Lung isolation in a patient with tracheal bronchus with difficult double-lumen tube placement
Year: 2026
Type: article
Abstract: Dear Editor, Lung isolation optimizes thoracic surgery conditions, but is complicated by tracheobronchial anomalies. Double-lumen tubes (DLTs) are ideal but anatomically challenging; bronchial blockers (BBs) serve as alternatives. A 50-year-old woman (160-cm height) with right upper lobe (RUL) bronchial carcinoma underwent right upper lobectomy. Airway examination suggested no difficulty. High resolution computed tomography (HRCT) thorax revealed RUL growth. After induction, 37Fr left-sided DLT (Rüsch Bronchopart®) could not be negotiated beyond the subglottis. Mask ventilation resumed; 9Fr Arndt BB was adopted as “Plan B.” Fiberoptic bronchoscopy (FOB) revealed unexpected tracheal bronchus [Figure 1a] – not picked up in HRCT [Figure 1b]. As BB cannot achieve complete right lung isolation, we placed 35Fr left-sided DLT, using FOB through the bronchial lumen as a visual intubation guide to ensure placement of the bronchial cuff within the left main bronchus (LMB).Figure 1: (a) Fiberoptic bronchoscopic examination revealed tracheal bronchus. L-Left mainstem bronchus; R1-Right mainstem bronchus; R2-Right upper lobe bronchus. (b) High resolution computed tomography of the thorax revealed only two openings at the carinal level“Tracheal” bronchus is a congenital anomaly where the RUL bronchus originates from the trachea instead of from the right main bronchus (RMB), either at the carinal level (carinal trifurcation) or more proximally. It is classified as Type I (abnormal bronchus ≥2 cm above carina with distal tracheal narrowing, Type II (abnormal bronchus ≥2 cm above carina without distal tracheal narrowing), or Type III (abnormal bronchus at/within 2 cm of carina).[1] Preoperative review of imaging for tracheobronchial anomalies is necessary for planning lung isolation. However, anomalies may be missed due to a mucus plug blocking the RUL origin or a narrow ostium overlooked in computed tomography (CT) with thicker slices (3–5 mm). Multidetector CT or CT 3D reconstruction (“virtual endoscopy”) better visualizes such anomalies.[2] Caution should be taken with preoperative bronchoscopy to avoid mistaking the high tracheal bronchus as the carina. Measuring RUL-to-carina distance helps in planning. Right lung isolation requires a preplanned strategy. Plan A: left-sided DLT – ensure bronchial lumen enters into LMB and not into bronchus intermedius (BI) using FOB guide, and tracheal cuff ends proximal to RUL take-off,[1,3] to avoid impairing RUL collapse/suction/continuous positive airway pressure (CPAP) during one lung ventilation (OLV). RUL-to-carina distance can hinder the appropriate positioning of both cuffs. Angulated/retracted LMB or narrow trachea (type I) also complicates correct, atraumatic positioning.[1,3] Plan B: BBs, with endotracheal tube (ETT) tip proximal to RUL take-off to avoid obstruction/intubation of RUL, causing atelectasis/hypoxia/barotrauma.[3] In type III, EZ-blocker can be positioned with limbs in RUL and BI,[1,4] though RUL angulation challenges positioning. Alternatives: BB into RMB through ETT/Univent tube with para-axial BB/Fogarty catheter into RUL[1,3,5] (risks ETT cuff damage, impaired deflation due to absence of lumen in Fogarty),[5] or ETT positioned to occlude tracheal bronchus with BB into BI[1] (impairs RUL collapse/suction/CPAP). Plan C: ETT into LMB, provided cuff-to-tip distance of ETT is shorter than the length of LMB to avoid left upper lobe obstruction.[4] Plan D: selective lobar isolation using BB to BI/RUL, depending on surgical needs. Left lung isolation is straightforward – ”Plan A” BB and “Plan B” left-sided DLT due to aforementioned challenges with DLTs. Withdrawing DLT during bronchial stapling risks RUL occlusion by the tracheal cuff, worsening hypoxemia. Plans need tailoring to individual anatomy [Figure 2].Figure 2: Decision tree for lung isolation in patients with tracheal bronchus. BI: bronchus intermedius, BB: bronchial blocker, CT: computed tomography, DLT: double-lumen tube, ETT: endotracheal tube, LMB: left main bronchus, RUL: right upper lobe. [Created in BioRender. R, A. (2026) https://BioRender.com/jjg7cah]In conclusion, preoperative review of tracheobronchial anatomy and a tailored airway plan are necessary for lung isolation. Unexpected findings necessitate readiness with successive plans. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Language: English
Subfield: Anesthesiology and Pain Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W7161634089