Case report
Single-lung ventilation with bronchofibroscopy during lung resection surgery
Oxigenación unilobar con fibroscopio durante cirugía de resección pulmonar
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A propósito de un caso" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1155 "Ancho" => 1267 "Tamanyo" => 252936 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Ultrasound view of the left inguinal canal.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "B.A. Rivas Rivero, A. Mira Puerto, J. Cuenca" "autores" => array:3 [ 0 => array:2 [ "nombre" => "B.A." "apellidos" => "Rivas Rivero" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Mira Puerto" ] 2 => array:2 [ "nombre" => "J." 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Cimadevilla Calvo, C. López Sánchez, J.M. Rabanal LLevot, L. Sánchez Moreno" "autores" => array:4 [ 0 => array:4 [ "nombre" => "B." "apellidos" => "Cimadevilla Calvo" "email" => array:1 [ 0 => "drbcimadevilla@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C." "apellidos" => "López Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "J.M." "apellidos" => "Rabanal LLevot" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "L." "apellidos" => "Sánchez Moreno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía Torácica, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Oxigenación unilobar con fibroscopio durante cirugía de resección pulmonar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 614 "Ancho" => 1267 "Tamanyo" => 121883 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Oxygenation of the right upper lobe during right middle lobe surgery. (A) View from lower chamber. (B) View from upper chamber.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Lung isolation is needed in thoracic surgery to allow the surgeon to visualise and manipulate the operative lung. While insertion of a double lumen tube (DLT) is the standard technique, the use of bronchial blockers (BB) is becoming more common.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A common problem during one-lung ventilation (OLV) is hypoxaemia, particularly in patients with reduced pulmonary function reserve. Approximately 5–10% of patients who survive lobectomy or pneumonectomy due to lung cancer develop secondary lung cancer within 5 years that often requires reintervention, sometimes involving resection of the contralateral lung. These patients cannot usually tolerate OLV and develop hypoxaemia. Several techniques are available to address this situation.</p><p id="par0015" class="elsevierStylePara elsevierViewall">First, lobe-selective bronchial blockade can be achieved by inserting a BB through a DLT or single lumen tube.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">1,2</span></a> However, BBs can only be used when a fiberoptic bronchoscope wide enough to accommodate the device is available, and the technique requires extensive training and excellent knowledge of the anatomy of the bronchial tree. BBs are also more expensive than DLTs, take longer to collapse the lung, and sometimes need to be repositioned several times during surgery. For these reasons, they are not available in all hospitals.</p><p id="par0020" class="elsevierStylePara elsevierViewall">A second option is the administration of continuous positive airway pressure through the blocked branch of the DLT. This, however, can obstruct video-assisted thoracoscopy (VATS), and usually requires reconversion to thoracotomy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The third option is to ventilate the spared lobe of the operated lung in order to increase the surface area available for gas exchange while minimising interference with the surgical field. This allows lung resection to be performed using VATS. To achieve this, we have devised a novel technique that involves administering O<span class="elsevierStyleInf">2</span> in the target lobe via the working channel of a flexible fibreoptic bronchoscope connected to a source of O<span class="elsevierStyleInf">2</span>. Gas is delivered at a flow rate of between 2 and 3<span class="elsevierStyleHsp" style=""></span>L, depending on the target peripheral oxygen saturation (SpO<span class="elsevierStyleInf">2</span>).</p><p id="par0030" class="elsevierStylePara elsevierViewall">We describe a clinical case in which this technique was used successfully in a patient with previous lung resection of the left upper lobe. The patient had been programmed for VATS resection of the right middle lobe (RML) due to tumour recurrence, and was unable to tolerate OLV.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0035" class="elsevierStylePara elsevierViewall">A 66-year-old man with a surgical history of left upper lobectomy plus lymphadenectomy 1 year previously due to squamous cell carcinoma pT1 N2, stage IIIA, had been diagnosed with recurrence in the RML in the latest follow-up. The patient was scheduled to undergo right middle lobectomy with VATS in the thoracic surgery operating room.</p><p id="par0040" class="elsevierStylePara elsevierViewall">His personal history was: no known allergies; ex-smoker of half a pack of cigarretes per day; percutaneous transluminal coronary angioplasty with stent 1 year previously. Background treatment: Adiro 100<span class="elsevierStyleSup">®</span>, bisoprolol 2.5<span class="elsevierStyleHsp" style=""></span>mg, atorvastatin 20, omeprazole and paracetamol/tramadol.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Additional studies included a high definition chest CT scan that showed changes secondary to upper left lobectomy; prevascular, bilateral paratracheal, subcarinal and prevascular mediastinal lymph nodes with no changes with respect to the previous study; normal cardiothoracic index, normal calibre aorta and pulmonary artery; stent in right coronary artery; middle lobe lesion showing slightly increased size and spiculation with respect to the previous study; no pleural effusion. Lung function tests showed: FVC 4.8<span class="elsevierStyleHsp" style=""></span>L (139.1%), FEV1 3.62<span class="elsevierStyleHsp" style=""></span>L/s (134%), ratio: 75.42%.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Once in the operating room, with baseline SpO<span class="elsevierStyleInf">2</span> of 94%, sinus rhythm at 63<span class="elsevierStyleHsp" style=""></span>bpm and blood pressure 150.82<span class="elsevierStyleHsp" style=""></span>mmHg, standard monitoring was performed. Before anaesthesia induction, the patient was preoxygenated for 5<span class="elsevierStyleHsp" style=""></span>min with FiO<span class="elsevierStyleInf">2</span> of 1, which increase SpO<span class="elsevierStyleInf">2</span> to 99%. After this, anaesthesia was induced with propofol (50<span class="elsevierStyleHsp" style=""></span>mg<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>125<span class="elsevierStyleHsp" style=""></span>mg), fentanyl (100<span class="elsevierStyleHsp" style=""></span>mcg), rocuronium (10<span class="elsevierStyleHsp" style=""></span>mg), and succinylcholine (100<span class="elsevierStyleHsp" style=""></span>mg). Face mask ventilation (Han grade III) was difficult, but intubation (Cormack–Lehane grade I) with a left 39 Fr DLT was easy. A dual catheter was placed in the right subclavian vein, the left radial artery, and a second 16G-gauge peripheral line was placed in the right arm. In addition, a right paravertebral catheter was placed at the level of T6. Anaesthesia was maintained with boluses of desflurane, remifentanil and rocuronium.</p><p id="par0055" class="elsevierStylePara elsevierViewall">OLV was started with SatO<span class="elsevierStyleInf">2</span> at 99% and EtCO<span class="elsevierStyleInf">2</span> at 35<span class="elsevierStyleHsp" style=""></span>mmHg in bipulmonary ventilation (BPV). Five minutes later, SatO<span class="elsevierStyleInf">2</span> fell to 84%, forcing us to return to BPV with FiO<span class="elsevierStyleInf">2</span> of 1. Pulmonary recruitment manoeuvres were performed, which brought SatO<span class="elsevierStyleInf">2</span> up to 100% with FiO<span class="elsevierStyleInf">2</span> of 0.8. After the third attempt of OLV with FiO<span class="elsevierStyleInf">2</span> of 1, it was clear that the patient would not tolerate OLV. Faced with this situation, we considered several options. On the one hand, a BB in the RML. This was ruled out, as there were no BBs available in our hospital. As a second option, we considered administering continuous positive airway pressure through the tracheal portion of the DLT. This is the most commonly used technique in our service in patients that do not tolerate OLV; however, it can obstruct VATS, and usually requires a thoracotomy. The third option, and the one we ultimately chose, was to use the right upper lobe (RUL) to increase the gas exchange surface area while minimising interference with the surgical field. This allowed us to continue with VATS lobectomy. To achieve this, we tested a novel technique that involves administering O<span class="elsevierStyleInf">2</span> in the RUL lobe via the working channel of a flexible fibreoptic bronchoscope inserted in the RUL bronchus and connected to a source of O<span class="elsevierStyleInf">2</span>. Gas was delivered at a flow rate of between 2 and 3<span class="elsevierStyleHsp" style=""></span>L (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). With the bronchoscope in place, the patient's SpO<span class="elsevierStyleInf">2</span> of 90%, increased to 92% after starting delivery of O<span class="elsevierStyleInf">2</span> through the working channel. During the rest of the intervention, while maintaining OLV, SpO<span class="elsevierStyleInf">2</span> ranged from 92% to 93% without interfering at any time with the VATS RML resection plus lymphadenectomy, and without the need to reposition the bronchoscope. The rest of the surgery was uneventful.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">An increasing number of patients require further thoracic surgery after undergoing lobectomy. Considering that lung function is reduced by around 23.8% after left upper lobectomy,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> it stands to reason that a patient requiring pulmonary resection in the contralateral lung will develope hypoxaemia during OLV. In addition, overloading the ventilated lung that already lost volume after the first surgery increases the risk of baro or volotrauma, and may trigger acute lung injury.</p><p id="par0065" class="elsevierStylePara elsevierViewall">There a several options available to prevent hypoxaemia in these patients or others with advanced lung disease that requires pulmonary resection surgery. However, the best strategy will depend on the availability of certain airway devices, or the experience of the anaesthesiologist.</p><p id="par0070" class="elsevierStylePara elsevierViewall">A useful technique is lobe-selective bronchial blockade using a BB, provided these devices are available, the operator is skilled in the use of a fibreoptic bronchoscope, and has a good understanding of bronchial anatomy. However, BBs often become dislodged, usually as a result of surgical manoeuvres, and lung deflation takes longer, since resistance to outflow/aspiration is much greater than with a DLT. If, for example, the operated lung needs to be ventilated to check the safety of the bronchial sutures and then re-blocked, it is sometimes necessary to reposition the BB and wait for lung deflation again. This manoeuvre is much faster and simpler with a DLT.</p><p id="par0075" class="elsevierStylePara elsevierViewall">To overcome these obstacles, we propose this novel one-lung oxygenation technique in which oxygen is delivered to one of the spared lobes of the operated lung. To achieve this, the fibreoptic bronchoscope is introduced into the spared lobe and low-flow oxygen is administered through the working channel.</p><p id="par0080" class="elsevierStylePara elsevierViewall">We believe that this technique has several advantages over BBs, including faster lung collapse, since a DLT is used; greater aspiration power and large calibre aspiration tubes, given the size of the DLT – a particular advantage in patients with secretions and in case of intrapulmonary bleeding; intralobar placement of the fibreoptic bronchoscope is technically easier than placement of the BB, especially in certain positions such as URL; the bronchoscope is less likely to migrate and need repositioning than the BB because it is not placed in the operated lobe; and finally, the flow of oxygen through the working channel of the fibreoptic bronchoscope can be varied according to the needs of the patient.</p><p id="par0085" class="elsevierStylePara elsevierViewall">However, there are several factors that need further investigation in order to optimise their benefits and detect potential risks. These include the potential for the bronchoscope to cause injury in the bronchial tree if left in place for a prolonged period of time; the factors that can lead to the clinical or technical failure of the procedure; the maximum oxygen flow that can be used without causing injury distal to gas administration; and determining which lobe is best to use in the case of right lobe resections.</p><p id="par0090" class="elsevierStylePara elsevierViewall">We believe this single-lobe oxygen therapy technique to be satisfactory, since it did not interfere with the surgical field, and allowed us to perform VATS lobectomy (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Furthermore, it was not necessary to interrupt surgery at any time to reposition the bronchoscope, and we did not observe any perioperative complications related to the technique. We believe, therefore, that this may be a simple alternative to traditional DLT lung isolation in patients with low functional reserve.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1092849" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1035705" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1092850" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1035706" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-11-26" "fechaAceptado" => "2018-02-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1035705" "palabras" => array:4 [ 0 => "Unilobar oxygenation" 1 => "Oxygenation with bronchofibroscopy" 2 => "Lung resection surgery" 3 => "One lung ventilation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1035706" "palabras" => array:4 [ 0 => "Oxigenación unilobar" 1 => "Oxigenación con fibrobroncoscopio" 2 => "Cirugía de resección pulmonar" 3 => "Ventilación unipulmonar" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lung isolation using one-lung ventilation is common during thoracic surgery procedures, as it allows proper visualisation and manipulation of the lung to be operated on. Selective lobar blockade has been described in patients that do not tolerate one-lung ventilation, and is usually achieved using endobronchial blockers. However, it depends on endobronchial blocker availability, its complexity regarding proper positioning, and the need for constant monitoring to ensure the correct placement of the bronchial seal.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">In the clinical case to be described, a new method was used to increase the available surface for oxygen exchange. This was accomplished by means of direct supply of oxygen through the bronchoscope's working channel to one of the not-to-be operated-on, non-ventilated lung lobes. With this technique, the surgeon had an optimal operating field, oxygenation from one-lung ventilation improved and no perioperative complications were found.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">El aislamiento pulmonar mediante ventilación unipulmonar es frecuente en procedimientos de cirugía torácica, ya que permite una mejor visualización y manipulación del pulmón a intervenir. El bloqueo lobar selectivo está descrito en pacientes que no toleran la ventilación unipulmonar y se suele realizar por medio del bloqueador bronquial. Sin embargo, su realización está condicionada por la necesidad de disponer de dicho bloqueador, por la complejidad para su correcta colocación y la necesidad de vigilancia intensiva para asegurar la adecuada colocación del sellado bronquial.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">En el caso que presentamos hemos aplicado una técnica novedosa para aumentar la superficie de intercambio de oxígeno. Se ha logrado mediante la administración directa de este por el canal del fibrobroncoscopio a uno de los lóbulos no ventilados no objeto de la cirugía. Mediante esta técnica, el cirujano se benefició de un campo quirúrgico óptimo, se mejoró la hipoxemia de la ventilación unipulmonar y no se observó ninguna complicación perioperatoria.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cimadevilla Calvo B, López Sánchez C, Rabanal LLevot JM, Sánchez Moreno L. Oxigenación unilobar con fibroscopio durante cirugía de resección pulmonar. Rev Esp Anestesiol Reanim. 2018;65:461–464.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 768 "Ancho" => 950 "Tamanyo" => 72120 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Oxygen supply connected to the working channel of the bronchofibroscope.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 614 "Ancho" => 1267 "Tamanyo" => 121883 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Oxygenation of the right upper lobe during right middle lobe surgery. (A) View from lower chamber. (B) View from upper chamber.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aislamiento pulmonar en pacientes con resecciones pulmonares previas: bloqueo lobular selectivo secuencial con bloqueador bronquial Fuji Uniblocker<span class="elsevierStyleSup">®</span>" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "O. Valencia Orgaza" 1 => "M.I. Real Navacerrada" 2 => "M. Cortés Guerrero" 3 => "A.F. García Gutierrez" 4 => "C. Marrón Fernández" 5 => "F. 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