Left main bronchus injury incurred during video double-lumen endobronchial tube intubation: A case report

Abstract

Endotracheal intubation is a basic skill performed by healthcare professionals worldwide which is generally considered safe and effective. Nevertheless, this method is associated with some risks that, can result in significant issues. Double-lumen endobronchial tubes (DLTs) are commonly used in thoracic surgery as the preferred tool for one-lung ventilation. In recent years, visualization technology has highlighted the advantages of video double-lumen endobronchial tubes (VDLTs), leading to their increased clinical use. Nevertheless, the potential safety hazards remain unaddressed. Herein, we report a case of left main bronchus injury during VDLT intubation in a 59-year-old female patient undergoing right upper and lower lobe resection. After smooth intubation with a 35-Fr VDLT, position was confirmed by fiberoptic bronchoscopy. At the end of surgery, a 2-cm laceration was found on the membranous portion of the left main bronchus. The injury was repaired with 4-0 absorbable sutures, and the patient recovered uneventfully and was discharged on day 5. Such complications should be published to share experiences and raise awareness among anesthesiologists and thoracic surgeons, emphasizing that even with advanced visualization, airway injury remains a possible risk factor.

1. Introduction

Endotracheal intubation, while is generally safe and effective, carries a non-negligible risk of airway complications, with an incidence ranging from 0.5% to 7% for both single- and double-lumen tubes. These complications range from minor injuries (e.g., laryngitis and tracheal irritation) to life-threatening conditions, such as tracheobronchial rupture [1]. Airway rupture is rare, but is associated with high morbidity and mortality if not promptly recognized and managed. Double-lumen tubes (DLTs) are the primary option for lung isolation during the perioperative period in clinical practice [2,3]. These devices enable selective one-lung ventilation, which is vital in many thoracic surgeries. Despite their favorable safety profile and ease of use [4,5], DLTs can also induce airway injury. Most injuries, such as laryngitis or tracheal irritation are minor [6,7]. DLTs can result in airway rupture, a catastrophic and potentially fatal complication [8,9].

Recent advances in visualization technology have enhanced anesthesia safety and quality control. VDLTs offer distinct advantages over conventional DLTs, including allowing the real-time visual confirmation of tube position and immediate detection of endobronchial malposition or cuff herniation. Consequently, VDLTs are used more commonly in clinical practice [10]. However, the presence of a built-in camera does not eliminate all risks; airway injury may still occur owing mechanical forces, cuff overdistension, or anatomical vulnerability.

VDLTs increasingly being used and are often perceived as safer; however, whether their use truly lowers the risk of major airway injury is unknown.

Herein, we report a case of bronchial injury during VDLT intubation, aiming to provide a clinical reference and to remind anesthesiologists and thoracic surgeons that vigilance remains essential even when using advanced airway devices. This case shows that video confirmation of tube position does not prevent mechanical or cuff-related injury, a point that has received little attention in earlier reports.

2. Case presentation

Informed consent was obtained from the patient for the publication of this case report and the accompanying images.

The patient was a 59-year-old female (60 kg, 150 cm) with a lung nodule who was scheduled to undergo partial resection of the right upper and lower lobes. She had an unremarkable medical history, and physical examination yielded no significant findings. Preoperative airway evaluation indicated a normal mouth opening and a Mallampati classification of class I [11]. Her American Society of Anesthesiologists (ASA) physical status was also class I [12].

Once informed consent was obtained, the patient was transferred to the operating room. Routine monitoring revealed a heart rate of 60 beats/min, blood pressure of 130/90 mmHg, and peripheral oxygen saturation (SpO₂) of 96%. Anesthesia was induced with intravenous propofol (3 mg/kg), sufentanyl (0.3 μg/kg), and rocuronium (0.6 mg/kg). Following adequate muscle relaxation, a left-sided 35-Fr VDLT was inserted under videolaryngoscopic guidance. The intubation proceeded smoothly, and proper placement of the tube was verified using fiberoptic bronchoscopy.

Subsequently, the patient was placed in the left lateral decubitus position. Fiberoptic bronchoscopy was conducted again to verify tube placement, and one-lung ventilation of the dependent (left) lung was initiated. Intraoperative oxygenation and tidal volume remained adequate throughout the surgery.

At the end of surgery, a minor air leak was observed in the subcarinal region during lung inflation and irrigation. Further exploration revealed exposure of the left main bronchial cuff and a 2 cm laceration on the membranous portion of the left main bronchus (Figure A, B, and C).

Fig. 1.

Intraoperative i of the left main bronchial injury.

We reviewed the operative video and surgical records, confirming that all dissections and lymph node harvests were conducted on the right side. No surgical instrument crossed the midline or touched the left main bronchi. Air leak was initially noticed during lung re-inflation after the wound had been closed, not during dissection. The tear itself was a linear, longitudinal split in the membranous portion, a type of injury typically caused by cuff overdistension or shearing force, rather than by a scalpel or cautery. Accordingly, we attributed the left main bronchus injury to the VDLT, specifically to the combination of anatomical mismatch in a small-statured female with a narrow left main bronchus and unrecognized cuff overdistension, rather than to surgical manipulation.

The surgeon immediately repaired the laceration with 4-0 absorbable sutures. Following repair, the patient was immediately extubated. The patient was made aware of the bronchial injury and repair. She reported no symptoms throughout her recovery period and expressed satisfaction with the information and care provided. The patient was discharged in good condition on postoperative day 5.

3. Discussion

Airway rupture is a rare but potentially catastrophic complication associated with DLTs that, occur during intubation, repositioning, or extubation [13]. The reported incidence of DLT-related airway rupture ranges from 0.19% to 0.26% [14,15]. The membranous section of the trachea lacks cartilaginous support, and is the most commonly injure area [16]. Involvement of the left main bronchus is more common than that of the right, a discrepancy which likely reflects the preferential use of left-sided DLTs given their wider margin of safety [17].

Herein, we present a case of a left main bronchus that occurred during VDLT intubation in a female patient. The patient was only 150 cm tall; such a small body size often associated with a narrower left main bronchus. The standard 35-Fr left-sided DLT designed for the average adult airways likely exerted continuous lateral pressure or shear stress on the relatively fragile membranous portion. In addition, we did not use cuff manometry during positioning or maintenance. Over-inflation of the bronchial cuff, even when the tube is in the correct position, can increase the intramural pressure sufficiently to cause mucosal ischemia and eventual tearing, particularly in the membranous area where support is lacking. This case is consistent with prior findings that women are more susceptible to DLT-related airway rupture because of a weaker membranous airway and smaller bronchial diameter. It further highlights a key limitation of visualization technology: while this technique can confirm the tube position, it does not monitor the cuff pressure or the mechanical fit between the tube and the patient's airway.

The reported risk factors for DLT-related airway rupture can be broadly categorized into patient- and surgery-related factors. Consistent with the predominance of female patients in the published literature, patient factors include female sex, chronic obstructive pulmonary disease, prior chest radiotherapy, and chronic steroid use [13,[18], [19], [20], [21]]. Operation-related factors include the use of a stylet, multiple intubation attempts, difficult intubation, oversized DLT selection, and overdistention of either the tracheal or bronchial cuff [13,18,22].

Although surgical manipulation during lymph node dissection is a recognized cause of airway injury, in the present case, the operative field was strictly limited to the right side and the tear was located on the contralateral left main bronchus. Moreover, air leakage was only detectable post-resection during lung reinflation, making direct surgical injury highly unlikely.

Based on our analysis, we recommend implementing the following measures to reduce the risk of complications in future practice. First, for short-statured female patients (e.g., height < 155 cm), a smaller DLT (e.g., 32-Fr or 28-Fr) should be considered based on preoperative imaging or bronchial diameter estimation. Second, routine cuff manometry should be performed immediately following bronchial cuff inflation, with pressures maintained below 25-30 cm H₂O, regardless of whether conventional or video DLT is used. Third, if an unexplained intraoperative air leak, subcutaneous emphysema, or ventilatory resistance occurs, clinicians should have a low threshold for prompt flexible bronchoscopy, as early detection is paramount to avoid delayed diagnosis and poor outcomes.

Clinicians should further maintain a high index of suspicion for bronchial injury when encountering unexplained intraoperative findings, such as air leak, subcutaneous emphysema, or increased ventilatory resistance. Early bronchoscopic diagnosis is additionally essential for appropriate management, ranging from conservative observation to surgical repair. In the present case, the prompt recognition of the laceration allowed immediate surgical repair using 4-0 absorbable sutures, followed by early extubation and uneventful recovery. This favorable outcome reinforces the principle that once an injury is recognized, timely intervention, whether conservative or surgical, is critical to prevent the progression to mediastinitis, sepsis, or prolonged air leaks.

This case report has several limitations. Firstly, as this was a single case report, our findings may not be applicable to all patients. This case also lacked cuff pressure measurements and postoperative bronchoscopic images to confirm the exact mechanism and healing. Nevertheless, we believe that the case offers a useful reminder that VDLTs do not guarantee safety, and the preventive measures we suggest are practical for routine use.

4. Conclusions

Herein, we report a case of left main bronchial rupture during VDLT intubation in a female patient. Although DLT-related airway injury has been previously reported, the primary distinguishing feature of this case is that the injury occurred despite the use of a VDLT. Most previous reports involved conventional blind placement. Our case demonstrates that real-time visualization confirms the position, but does not eliminate mechanical or cuff-related risks, a point that has not been emphasized in previous reports. Clinicians should remain vigilant regarding intraoperative signs of airway compromise. Early bronchoscopy is indispensable for prompt diagnosis and definitive management.

CRediT authorship contribution statement

Lijie Shi: Writing – review & editing, Writing – original draft. Hui Li: Conceptualization. Yuzhu Zhang: Resources. Nianhai Feng: Conceptualization. Xiaona An: Writing – review & editing, Writing – original draft.

Ethical approval and consent to participate

This case report was performed in compliance with the Declaration of Helsinki. Written informed consent was obtained from the patient for publication of this report and the accompanying figures. Institutional review board approval was waived due to the retrospective and single-case nature of this report.

Funding disclaimer

This research was supported by the Natural Science Foundation of Shandong Province of China (Grant No. ZR2022QH202).

Declaration of competing interests

None to declare.