The Incidence of Tracheal Bronchus in Thoracic Surgery Patients and Its Implication for Lung Isolation: A Retrospective Cohort Study

Anesthetic Management of One-Lung Ventilation in Patients With Tracheal Bronchus: A Narrative Review

Tracheal bronchus is a rare congenital tracheal abnormality that generally refers to the right upper lobe bronchus of the lung that originates from the trachea. Tracheal bronchus is usually asymptomatic and is often accidentally detected by fiberoptic bronchoscopy or computed tomography for other conditions. Depending on the location of the tracheal bronchial opening and possible anatomical variations, the management of 1-lung ventilation in patients with tracheal bronchus is a significant challenge for anesthesiologists. To provide a reference for anesthesiologists to better manage anesthesia in such patients, we review the pathophysiology, definition, and Conacher classification of tracheal bronchus and then discuss the diagnosis of tracheal bronchus and management of 1-lung ventilation during anesthesia according to the Conacher classification.

Forty days old infant with Pig Bronchus, presenting with recurrent pneumonia: A Case Report

Background

Pig bronchus is rare and usually asymptomatic, but it may also cause significant respiratory symptoms such as recurrent pneumonia, chronic bronchitis, atelectasis, and difficult airway management in surgical and critical care patients. This study is aimed to examine a case of pig bronchus in which the patient presented with recurrent pneumonia in her early days of life.

Case Report

A case report is the study design utilized in this assessment of a 40-days-old girl from a consanguineous marriage, who presented with cough and difficulty breathing for approximately a month. She was referred from a provincial hospital with no improvement in respiratory symptoms after three times hospitalization since birth. Radiological investigation revealed pig bronchus as the cause of recurrent pneumonia.

Conclusion

Pig bronchi, if not diagnosed on time, may result in severe lung infection that can even result in fatal disease. A high level of clinical suspicion is required to initiate an appropriate diagnostic workup. The gold standard modality for the diagnosis of pig bronchus is computed tomography (CT), ideally with multi-detector three-dimensional (3D) image reconstruction.

Recommendations and considerations for speeding the collapse of the non-ventilated lung during single-lung ventilation in thoracoscopic surgery: a literature review

Video-assisted thoracoscopic thoracic surgery has the advantages of less physical damage, less postoperative pain, and a rapid recovery. Therefore, it is widely used in the clinic. The quality of nonventilated lung collapse is the key point of thoracoscopic surgery. Poor lung collapse on the operative side damages surgical exposure and prolongs the process of surgery. Therefore, it is important to achieve good lung collapse as soon as possible after opening the pleura. Over the past two decades, there have been reports of advances in research on the physiological mechanism of lung collapse and several kinds of techniques for speeding up lung collapse. This review will inform the advances of each technique, make recommendations for reasonable implementation and discuss their controversies and considerations.

Combined use of the ProSeal laryngeal mask airway and a bronchial blocker vs. a double-lumen endobronchial tube in thoracoscopic surgery: A randomized controlled trial

STUDY OBJECTIVE

The combined use of the ProSeal laryngeal mask airway and a bronchial blocker may reduce postoperative hoarseness and sore throat. We aimed to test the feasibility and efficacy of this combination technique in thoracoscopic surgery.

DESIGN

A single-center, patient-assessor blinded, randomized controlled trial.

SETTING

Nagoya City University Hospital (between November 2020 and April 2022).

PATIENTS

A total of 100 adult patients undergoing lobectomy or segmentectomy by video- or robotic-assisted thoracoscopic surgery.

INTERVENTIONS

Patients were randomly assigned to either group using a combination of the ProSeal laryngeal mask airway and a bronchial blocker (pLMA+BB group) or a double-lumen endobronchial tube (DLT group).

MEASUREMENTS

The primary outcome was the hoarseness incidence on 1-3 postoperative days. Secondary outcomes included sore throat, intraoperative complications (hypoxemia, hypercapnia, surgical interruption, malposition of devices, unintended lung expansion, and ventilatory difficulty), lung collapse, device placement-related outcomes, and coughing during emergence.

MAIN RESULTS

A total of 100 patients underwent randomization (51 to the pLMA+BB group and 49 to the DLT group). After drop outs, a total of 49 patients in each group were analyzed per-protocol. The incidences of hoarseness in the pLMA+BB and DLT groups were 42.9% and 53.1% (difference, -10.2%; 95% confidence interval, -30.1% to 10.3%; p = 0.419), 18.4% vs. 32.7%, and 20.4% vs. 24.5% on postoperative day 1, 2, and 3, respectively. The incidences of sore throat in the pLMA+BB and DLT groups were 16.3% vs. 34.7% (difference, -18.4%; 95% confidence interval, -35.9% to -0.9%; p = 0.063) on postoperative day 1. In the pLMA+BB group, more intraoperative complications and less coughing during emergence were observed compared to the DLT group. Lung collapse and placement-related outcomes were comparable between the groups.

CONCLUSIONS

The combination of ProSeal laryngeal mask airway and bronchial blocker did not significantly reduce hoarseness compared to the double-lumen endobronchial tube.

Difficult lung separation. An insight into the challenges faced during COVID-19 pandemic

Difficult lung isolation or separation in patients undergoing thoracic surgery using one-lung ventilation might be attributed to upper airway difficulty or abnormal anatomy of the lower airway. Additionally, adequate deflation of the surgical lung can impair surgical exposure. The coronavirus disease 2019 (COVID-19) has a harmful consequence for both patients and anesthesiologists. Management of patients with difficult lung isolation can be challenging during the COVID-19 pandemic. Careful planning and preparation, preoperative routine testing, protective personal equipment, standard safety measures, proper preoxygenation, and individualize the patients care are required for successful lung separation. A systematic approach for management of difficult lung separation is centered around securing the airway and providing adequate ventilation using either a blocker or double-lumen tube. Several measures are described to expedite lung collapse.

VATS right apical segmentectomy for lung cancer in a patient with tracheal bronchus

INTRODUCTION

A tracheal bronchus is rarely observed, occurring in only 1% of all patients who undergo thoracic surgeries. We rarely encounter lung cancer in a patient with a tracheal bronchus; however, it is essential to know the distinctive perioperative management strategy for patients with a tracheal bronchus.

CASE PRESENTATION

We report a 72-year-old man with lung cancer located in the right apical segment supplied by a tracheal bronchus. Annual chest computed tomography performed as follow-up after colon cancer resection showed an enlarging pulmonary nodule with pure ground-glass opacity, which was suspected to be lung adenocarcinoma. The nodule was located in the right apical segment. The apical segment was independently supplied by a single pulmonary artery superior trunk and a tracheal bronchus that branched directly from the trachea at 1.2 cm above the carina. The pulmonary vein branching pattern was uncommon in that the central vein that usually runs through B2 (posterior bronchus) and B3 (anterior bronchus) was missing. The patient underwent video-assisted thoracoscopic apical segmentectomy under one-lung ventilation using a left-sided double-lumen tube.

DISCUSSION

Anomalous venous return accompanied with tracheal bronchus has been described in some reports. Since pulmonary vein is important during segmentectomy, the surgeon should pay particular attention to the venous return.

CONCLUSION

Preoperative three-dimensional graphic imagery helped us accurately identify the anatomical anomaly to enable the successful segmentectomy in a patient with a tracheal bronchus. We review the relevant literature regarding the perioperative management of patients with a tracheal bronchus.