Fluoroscopy-Guided Positioning of the Bronchial Blocker

Dear Sir,

Real-time (RT) fluoroscopy has been available in modern-day hybrid operating rooms. There are reports in the literature describing the use of fluoroscopy for positioning an endobronchial blocker in the pediatric population,[1] intubating the trachea in patients with difficult airway,[2] and endobronchial placement of a single-lumen endotracheal tube in children.[3] We report a case, wherein RT fluoroscopy was successfully used to position the bronchial blocker after failed flexible bronchoscopy (FOB) attempts.

A 31-year-old female patient, with a height of 154 cm presented with chronic cough and dyspnea on exertion for the past year. On evaluation, the patient was found to have adenocarcinoma of the right lower lobe and was posted for lobectomy. General anesthesia was induced with propofol, fentanyl, and vecuronium; a left-sided 35 Fr Mallinckrodt double-lumen endo-bronchial tube (DLT) was inserted but could not be passed beyond the glottis. FOB revealed narrowing of the tracheal lumen distal to vocal cords, suggestive of tracheomalacia. Therefore, the anesthesia team decided to place an endobronchial blocker. A 7.5 mm endotracheal tube was placed under direct laryngoscopy, and a bronchial blocker (COOPDECH™ [Diaken Medical Co. Ltd. Japan.]: Type B, length 600 mm, outer diameter 3 mm) was inserted. However, visualization was very poor with FOB due to thick mucus and bloody secretions. The blocker was advanced blindly, and fluoroscopy was used to visualize the location of the bronchial blocker, which was found to be in the right lower bronchus [Figure 1]. Under RT fluoroscopy guidance, the bronchial blocker was withdrawn and repositioned into the right main stem bronchus [Video 1]. The positioning of the bronchial blocker would not have been possible without RT fluoroscopy guidance.

Figure 1.

Fluoroscopy image of the right hemithorax shows bronchial blocker in the right lower lobe bronchus

FOB is the gold-standard technique for confirming the positioning of the DLT and bronchial blocker.[4] Disadvantages of using FOB are its limited field of vision, image interference from bleeding and secretions, the risk of airway injury, and trauma. Traditionally, the absence of air entry on auscultation was used for confirming the position of DLT, but it is not a reliable method due to variations in the tidal volume, compliance of the chest wall, and noise from the surrounding environment. In recent years, lung ultrasound has emerged as a non-invasive, simple, and effective technique to confirm lung isolation after DLT placement.[5] In our patient, after repositioning the bronchial blocker, lung ultrasound showed the absence of a lung sliding sign, thereby confirming the position of the bronchial blocker.

RT fluoroscopy may be an invaluable tool when confirmation by FOB is difficult due to anatomical deviations in the airway, secretions, and bleeding. The use of RT fluoroscopy in the present case allowed manipulation of the bronchial blocker under direct vision and successful lung isolation.

Declaration of patient consent

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.