Case Report

Incomplete Drainage of Total Pulmonary Lavage as a Cause of Double-Lumen Tube Malposition: A Case Report

by Susana González-Suárez1,2*, Victoria Santos Cores2, Karina Iraida Loor Reyes3

1Department of Surgery, Universitat Autònoma de Barcelona, Spain

2Department of Anesthesia, University Hospital Vall d’Hebron. Barcelona, Spain

3Department of Respiratory Medicine, University Hospital Vall d’Hebron. Barcelona, Spain

*Corresponding author: Susana González-Suárez, Department of Surgery, Universitat Autònoma de Barcelona, Spain.

Received Date: 28 December 2023

Accepted Date: 02 January 2024

Published Date: 04 January 2024

Citation: González-Suárez S, Santos Cores V, Loor Reyes KI (2024) Incomplete Drainage of Total Pulmonary Lavage as a Cause of Double-Lumen Tube Malposition: A Case Report. Ann Case Report 9: 1578. https://doi.org/10.29011/2574-7754.101578

Abstract

Introduction: Although a variety of techniques are available to achieve lung isolation in adults, double lumen tube (DLT) placement is essential for performing bronchoalveolar lavage (BAL) because it allows rapid conversion from one-lung ventilation to two-lung ventilation as well as optimal suction and drainage of lavage solution. Nevertheless, one of the main complications that can occur during BAL is retrograde migration of the DLT into the trachea, which can lead to interruption of ventilation and instillation of lavage fluid in both lungs. Case Presentation: 60-year-old man underwent total bronchoalveolar lavage under general anesthesia with placement of a DLT. During the procedure, drainage of lavage fluid was less than the amount of fluid instilled into the lung. A neutral position of the cervical spine and a deeper insertion of the bronchial tube were not sufficient to avoid the withdrawal of the DLT. Results: BAL could be performed by increasing the passive drainage time, and by active aspiration of the residual lung solution. The procedure was completed after observing that the last aliquot of the lung lavage was transparent. Discussion: Fluid retention with the consequent increase in pressure in the tracheobronchial tree favored the withdrawal of the DLT towards the trachea obstructing the airway. Conclusion: In case of incomplete drainage of lung lavage fluid accompanied by increased airway pressure, active aspiration of lavage fluid should be performed with a bronchoscope to avoid malposition of the DLT.

Keywords: Bronchoalveolar Lavage; Double Lumen Tube; Alveolar Proteinosis; Lung Lavage Solution

Introduction

Double-lumen endotracheal tube (DLT) is placed to isolate the lungs and provide independent ventilation. Indications for lung isolation include pulmonary contamination due to hemorrhage or infection, bronchopulmonary fistula, pulmonary cyst or bulla, severe hypoxemia due to unilateral lung disease, and whole bronchoalveolar lavage (BAL) [1]. The longer lumen (bronchial lumen) is designed to reach the main bronchus, whereas the shorter lumen (tracheal) ends in the distal trachea [2].

Some authors reported an incidence of malposition of the DLT in 42% of patients undergoing general anesthesia, which was related to postural changes, flexion, and extension of the neck (due to lengthening of the distance from the teeth to the tracheal carina), and surgical procedures around the pulmonary hilum that displace the DLT in a receding direction [3]. Also, although objective guidelines are lacking for the appropriate selection of DLT sizes, it is important to choose the best one for each patient to avoid malposition and respiratory obstruction problems. Generally, 39 Fr and 41 Fr tubes are used in adult men, while 35 Fr and 37 Fr DLTs are used in adult women; however, sex, age, height, and weight are poor predictors of tube size, [4,5] and direct measurement of bronchial width by chest CT, chest X-ray, or ultrasound are better predictors [6-8].

We present a case of repeated malposition of the DLT in a patient with pulmonary alveolar proteinosis undergoing BAL. The consideration of the measures described in the literature (neutral position of the cervical spine, deeper insertion of the bronchial tube) was not sufficient to avoid the withdrawal of the DLT, and pulmonary ventilation was compromised. Therefore, other causes of DLT malposition should be considered during alveolar proteinosis treatment.

Case Presentation

A 60-year-old man was diagnosed with primary alveolar proteinosis. The chest x-ray showed bilateral peribronchovascular infiltrates. The computerized tomography scan showed progression of bilateral diffuse pulmonary involvement with the appearance of extensive areas in a crazy-paving pattern (appearance of ground-glass opacities with superimposed interlobular and intralobular septal thickening). Bronchoalveolar fluid cytology showed the presence of macrophages (28%) (absence of hemosiderophages), lymphocytes (69%), neutrophils (3%), amorphous extracellular eosinophilic material (Periodic acid–Schiff positive) in nodular formations, and cytoplasmic staining of foam cells. Pulmonary function testing demonstrated normal spirometry with decreased diffusion capacity of the lung for carbon monoxide (35% of predicted). The distance walked in the six-minutes’ walk test was 527 m, maintaining a baseline SpO2 of 94% and a minimum of 89%. Given the recurrence of the disease, BAL was performed under general anesthesia.

At the beginning of the procedure, the equipment was checked, including 20 L of normal saline, an infusion of the serum system with a Y-piece connector and clamps, and a plastic container (Figure 1). The oxygen peripheral saturation (SpO2) was 90-94% on room air, non-invasive arterial tension was 132/80 mmHg and heart rate 72 bpm. Anesthetic induction was performed using fentanyl (150 µg), propofol (170 mg), and rocuronium (65 mg). We performed direct laryngoscopy and advanced the left-sided DLT to 39 Fr. Before starting lung lavage, pulmonary denitrogenation was performed using two-lung ventilation with 100% oxygen, volume-controlled ventilation (tidal volume of 530 mL), 13 breaths per minute, and positive end-expiratory pressure (PEEP) of 5 cm H2O for 30 min. The patient was placed in the supine position in an anti-Trendelenburg position (at a 30-degree angle). Thirty minutes before starting the BAL, a fiberoptic bronchoscope was inserted through the right lumen of the DLT to ensure the correct position of the DLT. Pressure-controlled ventilation was initiated for the right lung (maintaining tidal volume between 430-490 mL, 15 breaths per minute, PEEP 5 cm H20, and FiO2 0.6%). Then, BAL was started; 200 mL of saline was instilled to fill the left lung, and aliquots of 1000 mL of saline were infused at 38°, keeping the wash bags 40 cm above the mid-axillary line. After infusion of each 1000 mL aliquot, passive drainage of the effluent was performed for 10 min, without achieving a complete return of the instilled liquid despite increasing the drainage time.

After the instillation of 4000 mL of washing solution, we only recovered a total of 3100 mL and a strong increase in the maximum airway pressure up to 52 cm H2O was obtained without a capnography record. We suspected airway obstruction due to removal of the bronchial tube towards the trachea, confirmed by fiberoptic bronchoscopy. We decided to introduce the DLT more distally (the bronchial cuff was placed 4 cm deeper from the tracheal carina) near the first left bronchial branch, ensuring its patency, but the result was not successful.

 

Figure 1: Whole lung lavage equipment.

Finally, we managed to avoid the removal of the DLT after revision of the right bronchial tree with recovery and aspiration of 200 mL of saline, and with active aspiration of the residual solution from the left lung using fiberoptic bronchoscopy. The procedure continued by increasing the inspiratory pressure from 19 to 25 mmHg to maintain the tidal volume in the right lung (400 mL) and increasing the passive drainage time to 20 min after each instillation of lavage solution, followed by active aspiration of the residual solution. Even so, 9000 mL of saline was used to lavage the left lung, and only 7050 mL was recovered. The procedure was completed after observing that the last aliquot of the lung lavage was more transparent and without a precipitate (Figure 2).