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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 108-110

Airway and ventilation management for excision of recurrent bronchogenic cyst followed by removal of metallic bronchial stent in a child


Department of Anesthesia, CMC, Vellore, Tamil Nadu, India

Date of Submission22-Apr-2021
Date of Acceptance30-Apr-2021
Date of Web Publication10-Aug-2021

Correspondence Address:
Dr. Jacob Chandy
Department of Anesthesia, CMC, Vellore - 632 002, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/arwy.arwy_24_21

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  Abstract 


Conventional lung isolation is at times not possible as was the case with our child who had a migrated bronchial stent. The Cook® airway exchange catheter was used as a backup for oxygenation/ventilation in case of the stent getting stuck during its removal. A specially designed device for facilitating egress of air during jet ventilation was indigenously created and held as a backup plan.

Keywords: Cook® airway exchange catheter, lung isolation, stent


How to cite this article:
Chandy J, Rai E. Airway and ventilation management for excision of recurrent bronchogenic cyst followed by removal of metallic bronchial stent in a child. Airway 2021;4:108-10

How to cite this URL:
Chandy J, Rai E. Airway and ventilation management for excision of recurrent bronchogenic cyst followed by removal of metallic bronchial stent in a child. Airway [serial online] 2021 [cited 2021 Dec 2];4:108-10. Available from: https://www.arwy.org/text.asp?2021/4/2/108/323570




  Introduction Top


Bronchogenic cysts are congenital lung pathologies that present to the paediatric surgical division.[1],[2],[3] Anaesthetic considerations in the surgical management of these lesions include lung isolation and one-lung ventilation for thoracotomy. Rarely, these cysts recur and present with respiratory distress following the bronchial collapse. We report a case of a complicated recurrent left-sided bronchogenic cyst for surgery, wherein conventional methods of lung isolation could not be employed due to migration of the covered metal stent from the left main bronchus into the distal trachea close to the carina.


  Case Report Top


A 10-year-old-boy, diagnosed with foregut duplication cyst of the mediastinum, underwent marsupialisation of the cyst at the age of eight. He did well for 2 years after which he developed gradual onset of recurrent pain over the left side of the chest associated with occasional productive cough. Computerised tomography (CT) of the chest revealed features suggestive of increase in the size of the residual cyst with splaying and narrowing of the carina. The near-complete compression of the proximal left main bronchus resulted in the complete collapse of the left lung [Figure 1] and retained secretions. A metallic stent was inserted in the left main bronchus under general anaesthesia in an emergency setting. The child did well for a couple of months, following which he presented with recurrent symptoms. A repeat CT chest revealed a residual cyst. The stent placed in the left main bronchus had partially migrated into the trachea [Figure 2]. The bronchus beyond the stent could not be visualised. The child was scheduled for cyst excision followed by removal of the metallic stent.
Figure 1: Collapsed left lung due to the recurrent bronchogenic cyst

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Figure 2: Migrated metal stent at the carina

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On examination, the child had rhonchi in the infraclavicular region. All investigations were within the normal limits. There were many challenges in this case, the first among them being the method of one-lung ventilation. Conventional lung isolation strategies such as a double-lumen tube and bronchial blocker could not be used due to the presence of a metallic stent that had migrated from the left main bronchus onto the carina. Thus, it was decided to ventilate the right lung through a flexometallic tube placed endobronchially under fibreoptic bronchoscopic guidance. The child was placed in the semi-recumbent position as he had a history of cough in the supine position and an intravenous cannula was placed under local anaesthesia in the presence of parents. Dexmedetomidine and propofol infusions were started. Dexmedetomidine in a dose of 1 μg/kg was administered over 15 min followed by 0.5 μg/kg/hour. Propofol was simultaneously administered at 100 μg/kg/hour and a gentle laryngoscopy was performed to spray 2% lignocaine over the vocal cords and epiglottis and simultaneously grade the laryngoscopic view. After 2 min, the trachea was intubated with a 5.0 mm ID flexometallic cuffed endotracheal tube (ETT). Under fibreoptic bronchoscopic guidance, the ETT was advanced into the right main bronchus till the tip was just proximal to the take-off of the right upper lobar bronchus. The proximal part of the stent was visualised at the carina. Muscle paralysis was achieved with atracurium 15 mg after confirming the position of the ETT and the right lung was ventilated on pressure control mode.

Dexmedetomidine and propofol infusions were discontinued and anaesthesia was maintained with isoflurane in a mixture of air and oxygen. An epidural catheter was placed at T5-T6 level and the right internal jugular vein and right radial artery were cannulated.

Cyst excision with the repair of the bronchial defect was performed through a left thoracotomy. Analgesia was provided with 0.2% ropivacaine infusion via the epidural catheter along with systemic paracetamol and fentanyl. The surgical procedure took 4 h and resulted in 200 mL of blood loss.

The next challenge in this case was preparing for the removal of the covered metal stent. This was going to be performed under rigid bronchoscopy. The main concern was the possibility of not being able to ventilate and oxygenate the child should the metal stent get stuck at the level of the carina or the trachea. Our department did not have the Ventrain device which is a single use, small-lumen ventilation device designed for obstructed airway situations.[4],[5] The child was brought back onto spontaneous ventilation and total intravenous anaesthesia with dexmedetomidine and propofol was restarted. The ETT was suctioned and an-8 Fr 45-cm Cook® airway exchange catheter (AEC) was inserted through the ETT and the flexometallic tube was removed. The AEC was positioned in the right main bronchus with the help of fibreoptic bronchoscopy.

Rigid bronchoscopy was performed following topicalisation with 2% lignocaine. A 3.5 mm bronchoscope was introduced alongside the AEC. Spontaneous ventilation was supported with the help of a Jackson-Rees circuit connected to the ventilating port of the rigid bronchoscope. The AEC was connected to a jet ventilator via an indigenously prepared Y-connector device [Figure 3]. Jet ventilation of the right lung through the AEC was the planned rescue mode of ventilation. To ensure adequate egress of air, the Y connector device had one arm open to the atmosphere. This arm was occluded during jet ventilation. The indigenously prepared device had been used previously for similar cases and it was checked and tested before commencement of the case. The stent was removed without much difficulty. The child was transferred to the surgical high dependency unit for monitoring.
Figure 3: Jet ventilator connected to Cook® airway exchange catheter through a Y-connector

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  Discussion Top


The Cook® AEC is a long, hollow, semirigid catheter with a small internal diameter inserted through an ETT before extubation. It serves as conduit to administer oxygen manually by insufflation or using jet ventilation. It also acts as a stylet over which reintubation can be performed expeditiously should extubation failure occur.[6] Although the principles of use of an AEC are simple, failure to adhere to these can result in complications. When the amount of air entering the lung exceeds that which is exiting, a tension pneumothorax can result. Air entry with jet ventilation should be limited by setting a pressure limit of 25 psi and an inspiratory time limit of <1 s. Administering an FIO2 of 1.0 can provide life-sustaining ventilatory support.[7],[8] In our child, careful vigilance needed to be exercised in case jet ventilation through the AEC was needed because of the inability to remove a stent that gets stuck. The Y-connector was made for such an eventuality to help in the free egress of air.

In conclusion, the presence of a foreign body that was partially occluding the trachea complicated lung isolation and needed alternative safe options. An AEC and a rigid bronchoscope constituted the back-up plan for emergency oxygenation/ventilation in case the 'stuck stent' caused complete tracheal obstruction. We used an indigenously designed apparatus for providing a pathway for egress of air in case such an event occurred.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that the name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ramenofsky ML, Leape LL, McCauley RG. Bronchogenic cyst. J Pediatr Surg 1979;14:219-24.  Back to cited text no. 1
    
2.
Cohn JE, Rethy K, Prasad R, Mae Pascasio J, Annunzio K, Zwillenberg S. Pediatric bronchogenic cysts: A case series of six patients highlighting diagnosis and management. J Invest Surg 2020;33:568-73.  Back to cited text no. 2
    
3.
DuMontier C, Graviss ER, Silberstein MJ, McAlister WH. Bronchogenic cysts in children. Clin Radiol 1985;36:431-6.  Back to cited text no. 3
    
4.
Hamaekers AE, Borg PA, Enk D. Ventrain: An ejector ventilator for emergency use. Br J Anaesth 2012;108:1017-21.  Back to cited text no. 4
    
5.
de Wolf MW, Gottschall R, Preussler NP, Paxian M, Enk D. Emergency ventilation with the Ventrain® through an airway exchange catheter in a porcine model of complete upper airway obstruction. Can J Anaesth 2017;64:37-44.  Back to cited text no. 5
    
6.
Benumof JL. Airway exchange catheters: Simple concept, potentially great danger. Anesthesiology 1999;91:342-4.  Back to cited text no. 6
    
7.
Baraka AS. Tension pneumothorax complicating jet ventilation via a cook airway exchange catheter. Anesthesiology 1999;91:557-8.  Back to cited text no. 7
    
8.
Wise-Faberowski L, Nargozian C. Utility of airway exchange catheters in pediatric patients with a known difficult airway. Pediatr Crit Care Med 2005;6:454-6.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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