon cuff is really rare and difficult to be figured out.
In our hospital, the 4.0-mm bronchoscopes are often relatively insufficient to meet a large number of thoracic surgeries. Some anesthesiologists may intubate patients with “blind method”. The position of the BBs has to be confirmed through chest auscultation and clinical confirmation. In most cases, the method is reliable and effective, and the 4.0-mm bronchoscope is unnecessary for adjusting the BBs’ position [14, 15]. In this case, we got a satisfactory surgical field through blind intubation, but we failed to detect the unexpected bronchial obstruction without 4.0-mm bronchoscope timely. In order to prevent this kind of incidents, we should better use the 4.0-mm bronchoscope to monitor the whole BBs tube manipulations, including positioning, inflation, and deflation of the cuff.
It is very hard to explore the cause of middle lobe collapse without bronchoscope. At first, we suspected the middle lobe bronchus was obstructed by sputum, but there was very little secretion in the airway according to the iterative suction. The suction tube passed through the ET without any resistance, so we didn’t realize that it was the problem of a detached BBs cuff. The anesthesiologist confirmed to have deflated the proximal pilot inflator. It is most probable that the balloon cuff failed to deflate because of the mechanical malfunction of BBs device [16]. The cuff completely detached from the BBs catheter, which was withdrawn with extra force. We should be vigilant to avoid violent extubation when greater resistance is encountered. The cuff was coincidentally blown into the middle lobe bronchus by continuous positive airway pressure, which aimed to inflate the collapsed lung. Because of loosely wedge within the bronchus, the cuff just resulted an incomplete obstruction, which made the middle lobe able to inflate slowly. Routine inspection of the integrity of BBs catheter was neglected, otherwise the cuff detachment could be revealed in time. Therefore, it is important to inspect the BBs after removal to ensure the entire blocker has been removed from the patient’s airway. Although the patient had good outcomes, we still need to keep alert of the possibility of such kind of accidents. The balloon cuff might tightly wedge within the ET, and lead to a deadly complete airway obstruction which requires re-intubation in the lateral position. We were professional enough to detect the abnormal phenomenon before the end of surgical procedure, and make an appropriate decision to perform the 6.0-mm bronchoscope timely. The action prevented a serious iatrogenic event which might lead the patient death from happening.
In conclusion, the BBs tube malfunction did not generally appear in modern anesthesia due to strict quality control. Therefore, the cuff detachment might remain unnoticed during routine inspection, as what occurred in this case. We report this case to alert other colleagues that cuff detachment is still a possible event even it rarely happens. We should be vigilant to avoid violent extubation when greater resistance is encountered. It is important to check the BBs apparatus meticulously during the whole operative procedure. Surgeons must be aware of any unusual signs during the procedures of anesthesia and surgery so that undesirable complications could be detected immediately. Because direct visualization could clearly demonstrate the cause, the routine use of 4.0-mm bronchoscope during the entire airway management are highly recommended.