Ann Thorac Surg 1996;62:570-571
© 1996 The Society of Thoracic Surgeons
Case Report
A Technique of Positive-Pressure Single-Lung Ventilation Via a Silicone T-Y Stent
Robert L. Quigley, MD, PhD,
Kyra H. Bannister, MD,
Michael W. Chisdak, MD,
Felice L. Reitknecht, MD
Departments of Surgery, Anesthesia, and Medicine, Guthrie Clinic, Sayre, Pennsylvania
Accepted for publication February 23, 1996.
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Abstract
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Airway control and protection, in any operation, is the first priority. The presence of a T-Y stent in the proximal airway can complicate this fundamental principle. Here we describe an effective and safe technique for positive-pressure single-lung ventilation via a T-Y stent for a lung lobectomy.
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Introduction
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Historically the management of unresectable intrinsic/extrinsic major airway obstruction has been challenging for both the pulmonologist and the thoracic surgeon. In 1982 Westaby, Jackson, and Pearson [1] designed a bifurcated silicone stent for maintenance of tracheobronchial patency. Over the last decade the prevalence of this inert T-Y tube, although not yet ubiquitous, has increased [2]. Recently a patient presented to our clinic with such a device who required a right lower lobectomy for a biopsy-proven adenocarcinoma. In this report we detail a safe, simple technique of positive-pressure single-lung ventilation via a T-Y stent that avoids stent intubation and thus reduces the risk of dislodgement.
The patient is a 58-year-old woman who was noted to have a solitary pulmonary nodule on a routine annual chest roentgenogram. Her past medical history is significant for a squamous cell carcinoma of the distal trachea, which was treated with radiotherapy. Although the tumor was eradicated, tracheomalacia and symptoms of upper airway obstruction subsequently developed. This complication was managed by a T-Y stent (Hood Laboratories, Pembroke, MA) (Fig 1
). Since its insertion she has undergone several replacements for either removal of granulation tissue at the ostia of the proximal/distal limbs or traumatic dislodgement precipitated by coughing. It has been documented that symptoms of upper airway collapse develop within 6 hours of stent removal. Her physical examination was unremarkable. Her T limb was capped, and she ventilated and phonated through her nasopharynx. There was no supraclavicular or neck adenopathy. Routine laboratory examinations were within normal limits. High-resolution computed tomographic scan of the chest was used to evaluate the mediastinum, which was negative for adenopathy, and to determine the internal diameter of the limbs of the T-Y stent (tracheal limb = 0.9 cm; T-Y limbs = 0.65 cm). Pulmonary function testing demonstrated forced-expiratory volume in 1 second of 2.2 L with a delayed expiration phase consistent with upper airway obstruction.
After informed consent the patient was taken to the operating room. The T limb of the T-Y stent was uncapped and the universal end of a 5F endotracheal tube was connected to this limb to deliver oxygen via an adult circle circuit (Fig 2). Under intravenous sedation with midazolam and fentanyl, a radial arterial line and subclavian triple-lumen catheter were placed. With the patient in a semirecumbent position, her nares and oropharynx were anesthetized with topical lidocaine. General anesthesia was induced with isoflurane. With the patient spontaneously ventilating, a pediatric bronchoscope passed through a left nasopharyngeal tube (ie, a "trumpet") was used to help visually guide a 4F balloon Fogarty catheter beyond the right limb of the Y. A small 30-degree bend at the distal tip of the Fogarty catheter (with guidewire still in place) facilitated its direction through the distal right limb. The balloon was then inflated with 3 mL of 0.9% normal saline solution and put under tension to completely obstruct the distal right ostium. The wire, under tension, was then taped to her forehead. Her oropharynx was then packed with wet Kerlix gauze (Kendall Co, Mansfield, MA) to seal her upper airway and permit positive-pressure ventilation. Similarly the phalanged end of the nasal trumpet was packed with bone wax (around the Fogarty catheter) to seal this passage. At this time the patient was further sedated and paralyzed for mechanical ventilation via the T limb. A small airleak around the stoma of the tracheotomy was controlled with Vaseline gauze. Under these circumstances her airway pressure never exceeded 30 cm H2O with a tidal volume delivery of 600 mL.
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Fig 2. . Sagittal section of patient demonstrating technique of administration of positive-pressure single-lung ventilation. (RL = right lower; RM = right middle; RU = right upper.
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The patient was then positioned in the left lateral decubitus position and underwent an uneventful right lower lobectomy via a standard serratus-sparing lateral thoracotomy. Her right upper lobe was fully inflated during the procedure as the ostium to this bronchus could not and did not need to be occluded. Her muscle relaxant was reversed, and when spontaneous ventilation was demonstrable the packing was removed from her oropharynx, as was the Fogarty catheter from her airway. She was transferred to the intensive care unit with her nose trumpet in place. Her postoperative course was completely uneventful, and within 24 hours of the operation her T limb was capped and she resumed ventilation and phonation as previously described. She was discharged home on the fourth postoperative day.
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Comment
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The operating room manual provided by Hood Laboratories indicates that the T-Y device is not to be used for the administration of anesthesia or as a conduit for positive-pressure ventilation. These two relative contraindications are related, in the most part, to the configuration of the apparatus. First, there is no universal joint on the T piece to facilitate connection to a standard ventilator hose. Second, positive-pressure ventilation via the T piece would pass the pathway of least resistance-via the oropharynx. Third, instrumentation of the device (ie, with an endotracheal tube) can easily alter its location and potentially compromise the airway.
Our technique addresses all three issues and uses hardware readily available in any standard operating suite. We do suggest, however, that expertise with rigid bronchoscopy be available when dealing with these stents, as reinsertion can be both technically difficult and treacherous. If the device does become dislodged and such expertise is not readily available, most upper airways can be temporarily protected by simple intubation from above with a standard endotracheal tube.
We propose that this same procedure may be applied to cases of general anesthesia for elective general operations. The step of Fogarty balloon catheter placement would obviously be omitted. Because the use of these silicone stents is expected to continue to increase, it is just a matter of time before other centers will be faced with a similar challenge.
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Addendum
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Six months later the patient was noted to have a contralateral second non-small cell primary carcinoma. Anesthesia was similarly managed and an uneventful segmentectomy was performed.
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Acknowledgments
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We thank Dr Douglas J. Mathisen, Massachusetts General Hospital, and Dr Thomas W. Rice, The Cleveland Clinic, for serving as consultants on this case.
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Footnotes
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Address reprint requests to Dr Quigley, Section of Cardiothoracic Surgery, Guthrie Clinic, Guthrie Square, Sayre, PA 18840.
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References
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- Westaby S, Jackson JW, Pearson FG. A bifurcated silicone rubber stent for relief of tracheobronchial obstruction. J Thorac Cardiovasc Surg 1982;83:414–7.[Abstract]
- Cooper JD, Pearson FG, Patterson GA, et al. Use of silicone stents in the management of airway problems. Ann Thorac Surg 1989;47:371–8.[Abstract/Free Full Text]
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Abstract
Introduction
