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Case Reports

Veno-Venous Extracorporeal Membrane Oxygenation in Surgery for Bronchial Repair

^a Department of Anesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
^b Department of Cardiothoracic Surgery, Kuopio University Hospital, Kuopio, Finland
^c Department of Plastic Surgery, Kuopio University Hospital, Kuopio, Finland

Accepted for publication April 7, 2008.

^_* Address correspondence to Dr Korvenoja, Kuopio University Hospital, Puijonlaaksontie 2. Kuopio, 70210, Finland (Email: pekka.korvenoja{at}kuh.fi).

	Abstract

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Single-lung ventilation using a double-lumen endobronchial tube is often performed for surgical procedures involving the thorax. Tracheobronchial rupture during use of an endobronchial tube is an uncommon and serious complication. We present the case of a patient undergoing a right pneumonectomy who experienced a bronchial rupture due to a double-lumen endobronchial tube. Institution of veno-venous extracorporeal membrane oxygenation allowed removal of the endobronchial tube, and the repair was successfully performed. We hope that this information can provide further insight into the management of such a complication.

	Introduction

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Veno-venous extracorporeal membrane oxygenation (ECMO) provides support for severe respiratory failure where the body blood flow is maintained entirely by cardiac function. Venous blood outflow from the patient is accessed from the large central veins, and inflow is returned near the right atrium after oxygenation. Normally veno-venous ECMO is, however, combined with mechanical ventilation. Veno-arterial ECMO provides support for severe cardiac failure. It involves venous blood from the patient being accessed from the large central veins and returned to the arterial system in the aorta after it has gone through the oxygenator. In this setting, no mechanical ventilation is needed. Good results using either method during the initial stage of lung transplantation and following graft failure after lung transplantation are well documented [1].

This article reports the clinical use of veno-venous ECMO in the repair of a bronchial rupture without mechanical ventilation. Total ECMO enables adequate oxygenation and carbon dioxide removal without any contribution from the lungs [2]. We believe there has not been any similar case previously reported.

A previously healthy 56-year-old woman was admitted to the hospital with a central lung adenocarcinoma stage T2N0M0 of the right upper lobe for right pneumonectomy. Her pulmonary function test results were within normal limits. After induction of anesthesia, the patient was intubated with a 37-French left double-lumen endobronchial tube. Satisfactory positioning was confirmed by fiberscopy and auscultation. The patient was then turned to the left lateral decubitus position. After a right thoracotomy, collapse of the right nondependent lung was easily accomplished.

The patient underwent an uneventful right pneumonectomy. At the conclusion of the resection, while checking for leakage of the bronchial stump, the surgeons noted air leakage from the left bronchus. Exploration of this area revealed a 3-cm longitudinal laceration in the membranous portion of the left main-stem bronchus extending from the left upper lobe bronchus to the carina (Fig 1). The bronchial cuff was herniating through the laceration, whereas the tip of the tube was completely inside the lumen of the left main-stem bronchus. The cuffs were deflated, and the tube was carefully moved forward. Ventilation and oxygenation of the patient were possible, but visualization and assessment the extent of the rupture were impossible. Despite inserting the endobronchial tube deeper, the cuff still herniated from the rupture. The surgical repair required removal of the endotracheal tube.

View larger version (29K): [in this window] [in a new window]   Fig 1. The repair of the rupture using a pedicled right latissimus dorsi muscle flap. (A) Stay sutures placed around the rupture. (B) Rupture repaired with continuous suture and stay sutures placed through the free end of the muscle flap. (C) Repair completed with muscle flap sutured over the rupture.

Heparin (1 mg/kg) was given to achieve an activated coagulation time between 150 to 200 seconds during the operation. The outflow cannula was inserted through the right atrium into the inferior vena cava, and the inflow cannula was inserted through the right atrium appendix into the superior vena cava. The ECMO was started, and the flow rate was kept between 1.5 to 2.0 L/min. Mild hypothermia was used to reduce the oxygen consumption. A norepinephrine infusion was commenced, with the dose titrated to maintain a mean arterial pressure greater than 65 mm Hg. Pulsatility in pulmonary artery catheter waveform was seen as a sign of active pulmonary artery flow. Fractioned inspired oxygen concentration was kept constant at 1.0. Arterial oxygen saturation was assessed by peripheral pulse oximetry. Saturation of peripheral oxygen was maintained between 95% and 97%. Because the clinical condition was stable, the endobronchial tube was removed.

The rupture was repaired using continuous 4-0 suture (PDS II; Johnson & Johnson, Sommerville, NJ). A pedicled right latissimus dorsi muscle flap was used to reinforce the reconstruction (Fig 1). The muscle flap was dissected by a plastic surgeon and transposed into the chest cavity. The patient was on ECMO support for 48 minutes. During this period there was no mechanical ventilation support. In the arterial blood gas, analysis taken 35 minutes after ECMO was started, pH was 7.53, PaO₂ was 60.2 mm Hg, PaCO ₂ was 22.6 mm Hg, and base excess (BE) was 0.2. At the same time, a blood gas sample taken from the superior vena cava showed a saturation of 94.3%. After surgical repair while on ECMO, the patient was re-intubated with a single-lumen endotracheal tube, and mechanical ventilation was started. Then the patient was weaned from ECMO without any problems.

The patient was extubated 4 hours after the operation in the intensive care unit. In spite of the necessary systemic heparinization, bleeding was minimal. Postoperative recovery was uneventful, and the patient was discharged in good health and without further complications.

	Comment

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Airway rupture is a rare, but life-threatening complication of intubation with a double-lumen tube. The major factors that seem to be associated with this complication are tube placement, use of the bronchial lumen stylet, positioning of the tube, and cuff distention. Overdistension of either the bronchial or tracheal cuff is the most frequent factor cited as the cause of airway rupture. The largest tube that will safely fit the airway should be chosen because larger tubes require less air in the bronchial cuff, and there is less chance that it will be advanced too deeply into the bronchus [3]. In our case, the possible reason might have been the repositioning of the tube while checking for leakage of the bronchial stump.

Sometimes the surgical management of the rupture is possible with mechanical ventilation, but as in our case, either extracorporeal oxygenation circulation support or jet ventilation may be needed.

Using the jet ventilation and a catheter inserted through the operative field beyond the rupture would give the possibility to work on almost an immobile field. However, ventilating the lower lobe only would risk the oxygenation and removal of carbon dioxide. Using high-frequency percussive ventilation with a tracheal tube allows a good gas exchange, but it causes airway leakage through the rupture and worsens the surgical conditions [4].

Veno-arterial ECMO provides both gas exchange and cardiac support, but reduces pulmonary artery flow. Lung ischemia produced by inadequate pulmonary artery circulation can cause acute lung injury if followed by reperfusion with oxygenated blood [5].

Veno-venous ECMO enables adequate oxygenation, maintaining pulmonary artery circulation and reducing the risk of acute lung injury. Arterial oxygenation during total veno-venous ECMO in our patient indicated no significant recirculation, despite the relatively short distance between the outflow and inflow cannulas. Probably due to lower bypass flow, the drainage blood is oversaturated and there is less recirculation [6]. To achieve a satisfactory arterial PaO₂, an optimal match between the bypass flow and cardiac output is important.

Also, mild hypothermia was used to reduce oxygen consumption. We achieved a satisfactory arterial PaO₂ and stabile hemodynamics, and normal PaCO₂ removal for 48 minutes without mechanical ventilation with an ECMO flow at 50% of the cardiac index. The use of systemic heparinized surfaces enables minimal systemic heparinization and could thus be expected to reduce bleeding complications.

In conclusion, we report a case in which adequate arterial tissue oxygenation with total extracorporeal membrane oxygenation can be achieved with a veno-venous bypass technique. Acceptable oxygenation and carbon dioxide removal can be provided without any contribution from the lungs. It also enables very good surgical conditions. Total veno-venous ECMO offers an alternative for treatment of bronchial rupture when mechanical ventilation is not possible.

	References

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1. Aigner C, et al. Institutional experience with extracorporeal membrane oxygenation in lung transplantation Eur J Cardiothorac Surg 2007;31:462-467.[Abstract/Free Full Text]
2. Wetterberg T, Steen S. Total extracorporeal lung assist-a new clinical approach Intensive Care Med 1991;17:73-77.[Medline]
3. Fitzmaurice BG, Brodsky JB. Airway rupture from double-lumen tubes J Cardiothorac Vasc 1999;13:322-329.
4. Lucangelo U, et al. High-frequency percussive ventilation during surgical bronchial repair in a patient with one lung BJA 2006;96:533-536.[Medline]
5. Baudouin SV. Lung injury after thoracotomy BJA 2003;91:32-42.
6. Gattinoni L, et al. Low-frequency positive pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure JAMA 1986;256:881-886.[Abstract/Free Full Text]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Korvenoja, P. Articles by Berg, L. Search for Related Content PubMed PubMed Citation Articles by Korvenoja, P. Articles by Berg, L. Related Collections Mechanical Circulatory Assistance