The Science Journal of the American Association for Respiratory Care

2005 OPEN FORUM Abstracts


Robert R Demers, BS, RRT; Gregory B Hammer, MD; Lorry R Frankel, MD; Saraswati Kache, MD; Lucile Packard Children’s Hospital at Stanford, Palo Alto, CA 94304

The bronchial blocker, a relatively new device that has proven useful for undertaking single-lung ventilation (SLV), can be inserted through a previously-placed endotracheal tube (ETT), without obliging the clinician to extubate the patient. Ms. T. P., a 14-year-old patient, presented to the Emergency Department in respiratory distress. In the face of progressive clinical worsening, the patient was intubated with a 7.0 mm ID ETT and placed on a Dräger Evita ventilator. Synchronized intermittent mandatory ventilation (SIMV) was initiated with pressure support (PS). The SIMV rate was set to 24 breaths/minute, the fraction of inspired oxygen (FIO2) was adjusted to 0.55, the peak inspiratory pressure (PIP) was set to 30 cm H2O, the PS level was set to 10 cm H2O, and positive end-expiratory pressure (PEEP) was adjusted to 15 cm H2O. On the ninth hospital day, the patient’s compliance was observed to fall abruptly, and copious amounts of fresh blood began to emanate from the ETT. This prompted the pediatric intensivist to perform a fiberoptic bronchoscopy (FOB) procedure. Massive left-sided pulmonary hemorrhage was noted. The decision was made to insert a bronchial blocker into the left mainstem bronchus, in an attempt to: 1) prevent soiling of the right lung by blood; 2) promote tamponade of the left lung; and 3) facilitate re-expansion of the left lower lobe. As soon as the (5-French) bronchial blocker was secured, a continuous positive airway pressure (CPAP) level of 22 cm H2O (16.3 mm Hg) was applied to the proximal end of the device by means of a flow-inflating reservoir bag. Tidal volume to the contralateral lung was adjusted to 260 mL at an FIO2 of 0.85, a PS of 8 cm H2O, and a PEEP setting of 10 cm H2O. 42 hours after the blocker had been placed, a repeat FOB procedure was undertaken, at which time copious organized clots were removed from the left segmental bronchi. One observer remarked that many of these stringy clots resembled “red yarn”. Inspection of the right mainstem bronchus revealed that no soiling of that lung had occurred. A followup chest radiograph demonstrated reinflation of the left lower lobe, and confirmed that the right lung was free of clots. The patient’s subsequent ventilator course was uneventful, and she was discharged to home on the thirty-fifth hospital day, carrying a discharge diagnosis of Wegener’s granulomatosis.

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