Bronchus perforation by EZ-BlockerTM endobronchial blocker during esophageal resection after neoadjuvant
chemoradiation -a case report-

Background:Double lumen tube (DLT) intubation is the most commonly used technique for lung separation. Bronchial blockers (BB) are an alternative, especially for difficult airways. The EZ-bronchial blocker (EZB) is the newest device of the BB family. Methods:A randomised, controlled trial was conducted in 80 patients undergoing elective thoracic surgery using DLT or SLT plus EZB for lung separation (German Clinical Trial Register DRKS00014816). The objective of the study was to compare the clinical performance of EZB with DLT. Primary endpoint was total time to successful lung separation. Secondary endpoints were time subsections, quality of lung collapse, difficulty of intubation, any complications during the procedure, incidence of objective trauma of the oropharynx and supraglottic space and intubation-related subjective symptoms.Results:74 patients were included, DLT group (n = 38), EZB group (n = 36). Median total time for lung separation [IQR] in DLT group was 234 seconds [207 to 294] versus 298 seconds [243 to 369] in EZB group (P=0.007). Quality of lung collapse was equal in both groups, DLT group 89.5% were excellent vs. 83.3 % in the EZB group (P=0.444). Inadequate lung collapse in five patients of the EZB group resulted in unsuccessful repositioning attempts and secondary DLT placement. Endoscopic examinations revealed significantly more carina trauma (P=0.047) and subglottic haemorrhage (P=0.047) in the DLT group. Additionally, postoperative subjective symptoms (sore throat, hoarseness) were more common in the DLT group, as were speech problems.Conclusions:Using the EZB results in prolonged lung separation compared to DLT, prima facie with equal quality of lung collapse for the thoracic surgeon. Five crossover cases demonstrated the superiority of the use of left-sided DLT especially in the indication for EZB for a right open thoracotomy or right video-assisted thoracoscopic surgery (VATS). Using the EZB showed only little evidence for reducing objective airway trauma e.g. less carina trauma as well as subjective complaints.Trial registration:German Clinical Trial Register DRKS00014816, prospectively registered on 07.06.2018https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014816

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“…Severe trauma such as bronchus perforation did not occur in our patients (13) and no patients required intervention to treat an airway damage.…”

Section: Incidence Of Airway Traumamentioning

confidence: 70%

Comparison of Double-Lumen Tube and EZ-Blocker for Lung Separation in Thoracic Surgery - A Randomised Controlled Clinical Trial

Risse

Szeder

Schubert

et al. 2021

Preprint

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“…Tracheobronchial rupture is a rare, but serious and potentially fatal complication of airway instrumentation that has been reported with the use of endotracheal tube introducers, DLTs, and EBBs [ 2 – 5 ]. The incidence of post-intubation tracheobronchial rupture is difficult to estimate due to its rarity, but is estimated to occur in 1:20,000 to 1:75,000 intubations [ 6 , 7 ].…”

Section: Discussionmentioning

confidence: 99%

“…Risk factors for post-intubation tracheobronchial rupture have been previously described, broadly divided into mechanical and anatomical factors as summarised in Table 1 [ 2 , 7 – 12 ]. In this unfortunate case, advanced age, tumour-related inflammation and adherent, friable soft tissue surrounding the LMSB were the only predisposing risk factors.…”

Section: Discussionmentioning

confidence: 99%

“…Endobronchial blockers may also reduce the incidence of postoperative hoarseness, sore throat, and vocal cord lesions when compared to DLTs [ 1 ]. Although tracheobronchial mucosal injury can occur with the use of EBBs, bronchus perforation or rupture is rare, and few case reports exist in the literature [ 2 ]. Until now, bronchial and tracheal rupture has been more frequently reported with DLT use as opposed to EBBs.…”

Section: Introductionmentioning

confidence: 99%

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Bronchial rupture following endobronchial blocker placement: a case report of a rare, unfortunate complication

Chia

et al. 2021

BMC Anesthesiol

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Background Lung separation may be achieved through the use of double lumen tubes or endobronchial blockers. The use of lung separation techniques carries the risk of airway injuries which range from minor complications like postoperative hoarseness and sore throat to rare and potentially devastating tracheobronchial mucosal injuries like bronchus perforation or rupture. With few case reports to date, bronchial rupture with the use of endobronchial blockers is indeed an overlooked complication. Case presentation A 78-year-old male patient with a left upper lobe lung adenocarcinoma underwent a left upper lobectomy with a Fuji Uniblocker® as the lung separation device. Despite an atraumatic insertion and endobronchial blocker balloon volume within manufacturer specifications, an intraoperative air leak developed, and the patient was found to have sustained a left mainstem bronchus rupture which was successfully repaired and the patient extubated uneventfully. Unfortunately, the patient passed on in-hospital from sepsis and other complications. Conclusion Bronchial rupture is a serious complication of endobronchial blocker use that can carry significant morbidity, and due care should be exercised in its use and placement. Bronchoscopy should be used during insertion, and the volume and pressure of the balloon kept to the minimum required to prevent air leak. Bronchial injury should be considered as a differential in the presence of an unexplained air leak.

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“…I read, with great interest, the case report “Bronchus perforation by EZ-Blocker TM endobronchial blocker during esophageal resection after neoadjuvant chemoradiation” [1]. I congratulate the authors for reporting the first incidence of bronchus perforation by EZ-Blocker TM and, more importantly, for the successful management of this rare complication.…”

mentioning

confidence: 99%

Comment on “bronchus perforation by EZ-BlockerTM endobronchial blocker during esophageal resection after neoadjuvant chemoradiation”

Parab

2019

Korean J Anesthesiol

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I read, with great interest, the case report "Bronchus perforation by EZ-Blocker TM endobronchial blocker during esophageal resection after neoadjuvant chemoradiation" [1]. I congratulate the authors for reporting the first incidence of bronchus perforation by EZ-Blocker TM and, more importantly, for the successful management of this rare complication. Regarding this, I wish to make a few comments.In this patient, airway control was secured using single lumen tube (SLT) insertion followed by EZ-Blocker TM insertion under bronchoscopic guidance. The patient was planned to undergo laparoscopic surgery followed by thoracoscopic surgery. Therefore, there was no need for lung isolation during the first half of the surgery. Many studies on laparoscopic procedures have reported cephalad movement of the carina because of pneumoperitoneum creation and Trendelenburg position during the laparoscopic surgery [2,3]. Such movement, in the presence of an EZ-Blocker TM hinging against the carina, could result in dislodgement of the blocker, followed by bronchial perforation. In this case, the risk was further potentiated by old age, possibility of microangiopathy (patient was a known case of coronary artery disease), and irradiation, leading to mucosal fragility. Moreover, EZ-Blocker TM , unlike other bronchial blockers, has pointed tips for bronchial segments. As all lung isolation devices potentially carry risk of damage to the airway mucosa (double lumen tubes [DLTs] carry a higher risk than blockers), their use should be restricted only to the segment of the surgery in which lung isolation is required. In this case, authors could have planned bronchial blocker insertion after completion of the laparoscopic surgery.Furthermore, authors mentioned that bronchoscopic inspection of EZ-Blocker TM position was difficult in the prone position because of central airway collapse below the SLT level. This could have resulted in missing the blocker dislodgement. This is a common finding when bronchoscopy is performed in the prone position. In such cases, by positioning the bronchoscope at the SLT tip, the endotracheal tube can be pushed toward the carina under direct vision. While making this movement, the blocker should not be fixed to the SLT at its proximal end in order to prevent excessive pressure on the carina or bronchial mucosa. This maneuver helps open the collapsed lower airway, without distal movement of the blocker. Once the position of the blocker is confirmed, SLT can be withdrawn slightly so that the SLT tip lies away from the carina. It is also important to inflate the bronchial cuff after changing the patient's position. Blockers with inflated cuffs tend to get displaced while changing the patient's position. Keeping the SLT tip close to the carina can prevent retrograde displacement of the endobronchial blocker, as described by Ho et al. [4]. This technique carries a potential risk of injury to the carina; therefore, it should not be used when

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Bronchus perforation by EZ-BlockerTM endobronchial blocker during esophageal resection after neoadjuvant chemoradiation -a case report-

Cited by 13 publications

References 6 publications

Comparison of Double-Lumen Tube and EZ-Blocker for Lung Separation in Thoracic Surgery - A Randomised Controlled Clinical Trial

Comparison of Double-Lumen Tube and EZ-Blocker for Lung Separation in Thoracic Surgery - A Randomised Controlled Clinical Trial

Bronchial rupture following endobronchial blocker placement: a case report of a rare, unfortunate complication

Comment on “bronchus perforation by EZ-BlockerTM endobronchial blocker during esophageal resection after neoadjuvant chemoradiation”

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