REVIEWREVIEW

TRACHEAL BRONCHUSTRACHEAL BRONCHUSOne-Lung Ventilation in patients with One-Lung Ventilation in patients with

Young-Jin MoonYoung-Jin MoonDepartment of Anesthesiology and Pain MedicineDepartment of Anesthesiology and Pain Medicine

Asan Medical CenterAsan Medical Center

TABLE of CONTENTSTABLE of CONTENTS

I.I. CASE presentationCASE presentation

II. Tracheal Bronchus?II. Tracheal Bronchus?

III. ClassificationIII. Classification

IV. OLV of tracheal bronchusIV. OLV of tracheal bronchus ; using bronchial blocker and DLT ; using bronchial blocker and DLT

V. V. In siIn single lumen tubengle lumen tube

REVIEWREVIEW

CASECASE

Congenital anomaly of central airwayCongenital anomaly of central airway

0.1 - 3 %0.1 - 3 %

Right upper lobeRight upper lobe >>>> Left upper lobe / Both Left upper lobe / Both

Childhood : Wheezing, Infection, Bronchiectasis, Childhood : Wheezing, Infection, Bronchiectasis, Associated anomalies Associated anomalies

AdultAdult : : AsymtommaticAsymtommatic, Rarely malignancies, Rarely malignancies

have minimal clinical implication,have minimal clinical implication, BUT When OLV is needed... BUT When OLV is needed...

Bronchus originating from TracheaBronchus originating from Trachea

TRACHEAL BRONCHUSTRACHEAL BRONCHUS

Normal AnatomyNormal Anatomy

ClassificationClassification

Type IType I Type IIType II Type IIIType III

Simplified by I.D. Conacher Simplified by I.D. Conacher

ClassificationClassificationSimplified by I.D. Conacher Simplified by I.D. Conacher

Type I Type I 2 cm2 cm above the carina above the carina

with the with the distal trachea narroweddistal trachea narrowed

Type IIType II > 2 cm> 2 cm above the carina above the carina with with normalnormal diameter of the distal diameter of the distal tracheatrachea

Type IIIType III < 2 cm < 2 cm above the level of the carinaabove the level of the carina

One-Lung Ventilation StrategyOne-Lung Ventilation Strategy

Lt. mainLt. main

Rt. mainRt. mainTracheal bronchusTracheal bronchus

Sarah H., A&A 2011Sarah H., A&A 2011 : : Challenging Lung IsolationChallenging Lung Isolation Secondary to Secondary to AAberrant Tracheobronchial Anatomyberrant Tracheobronchial Anatomy

Anthony M.-H. Ho, A&A 2004Anthony M.-H. Ho, A&A 2004 : :tracheal bronchus <2 cmtracheal bronchus <2 cm of the carina of the carina Lt. DLTLt. DLT is available is available

One-Lung Ventilation StrategyOne-Lung Ventilation Strategy

Type IIIType III

William C. Culp, A&A 2004William C. Culp, A&A 2004 : Sequential One-Lung Isolation : Sequential One-Lung Isolation Using a Using a Double Arndt Bronchial BlockerDouble Arndt Bronchial Blocker Technique Technique

One-Lung Ventilation StrategyOne-Lung Ventilation Strategy

YY.S..S. Choi, Y Choi, Y.L..L. Kwak, Kwak, KJA 2010KJA 2010 : : Problematic tracheal intubationProblematic tracheal intubation withwith unrecognized tracheal bronchus unrecognized tracheal bronchus

Repeated sudden increased of PIP with a falling VRepeated sudden increased of PIP with a falling VTT

In In Single lumen tuSingle lumen tube?be?

Tracheal Bronchus was diagnosed after operationTracheal Bronchus was diagnosed after operation

ReferenceReference1.1. Conacher, I. D. (2000). Implications of a tracheal bronchus for adult anaesthetic practice. British Journal of Anaesthesia, 85(2), 317–320.Conacher, I. D. (2000). Implications of a tracheal bronchus for adult anaesthetic practice. British Journal of Anaesthesia, 85(2), 317–320.

2.2. Brodsky, J. B., & Mark, J. B. (1991). Bilateral upper lobe obstruction from a single double-lumen tube. Anesthesiology, 74(6), 1163–1164.Brodsky, J. B., & Mark, J. B. (1991). Bilateral upper lobe obstruction from a single double-lumen tube. Anesthesiology, 74(6), 1163–1164.

3.3. Campos, J. H. (2007). Which device should be considered the best for lung isolation: double-lumen endotracheal tube versus bronchial blockers. CurrCampos, J. H. (2007). Which device should be considered the best for lung isolation: double-lumen endotracheal tube versus bronchial blockers. Current opinion in anaesthesiology, 20(1), 27–31. doi:10.1097/ACO.0b013e3280111e2aent opinion in anaesthesiology, 20(1), 27–31. doi:10.1097/ACO.0b013e3280111e2a

4.4. Choi, Y. S., Kwak, Y. L., Choi, H. G., Oh, S. Y., & Lee, J. W. (2010). Anesthetic experience of an adult patient with an unrecognized tracheal bronchus -Choi, Y. S., Kwak, Y. L., Choi, H. G., Oh, S. Y., & Lee, J. W. (2010). Anesthetic experience of an adult patient with an unrecognized tracheal bronchus -A case report. Korean Journal of Anesthesiology, 59(Suppl), S13. doi:10.4097/kjae.2010.59.S.S13A case report. Korean Journal of Anesthesiology, 59(Suppl), S13. doi:10.4097/kjae.2010.59.S.S13

5.5. Culp, W. C., Jr., & Kinsky, M. P. (2004). Sequential One-Lung Isolation Using a Double Arndt Bronchial Blocker Technique. Anesthesia & Analgesia, 99Culp, W. C., Jr., & Kinsky, M. P. (2004). Sequential One-Lung Isolation Using a Double Arndt Bronchial Blocker Technique. Anesthesia & Analgesia, 99(3), 945–946. doi:10.1213/01.ANE.0000132697.22933.8C(3), 945–946. doi:10.1213/01.ANE.0000132697.22933.8C

6.6. Ho, A. M. H., Karmakar, M. K., Lam, W. W. M., Lam, F. O., Lee, T. W., Ng, S. K., & Chung, D. C. (2004). Does the Presence of a Tracheal Bronchus AffHo, A. M. H., Karmakar, M. K., Lam, W. W. M., Lam, F. O., Lee, T. W., Ng, S. K., & Chung, D. C. (2004). Does the Presence of a Tracheal Bronchus Affect the Margin of Safety of Double-Lumen Tube Placement? Anesthesia & Analgesia, 99(1), 293–295. doi:10.1213/01.ANE.0000118106.09944.E7ect the Margin of Safety of Double-Lumen Tube Placement? Anesthesia & Analgesia, 99(1), 293–295. doi:10.1213/01.ANE.0000118106.09944.E7

7.7. Lee, H.-L., Ho, A. C., Cheng, R. K., & Shyr, M.-H. (2002). Successful one-lung ventilation in a patient with aberrant tracheal bronchus. Anesthesia & AnLee, H.-L., Ho, A. C., Cheng, R. K., & Shyr, M.-H. (2002). Successful one-lung ventilation in a patient with aberrant tracheal bronchus. Anesthesia & Analgesia, 95(2), 492–493. doi:10.1213/01.ANE.0000021364.42109.AAalgesia, 95(2), 492–493. doi:10.1213/01.ANE.0000021364.42109.AA

8.8. Stene, R., Rose, M., Weinger, M. B., Benumof, J. L., & Harrell, J. (1994). Bronchial trifurcation at the carina complicating use of a double-lumen tracheStene, R., Rose, M., Weinger, M. B., Benumof, J. L., & Harrell, J. (1994). Bronchial trifurcation at the carina complicating use of a double-lumen tracheal tube. Anesthesiology, 80(5), 1162–1164.al tube. Anesthesiology, 80(5), 1162–1164.

9.9. Suzuki, M., Matsui, O., Takemura, A., Kobayashi, T., Yoneda, K., & Shibata, Y. (2006). Four cases of accessory cardiac bronchus incidentally detected Suzuki, M., Matsui, O., Takemura, A., Kobayashi, T., Yoneda, K., & Shibata, Y. (2006). Four cases of accessory cardiac bronchus incidentally detected on multi-detector CT. European Journal of Radiology Extra, 57(2), 47–50. doi:10.1016/j.ejrex.2005.11.003on multi-detector CT. European Journal of Radiology Extra, 57(2), 47–50. doi:10.1016/j.ejrex.2005.11.003

10.10. Wiser, S. H., & Hartigan, P. M. (2011). Challenging Lung Isolation Secondary to Aberrant Tracheobronchial Anatomy. Anesthesia & Analgesia, 112(3), Wiser, S. H., & Hartigan, P. M. (2011). Challenging Lung Isolation Secondary to Aberrant Tracheobronchial Anatomy. Anesthesia & Analgesia, 112(3), 688–692. doi:10.1213/ANE.0b013e318206917a688–692. doi:10.1213/ANE.0b013e318206917a

11.11. Yildiz, H., Ugurel, S., Soylu, K., Tasar, M., & Somuncu, I. (2006). Accessory cardiac bronchus and tracheal bronchus anomalies: CT-bronchoscopy and Yildiz, H., Ugurel, S., Soylu, K., Tasar, M., & Somuncu, I. (2006). Accessory cardiac bronchus and tracheal bronchus anomalies: CT-bronchoscopy and CT-bronchography findings. Surgical and Radiologic Anatomy, 28(6), 646–649. doi:10.1007/s00276-006-0147-3CT-bronchography findings. Surgical and Radiologic Anatomy, 28(6), 646–649. doi:10.1007/s00276-006-0147-3