An example of difficulty in positioning of two-cavity bronchial duct catheterination in patients with trachea diverticulity

The patient, male, 53 years old, 172 cm, 55kg, was admitted to hospital for "coughing sputum with hemorrhage for more than half a year"There has been a history of emphysema and bronchodilomaSix years ago due to a car accident caused a right lung bruise, multiple rib fractures, surgery (specific surgical procedures unknown), there is a history of tracheotomy and blood transfusion historyDeny a history of smoking and drink a small amount of alcoholCheck body: double lung breathing sound thick, heart rhythm, flat abdomen, double lower extremities without edemaChest CT: two emphysema, two pulmonary bronchial dilation associated infection, right lung upper lobe for (Figure 1)lung function: mild mixed ventilation dysfunction, moderate decrease in nitric oxide dispersion, FEV12.23L, FEV1/FVC98.27%Bronchscopy examination: the upper section of the upper section of the right side of the wall is partially pull-up dilation, part of the cartilage ring disappears, the tube cavity is smooth, the protrusion sharp (Figure 2)diagnosed with a damaged right upper lung, and a right upper lung lobe removalPreoperative blood routine: RBC4.69 x 1012/L, Hb135g/L, WBC 6.24 x 109/L, neutrophils 63.4%, PLT199 x 109/LLiver and kidney function: ALB39g/L, ALT14U/L, AST19U/L, Scr75mmol/L, BUN7.1mmol/LBlood clotting function: PT12.6s, APTT35.2s, INR1.09specialist examination: teeth intact, good neck activity, opening length of 3 cm, armor pitch ingarm s6.5 cm, Mallampatti I gradeThe patient entered the room with an epidural outer permeal puncture tube and an intra-neck venous puncture tubeConnect II, V five-conductive electrocardiogram to monitor noninvasive arterial blood pressure and SpO2HR72 times/min, BP110/68mmHg, SpO2 99% Anesthetic induced to give propofol TCI4.0 sg/ml, riffenteni TCI0.2 sg-kg-1-min-1, schfentany 20?g, roco bromide ammonium 40mg Normal laryngoscope exposure under the Cormack-Lehane score I grade, placed in 39Fr double cavity tube (tube diameter 13mm), through the sound door 1 to 2 cm when the resistance is greater, considering the patient's history of trachea cut, the narrowness of the sound door, then replace 37Fr double cavity tube (tube diameter 12.3mm), the tube intubation process smoothly, the tube bronchial end smoothly into the left main bronchial tube After the positioning of the fiber boscopic mirror, the trachea jacket and bronchial sac injection, trachea jacket sac injection (-10 ml) after see the double cavity tube significantly shifted, the tube bronchial end slide out of the left main bronchial tube readjust the catheter position, re-positioned after the bronchial jacket sac injection (3 ml), the double cavity tube no shift, the trachea jacket sac injection gas (-10 ml) after the double cavity tube again slideout out of the left main bronchial tube Repeated attempts (to increase catheter depth, neck flexion) still fail to locate Finally to the bronchial jacket sac injection gas 3 ml, tracheostomy sac injection gas 5 ml, again fiber mirror positioning, found that the catheter placed in place, did not see the catheter slip out again Secure the double cavity tube (30 cm from the door teeth), connect the ventilator mechanical ventilation, and begin the operation anaesthetic induction and postoperative blood gas analysis: pH7.28, PaO2150mmHg, PaCO252mmHg, BE-2.8mmol/L, lactic acid 0.5mmol/L, blood sugar 6.9mmol/L During the operation of single lung ventilation FiO270% to 80%, maintain PETCO245 to 50mmHg, as needed intermittent epidural injection 0.15% bubbcoin, intravenous injection of sefentani and shun aquor ammonium Final line right upper pulmonary lobe excision and pleural sorceration, surgery time 6h, intraoperative bleeding about 2000 ml, crystal transmission 2000ml, colloid 1000ml, plasma 400ml, less plasma 800ml, surgical urine volume of 400ml After the surgical treatment of the patient met the extraction instructions, the double cavity bronchocatheter catheter was removed and transferred to the surgical ward hr68 times/min, BP96/51mmHg, SpO2100% when into the ward Blood gas analysis: pH7.30, PaO2197mmHg, PaCO247mmHg, Hb83g/L, BE-3.2mmol/L, lactic acid 1.2mmol/L Transferred to the general ward on the second day after surgery and discharged 2 weeks later In order to further clarify the cause of the difficulty of positioning the double cavity tube, the 3rd day after surgery, three-dimensional reconstruction of CT, the results suggest that the trachea diverticulum, the diverticulum is located in the protrusion about 5.6 cm, the length (parallel with the trachea) about 3.5 cm, the maximum cross-section of about 3.2 cm discussion
trachea diverticula is a cystic lesions that affect the trachea and the main bronchial tube, protruding from the trachea and bronchial cavity The disease is rare, with incidences of about 1 per cent in adults and 0.3 per cent in children, respectively The trachea diverticula can be divided into congenital and acquired two types Congenital diverticulum is generally small, narrow with the trachea connection, often located under the sound door 4 to 5 cm or protrusion, the diverticulity wall contains smooth muscle, cartilage, respiratory epithelial tissue and other similar to the normal trachea wall structure Acquired diverticulity is generally large, with wide mouths connected to the airways, often located in the right rear side wall of the trachea, the diverticulity wall is mostly composed of respiratory epithelial tissue The trachea diverticulum can have no obvious clinical manifestations, only by CT, bronchoscopy or biopsy accidentally found that the large diverticulum can be used as a "store" of pus secretions, resulting in repeated respiratory infections, coughing, coughing sputum, breathing difficulties, hemorrhage, hissing, neck abscess, swallowing difficulties and so on asymptomatic trachea diverticula without active treatment, elderly patients with recurrent infections can be given supportive treatment, and surgery is more suitable for children In this case, patients have a history of emphysema, bronchodliasise and lung trauma, and chronic stress in the airways is more likely to cause acquired diverticulity Goo and others point out that people with chronic obstructive pulmonary disease (COPD) with a long history of coughing and sputum should be alert to the possibility of a trachea diverticulum The clinical manifestations, lung function determination and imaging performance of the trachea diverticulum were similar to COPD, and there was some correlation between the two diseases The effects of trachea diverticulum on anesthesia mainly include intubation difficulties, ventilation difficulties, complications related to positive pressure ventilation, etc Salhotra and others have reported a case of difficult intubation of 11-year-old male children, suffering from Lesch-Nyhan syndrome, in the general anesthesia trachea intubation under the sound door of the trachea 1 cm "difficult to pass", after the CT show edified under the sound door 9mm trachea diverticula In addition, the trachea ducts into the diverticulity room can also cause ventilation difficulties Davies reported an extra-anticipated case of the unexpected difficult intubation, which was also followed by the trachea diverticulity under the sound door and the extreme conchperito (almost 90 degrees), which eventually failed and was performed with a larynx ventilation Therefore, patients who have been diagnosed with trachea diverticulum or suspicious trachea diverticulum surgery should perform trachea 3D reconstruction CT clear the size, location (relationship with sound doors and protrusions), whether there is abnormally narrow trachea The walls of the trachea diverticulal is weaker than the normal trachea wall, especially the acquired diverticulitous walls are mostly composed of the upper skin tissue of the respiratory tract, and there is a risk of perforation of the diverticulity under positive pressure ventilation there are literature reports that a 90-year-old male patient after full hemp intubation appeared subcutaneous and swollen, bronchoscopy examination inhale crosstalk door under 4 cm see 0.5 cm x 2.5 cm size trachea diverticulity room, exhalation of the diverticulity chamber collapsed The presemawas is suspected to be caused by perforation of the diverticulity during positive pressure ventilation Allaert and others reported a case of swelling of the neck and upper chest after the full hemp intubation, and after surgery it was found that the bulge was on to the 3 cm trachea diverticulity Therefore, patients diagnosed with trachea diverticulity are the preferred area anaesthetic in order to avoid airway-related problems, followed by general anaesthetic larynx ventilation (to retain autonomous breathing as much as possible), and finally, a general anaesthetic trachea intubation Patients with the necessary tracheal intubation, choose the appropriate type of tracheal catheter, pre-estimate the position relationship between the diverticulum and the tip of the catheter and the sac, or use bronchoscopy after intubation to observe whether the opening of the divertord is closed, try to avoid the diverticulity at the far end of the tip of the catheter, so as not to cause the venting pressure too high during surgery to cause the diverticos perforation If necessary, select a double cavity bronchial catheter instead of a single-cavity tube closed diverticulity opening reported that the first full hemp intubation caused the diverticula perforation, the second general anesthesia doctor chose the double cavity bronchoscoscoconal catheter successfully completed the operation In this case, the patient's diverticulum is located about 5.6 cm on the protrusion, the cartilage ring of the upper section of the trachea disappears, the airway support and elasticity are weakened, and the position of the double-cavity bronchial tube tube sac is adjacent to the divertchamber, resulting in a large number of gas injections of the trachea sac after the end of the ductal bronchial tube is easily sliding out of the left main bronchi Considering the location of the patient's trachea diverticulity, if the trachea intubation is required in the future, positive pressure ventilation has the risk of perforation of the diverticula, airway management needs to be highly noted , the tracheostomy patients can have no obvious clinical manifestations, only by CT 3D reconstruction, bronchoscopy or biopsy accidentally found, in the absence of auxiliary examination is difficult to confirm Plus the diverticula is mostly present in the main airway, some positions are higher close to the sound door, chest CT leakage, which requires anesthesiologists to enhance the understanding of the disease and exercise the ability to read the film before surgery, especially for patients with high-risk factors such as airway damage or trachea incision history, can identify the trachea diverticulum and its effect on airway establishment, give the correct treatment