Intraoperative Respiratory Management of bronchial Compression
and Tracheal Tear due to a Descending Thoracic Aneurysm
Tamara Rice, MD, Felipe Urdaneta, MD
Dept of Anesthesiology, University of Florida
Case Report: A 54 year old man was scheduled for repair of a
Type 2 aortic dissection. His past medical history was
unremarkable except for 25-50 pack-years of smoking. He
presented to an outlying hospital with a 2 day history of
stridor. CT scan revealed an aortic dissection measuring 10 by 8
cm that extended from the level of the arch to the celiac axis
and superior mesenteric arteries. It compressed both the right
and left mainstem bronchi to a 2 mm AP diameter. The patient was
intubated and jet ventilated. He subsequently developed
bilateral pneumothoraces and subcutaneous emphysema from head to
toe requiring bilateral chest tubes.
He was transferred to our institution for definitive treatment.
In the intensive care unit the patient was sedated with propofol
and paralyzed with a vecuronium infusion. Nitroprusside and
esmolol infusions were administered for blood pressure control.
His ventilator settings were SIMV 10, TV 660 ml, CPAP of 5, FIO2
40% with an oxygen saturation of 100%. His blood pressure was
123/61 mm Hg with a heart rate of 80 beats/min. Preoperative
labs were remarkable for a hematocrit of 27.9%, Na+ 140, K+ 3.1,
Cl 108, CO2 22, Bun 27, Cr 1.3 and glucose 123. His arterial
blood gas showed pH 7.37, pCO2 31.4, pO2 137, HCO3 17.8 with a
base deficit of 6.1. Lung exam revealed bilateral equal breath
sounds with crackles.
Anesthetic induction was given with 1 mg of fentanyl, 10 mg of
midazolam and 10 mg of pancuronium. He was continued on
nitroprusside at 1 µg/kg/min and esmolol at 119 µg/kg/min.
Fiberoptic bronchoscopy revealed the trachea was patent to the
carina where the trachea appeared bloody and irregular from the
tip of the endotracheal tube. The left main bronchus was totally
compressed 1-2 cm beyond the carina as was the right mainstem
bronchus, both opened to a 1-2 mm diameter with positive
pressure ventilation. To give the surgeons easier access to the
left chest a bronchial blocker was placed with the fiberoptic
scope with some difficulty; advancing the blocker during
positive pressure breaths. Approximately 2 cm distal to the
compressed left mainstem bronchus, the airway appeared normal,
the bronchial blocker was inflated and the left lung was
deflated uneventfully. A left thoracoabdominal incision was
performed. In the course of repair it was noted that the aortic
dissection had completely eroded through the membranous trachea
at the level of the carina. Ventilation became difficult with
brief desaturation, resolved with dropping bronchial blocker and
ventilation of both lungs. For repair of the tracheal tear the
bronchial blocker was withdrawn and the ETT was advanced into
the right mainstem bronchus under direct visualization from the
surgeon. The operation continued uneventfully with a pericardial
patch repair to the trachea. The patient did well post
operatively and was extubated on POD #1 after bronchoscopy that
revealed complete resolution of bronchial compression. He was
discharged home 9 days after surgery.
Discussion: One lung ventilation for this case could be achieved
with either a left or right-sided double lumen endotracheal tube
or a bronchial blocker. There are advantages and disadvantages
to each method that will be discussed.
