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Giant lung bullae are usually seen in patients with severe chronic obstructive pulmonary disease. Over time, air trapping leads to severe dyspnea and CO2 accumulation. In severe cases, overinflation and rupture of the bulla can cause secondary life-threatening tension pneumothorax. Since positive pressure ventilation exerts deleterious effects on the bulla, general anesthesia is always challenging in patients with giant bullae. We encountered remarkable intraoperative hypercapnia and decreased tidal volume in a 58-year-old male patient with bilateral bullae who underwent right upper bullectomy, due to overinflation of a bulla located in the upper lobe of the ventilated side. Through this experience, to avoid further overinflation, we devised an original, unique and simple airway management strategy using a standard double lumen tube (DLT), which only requires slightly deeper advancement of the DLT to achieve selective lobar blockade during one lung ventilation (OLV). Following the first case, we used this strategy in a 48-year-old male patient who underwent left giant bullectomy, resulting in successful airway management without overinflation during OLV. We recommend our strategy as an option for successful intraoperative airway management during OLV in select bullectomy patients with bilateral giant bullae.

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BACKGROUND: Minimally invasive cardiac surgery (MICS) is increasingly performed due to faster recovery time and lower postoperative complications when compared with the traditional open surgery. However, hypoxemia in lung isolation duration after cardiopulmonary bypass (CPB) surgery has been the focus of anesthesiologists' attention. In the present study, we designed a novel lung isolation strategy to improve oxygenation using a bronchial blocker (BB) to isolate the right middle and lower lobes and preserve the ventilated right upper lobe without affecting the surgical field. METHODS: Patients who had undergone right lateral mini-thoracotomy, a MICS, between August 2018 and February 2019, were enrolled in this randomized controlled study. Patients were randomly divided into a modified lung isolation group (group M) and a conventional lung isolation group (group C). In group M, BBs were used to block the bronchus intermedius, while left-sided double lumen endotracheal tubes were used in group C to isolate the right lung. The primary outcome was to determine the number of patients who required an increase in ventilation volume due to hypoxemia during lung isolation after CPB. RESULTS: Sixty-one patients (30 in group C and 31 in group M) were enrolled. Five patients in group M were converted to right lung isolation due to poor surgical field exposure. During lung isolation after CPB, the number of patients with hypoxemia was lower in group M than group C (5/31 vs. 15/30, P=0.005). CONCLUSIONS: The novel modified lung isolation strategy reduced the incidence of hypoxemia after CPB.

RESUMEN

Lung isolation is essential during thoracic surgery, as it allows the thoracic surgeon to visualise and work in the surgical field. The occurrence of hypoxaemia during lung isolation is common, and is even more so in patients with decreased pulmonary functional reserve. The clinical cases are presented of 2 patients with a history of left pulmonary resections (1st left lower lobectomy, 2nd left lower lobectomy and left upper lobe segmentectomy), in which sequential selective lobar blockade was performed with Fuji Uniblocker® endobronchial blocker for performing right lung atypical resections (right upper lobe, middle lobe, and right lower lobe). In our experience the technique was successful, the surgical field was optimal and no intra- or post-operative complications were found. This technique may be an alternative to traditional lung isolation in patients with compromised respiratory function (low functional reserve or previous contralateral lung resections).

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