Second thoracoscopic left lobectomy in a case of difficult single lung ventilation during left tracheobronchial intubation

Second thoracoscopic left lobectomy in a case of difficult single lung ventilation during left tracheobronchial intubation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Second thoracoscopic left lobectomy in a case of difficult single lung ventilation during left tracheobronchial intubation Bo Jiao, Jingyi Wang, Zhuxuan Song, Wen Si, Yangdong Han This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3724591/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The accessory bronchus is a physiological congenital malformation suggestive of abnormal bronchial growth that is present in 0.1%-2% of the general population. Providing adequate perioperative single-lung ventilation and airway management to affected patients remains a persistent challenge facing anesthesiologists. Case presentation In the present report, we describe a rare case of abnormal airway anatomy in a patient with lung cancer who exhibited a bronchial opening entering the right upper lobe and who had a history of right lower lobectomy for lung cancer. In addition to the normal opening, this patient exhibited a distinct tracheobronchial opening in the upper right lobe of the lung originating directly from the trachea and above the protuberans. However, the patient had two side tracheal bronchi that he could see above the bronchus. Using left single lumen endotracheal intubation and right lung single lung ventilation, the patient underwent left lower lung lobectomy, and no anesthetic complications were observed during recovery. Conclusions In this case, timely tracheobronchial identification and successful single-lung ventilation of the right lung while avoiding hypoxemia were central to appropriate anesthesia management. Bronchial anatomy lobectomy anaesthesia Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Medical and societal advances in recent years including higher rates of lung computed tomography (CT) examination have led to more patients being tested during earlier stages of lung disease and undergoing active forms of treatment such as lobectomy [ 1 , 2 ] . Continuous improvements in operative procedures have enabled patients to recover more quickly once surgery is complete [ 3 ] . The use of double-lumen tubes when performing surgical procedures has also become increasingly common, but levels of bronchial variability are high, which has the potential to adversely affect the use of these tubes [ 4 , 5 ] . Acobronchus is an abnormality that affects an estimated 0.1%-2% of the general population. In the clinic, many anesthesiologists find that bronchial anatomical variations can complicate intraoperative positioning, potentially resulting in prolonged intraoperative periods of low oxygen saturation [ 6 – 8 ] . This, in turn, can result in negative patient outcomes. It is thus important that anesthesiologists master the anatomical considerations of each patient based on a comprehensive review of available preoperative scans. Case presentation A 54-year-old female (156 cm, 69 kg) was admitted to the hospital following the discovery of a nodule in her lower left lung. She had previously undergone thoracoscopic lower lobectomy of the right lung with lymph node dissection at China-Japan Union Hospital of Jilin University 17 months ago. Subsequent review revealed the presence of a ground-glass density nodular shadow in the lower lobe of her left lung, and she was therefore scheduled to undergo an elective thoracoscopic pulmonary wedge resection. The insertion of a left-sided double-lumen bronchial catheter for ventilation was planned after communication with the thoracic surgeon. After entering the operating room, the patient was provided with routine anesthetic monitoring. General anesthesia induction was achieved using intravenous sufentanil (25 ug), propofol (100 mg), and cisatracurium (10 mg) for neuromuscular blockage. A 35-Fr left-sided double-lumen tube was then used for intubation using a No. 3 laryngoscope, with this tube being inserted to a depth of 30 cm from the upper incisors. Sevoflurane and remifentanil were used for maintenance anesthesia. After intubation, the distance of the double-lumen bronchial catheter from the incisors was adjusted. Both lungs were auscultated with a stethoscope, revealing no breath sounds on the auscultation of the right lung field. This, coupled with the high resistance that was felt during manual ventilation, prompted immediate fibrilloscopy. No tracheal carina was detected when the fiberoptic bronchoscope was used to probe the right catheter (Fig. 1 ). To aid localization, the thoracic surgeon had stained it in advance using a blue dye, which resulted in difficulties distinguishing the location of the blue bronchial cuff. We were ultimately able to establish the positioning of the blue bronchial cuff based on light reflection from the cuff upon pumping air. However, a distinct tracheal carina was not detectable. We then adjusted the catheter depth while providing manual ventilation, and when we advanced it inward by ~ 1 cm, we felt moderate resistance to ventilation and fixed the tube in this position. Reexamination revealed normal breath sounds in the right lung field, and the peak inspiratory pressure (PIP) for single right lung ventilation at this time was 30 cm H 2 O. After the endotracheal tube had been secured, the patient was adjusted into a right recumbent position. During the procedure, the ventilator was set to volume control mode and the patient was provided with pure oxygen at an oxygen flow rate of 2 L/min, with a tidal volume of 300 mL, single right-lung ventilation with a frequency of 15 breaths/min, PIP of 30 cm H 2 O, and venous oxygen saturation (SpO2) that was maintained at 92%, with stable heart rate and blood pressure. As the patient only had two remaining right lung lobes, these vital signs were considered more than satisfactory. At ~ 30 minutes into the procedure, their PIP rose to 40 cm H 2 O while their SpO 2 rapidly declined. After emergency bilateral ventilation their SpO 2 returned to normal levels. Given that the patient had undergone lobectomy 17 months prior and exhibited severe thoracic adhesions, it is likely that maneuvering by the operating surgeon during this procedure pulled on the tracheal tube such that it retracted slightly. Accordingly, we advanced the catheter inward by ~ 0.5 cm. When single-lung ventilation of the right lung was repeated, the patient’s PIP decreased while her SpO 2 stabilized at 94%. The total duration of anesthetization was 100 min, and there were no intraoperative or postoperative complications. Discussion A subsequent review of the data from this patient revealed that their atypical tracheobronchial and lower right lung lobe anatomy were the cause of the difficulties encountered during unilateral right lung ventilation(Fig. 2 , 3 , 4 , 5 ).A correct double-lumen bronchial intubation should look like this(Fig. 6 simulated diagram A). Given these anatomical anomalies, deep tube insertion would block the right tracheobronchus (Fig. 6 simulated diagram C), while more shallow insertion would directly block the right bronchial branch (Fig. 6 simulated diagram B) [ 9 ] . These factors prevented the adjustment of the distance between the tube and the incisors based on the observed bulge normally used in this context. As the patient’s right lower lobe had been resected, this also damaged their lung oxygenation such that their SpO 2 declined rapidly upon unilateral right lung ventilation [ 10 ] . Indeed, during the procedure, their SpO 2 decreased and their PIP increased, likely because the displacement of the blue cuff resulted in the blockage of the right bronchial branch and the fact that the ventilatory function of the remaining right upper lobe was insufficient, as confirmed by the success of the subsequently employed treatment place(Fig. 6 simulated diagram D). A complex case such as the one presented herein represents a unique challenge, testing the ability of the attending anesthesiologist to rescue patients and their anatomical knowledge of the bronchi. Conclusions This case underscores the importance of anesthesiologists being aware of the potential for bronchial anatomical variation. It is important that available CT results be reviewed and that the direction of the trachea be assessed, with careful auscultation and confirmation of the bronchial direction during bronchoscopy procedures. Rather than relying solely on radiologist reports, anesthesiologists should comprehensively assess available preoperative scans [ 11 ] . However, conventional radiological imaging may be insufficient to detect these abnormalities, requiring more sophisticated and advanced reconstruction techniques. In cases where hypoxemia occurs, it is important to avoid panic and to initially stabilize the patient’s condition followed by the exclusion of possible events, and the establishment of a targeted treatment approach. Declarations Availability of data and materials The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. Acknowledgements The authors thank the patient who participated in this study. Funding Not applicable. Author information Authors and Affiliation Department of Anesthesiology, Bethune Third Hospital of Jilin University,Jilin, 130000, People's Republic of China Bo Jiao , Jingyi Wang , Zhuxuan Song , Wen Si & Yangdong Han Contributions JB collected data and consent and drafted the initial manuscript.WJY and SZX are both substantively revised and edited the initial manuscript.HYD was the supervising author. SW revised the article critically for important intellectual content.All authors read and approved the final manuscript. Corresponding author Correspondence to Yangdong Han Ethics declarations Ethics approval and consent to participate Not applicable. Consent for publication Written informed consent was obtained from the patient for publication of identifying images or other personal or clinical details of this case report. Competing interests The authors declare that they have no competing interests. References QI J, LI M, WANG L, et al. National and subnational trends in cancer burden in China, 2005-20: an analysis of national mortality surveillance data [J]. The Lancet Public health. 2023;8(12):e943–e55. ZHENG Y, DONG J, YANG X, et al. Benign-malignant classification of pulmonary nodules by low-dose spiral computerized tomography and clinical data with machine learning in opportunistic screening [J]. Cancer Med. 2023;12(11):12050–64. LIM E, HARRIS R, MCKEON H et al. Impact of video-assisted thoracoscopic lobectomy versus open lobectomy for lung cancer on recovery assessed using self-reported physical function: VIOLET RCT [J]. Health technology assessment (Winchester, England), 2022, 26(48): 1–162. MARTíN-RUIZ S, GUTIéRREZ-COLLAR C, FORCéN VICENTE DE VERA, E, et al. The bronchial segmentation and its anatomical variations. A clinical-anatomic and bronchoscopy study [J]. Annals of anatomy = Anatomischer Anzeiger: official organ of the Anatomische Gesellschaft. 2021;235:151677. WOOTEN C, PATEL S. CASSIDY L, et al. Variations of the tracheobronchial tree: anatomical and clinical significance [J]. Volume 27. Clinical anatomy (New York, NY); 2014. pp. 1223–33. 8. CHO H, KIM H, GONG H, et al. Incidental left main bronchus obstruction during left-sided double-lumen tube intubation of a patient with an unrecognized tracheal bronchus: A case report [J]. Medicine. 2016;95(52):e5674. YOSHIMURA T, UEDA K, KAKINUMA A, et al. Difficulty in placement of a left-sided double-lumen tube due to aberrant tracheobronchial anatomy [J]. J Clin Anesth. 2013;25(5):413–6. WISER S, HARTIGAN P. Challenging lung isolation secondary to aberrant tracheobronchial anatomy [J]. Anesth Analg. 2011;112(3):688–92. HO A, KARMAKAR M, LAM W, et al. Does the presence of a tracheal bronchus affect the margin of safety of double-lumen tube placement? [J]. Anesth Analg. 2004;99(1):293–5. KARZAI W. Hypoxemia during one-lung ventilation: prediction, prevention, and treatment [J]. Anesthesiology. 2009;110(6):1402–11. CHEN Y, GUO Y, MI W, et al. Anatomy of the right upper lobe revisited and clinical considerations in Chinese population [J]. PLoS ONE. 2020;15(11):e0242178. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3724591","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":260599268,"identity":"d7c52169-2011-4a9e-9110-ff3d2540c95a","order_by":0,"name":"Bo Jiao","email":"","orcid":"","institution":"Jilin University","correspondingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Jiao","suffix":""},{"id":260599271,"identity":"9c72205a-b53d-4656-99b3-d7757fd78739","order_by":1,"name":"Jingyi Wang","email":"","orcid":"","institution":"Jilin 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Han","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuElEQVRIiWNgGAWjYBACAxDBU8EmA6IlSNByho2HRC28bQwkaDFnP3tM4u08Ph6DA8wHb/Mw2OUR1GLZk5cmOXcbG1ALW7I1D0NyMWGHHcgxk+YFa+Exk+ZhOJDYQFDL+TdALXNAWvi/EanlBsiWBrAtbMRqeWNsOecYG4/kYTYgwyCZGIflGN54U3NMju9488MbbyrsCGsBAhZgdBxjYGAGm0CEeiBg/sDAUEOc0lEwCkbBKBiZAAA3yzTS+OBh0wAAAABJRU5ErkJggg==","orcid":"","institution":"Jilin University","correspondingAuthor":true,"prefix":"","firstName":"Yangdong","middleName":"","lastName":"Han","suffix":""}],"badges":[],"createdAt":"2023-12-08 08:59:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3724591/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3724591/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":48493471,"identity":"250459ae-344e-4496-a731-afe765181c30","added_by":"auto","created_at":"2023-12-19 20:59:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":6788,"visible":true,"origin":"","legend":"\u003cp\u003eThe circle on the far left represents the right bronchi\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3724591/v1/706fd62c7c0a26e25ebac7c2.png"},{"id":48493458,"identity":"29806e0a-07af-48c2-8f68-522de69c20fb","added_by":"auto","created_at":"2023-12-19 20:59:18","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":28192,"visible":true,"origin":"","legend":"\u003cp\u003eTracheobronchial tubes are marked with arrows\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3724591/v1/3ea7ac13897b4706109bec11.jpeg"},{"id":48493459,"identity":"87710ae4-5a0f-4102-8981-17a6e4d94ba9","added_by":"auto","created_at":"2023-12-19 20:59:18","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":105469,"visible":true,"origin":"","legend":"\u003cp\u003eThe second preoperative lung CT results for this patient.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-3724591/v1/d45efc4dbc5b6a9346236e6c.png"},{"id":48493473,"identity":"d97d2cb6-bab9-480e-b9aa-1a2e5966fbde","added_by":"auto","created_at":"2023-12-19 20:59:19","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":185232,"visible":true,"origin":"","legend":"\u003cp\u003eNormal X-ray findings First postoperative chest x-ray Second postoperative chest x-ray\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-3724591/v1/2ad720e5263cae4853926ffd.png"},{"id":48493465,"identity":"55ffe17e-1ee3-47f5-8428-3a8864e9c51a","added_by":"auto","created_at":"2023-12-19 20:59:18","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":3883,"visible":true,"origin":"","legend":"\u003cp\u003eAnatomical diagram of the patient\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3724591/v1/c3fd279c0e68a0c130998ec6.jpeg"},{"id":48493469,"identity":"fb76ee02-f6a9-43b7-a268-96993b7495f5","added_by":"auto","created_at":"2023-12-19 20:59:18","extension":"jpeg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":58469,"visible":true,"origin":"","legend":"\u003cp\u003eSimulated diagram. \u003cstrong\u003eA. \u003c/strong\u003eThe normal condition. \u003cstrong\u003eB, C. \u003c/strong\u003eThe process of tube adjustment. \u003cstrong\u003eD. \u003c/strong\u003eThe final position for this patient.\u003c/p\u003e","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-3724591/v1/bba678582deb7426839bcc8b.jpeg"},{"id":54768454,"identity":"49d2e635-f744-4247-b07a-6928d8e12242","added_by":"auto","created_at":"2024-04-16 13:35:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":669585,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3724591/v1/c5ad3e7e-74c9-47e9-bd01-f2f1f284bad4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Second thoracoscopic left lobectomy in a case of difficult single lung ventilation during left tracheobronchial intubation","fulltext":[{"header":"Background","content":"\u003cp\u003eMedical and societal advances in recent years including higher rates of lung computed tomography (CT) examination have led to more patients being tested during earlier stages of lung disease and undergoing active forms of treatment such as lobectomy\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Continuous improvements in operative procedures have enabled patients to recover more quickly once surgery is complete\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. The use of double-lumen tubes when performing surgical procedures has also become increasingly common, but levels of bronchial variability are high, which has the potential to adversely affect the use of these tubes \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Acobronchus is an abnormality that affects an estimated 0.1%-2% of the general population. In the clinic, many anesthesiologists find that bronchial anatomical variations can complicate intraoperative positioning, potentially resulting in prolonged intraoperative periods of low oxygen saturation\u003csup\u003e[\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. This, in turn, can result in negative patient outcomes. It is thus important that anesthesiologists master the anatomical considerations of each patient based on a comprehensive review of available preoperative scans.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 54-year-old female (156 cm, 69 kg) was admitted to the hospital following the discovery of a nodule in her lower left lung. She had previously undergone thoracoscopic lower lobectomy of the right lung with lymph node dissection at China-Japan Union Hospital of Jilin University 17 months ago. Subsequent review revealed the presence of a ground-glass density nodular shadow in the lower lobe of her left lung, and she was therefore scheduled to undergo an elective thoracoscopic pulmonary wedge resection. The insertion of a left-sided double-lumen bronchial catheter for ventilation was planned after communication with the thoracic surgeon.\u003c/p\u003e \u003cp\u003eAfter entering the operating room, the patient was provided with routine anesthetic monitoring. General anesthesia induction was achieved using intravenous sufentanil (25 ug), propofol (100 mg), and cisatracurium (10 mg) for neuromuscular blockage. A 35-Fr left-sided double-lumen tube was then used for intubation using a No. 3 laryngoscope, with this tube being inserted to a depth of 30 cm from the upper incisors. Sevoflurane and remifentanil were used for maintenance anesthesia.\u003c/p\u003e \u003cp\u003eAfter intubation, the distance of the double-lumen bronchial catheter from the incisors was adjusted. Both lungs were auscultated with a stethoscope, revealing no breath sounds on the auscultation of the right lung field. This, coupled with the high resistance that was felt during manual ventilation, prompted immediate fibrilloscopy. No tracheal carina was detected when the fiberoptic bronchoscope was used to probe the right catheter (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). To aid localization, the thoracic surgeon had stained it in advance using a blue dye, which resulted in difficulties distinguishing the location of the blue bronchial cuff. We were ultimately able to establish the positioning of the blue bronchial cuff based on light reflection from the cuff upon pumping air. However, a distinct tracheal carina was not detectable. We then adjusted the catheter depth while providing manual ventilation, and when we advanced it inward by ~\u0026thinsp;1 cm, we felt moderate resistance to ventilation and fixed the tube in this position. Reexamination revealed normal breath sounds in the right lung field, and the peak inspiratory pressure (PIP) for single right lung ventilation at this time was 30 cm H\u003csub\u003e2\u003c/sub\u003eO.\u003c/p\u003e \u003cp\u003eAfter the endotracheal tube had been secured, the patient was adjusted into a right recumbent position. During the procedure, the ventilator was set to volume control mode and the patient was provided with pure oxygen at an oxygen flow rate of 2 L/min, with a tidal volume of 300 mL, single right-lung ventilation with a frequency of 15 breaths/min, PIP of 30 cm H\u003csub\u003e2\u003c/sub\u003eO, and venous oxygen saturation (SpO2) that was maintained at 92%, with stable heart rate and blood pressure. As the patient only had two remaining right lung lobes, these vital signs were considered more than satisfactory. At ~\u0026thinsp;30 minutes into the procedure, their PIP rose to 40 cm H\u003csub\u003e2\u003c/sub\u003eO while their SpO\u003csub\u003e2\u003c/sub\u003e rapidly declined. After emergency bilateral ventilation their SpO\u003csub\u003e2\u003c/sub\u003e returned to normal levels. Given that the patient had undergone lobectomy 17 months prior and exhibited severe thoracic adhesions, it is likely that maneuvering by the operating surgeon during this procedure pulled on the tracheal tube such that it retracted slightly. Accordingly, we advanced the catheter inward by ~\u0026thinsp;0.5 cm. When single-lung ventilation of the right lung was repeated, the patient\u0026rsquo;s PIP decreased while her SpO\u003csub\u003e2\u003c/sub\u003e stabilized at 94%. The total duration of anesthetization was 100 min, and there were no intraoperative or postoperative complications.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eA subsequent review of the data from this patient revealed that their atypical tracheobronchial and lower right lung lobe anatomy were the cause of the difficulties encountered during unilateral right lung ventilation(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e,\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e,\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e,\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).A correct double-lumen bronchial intubation should look like this(Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e simulated diagram A). Given these anatomical anomalies, deep tube insertion would block the right tracheobronchus (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e simulated diagram C), while more shallow insertion would directly block the right bronchial branch (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e simulated diagram B)\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. These factors prevented the adjustment of the distance between the tube and the incisors based on the observed bulge normally used in this context. As the patient\u0026rsquo;s right lower lobe had been resected, this also damaged their lung oxygenation such that their SpO\u003csub\u003e2\u003c/sub\u003e declined rapidly upon unilateral right lung ventilation \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Indeed, during the procedure, their SpO\u003csub\u003e2\u003c/sub\u003e decreased and their PIP increased, likely because the displacement of the blue cuff resulted in the blockage of the right bronchial branch and the fact that the ventilatory function of the remaining right upper lobe was insufficient, as confirmed by the success of the subsequently employed treatment place(Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e simulated diagram D). A complex case such as the one presented herein represents a unique challenge, testing the ability of the attending anesthesiologist to rescue patients and their anatomical knowledge of the bronchi.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis case underscores the importance of anesthesiologists being aware of the potential for bronchial anatomical variation. It is important that available CT results be reviewed and that the direction of the trachea be assessed, with careful auscultation and confirmation of the bronchial direction during bronchoscopy procedures. Rather than relying solely on radiologist reports, anesthesiologists should comprehensively assess available preoperative scans \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. However, conventional radiological imaging may be insufficient to detect these abnormalities, requiring more sophisticated and advanced reconstruction techniques. In cases where hypoxemia occurs, it is important to avoid panic and to initially stabilize the patient\u0026rsquo;s condition followed by the exclusion of possible events, and the establishment of a targeted treatment approach.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eThe authors thank the patient who participated in this study.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAuthor information\u003c/p\u003e\n\u003cp\u003eAuthors and Affiliation\u003c/p\u003e\n\u003cp\u003eDepartment of Anesthesiology, Bethune Third Hospital of Jilin University,Jilin, 130000, People's Republic of China\u003c/p\u003e\n\u003cp\u003eBo Jiao , Jingyi Wang , Zhuxuan Song , Wen Si \u0026amp; Yangdong Han\u003c/p\u003e\n\u003cp\u003eContributions\u003c/p\u003e\n\u003cp\u003eJB collected data and consent and drafted the initial manuscript.WJY and SZX are both substantively revised and edited the initial manuscript.HYD was the supervising author.\u0026nbsp;SW revised the article critically for important intellectual content.All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eCorresponding author\u003c/p\u003e\n\u003cp\u003eCorrespondence to Yangdong Han\u003c/p\u003e\n\u003cp\u003eEthics declarations\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of identifying images or other personal or clinical details of this case report.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eQI J, LI M, WANG L, et al. National and subnational trends in cancer burden in China, 2005-20: an analysis of national mortality surveillance data [J]. The Lancet Public health. 2023;8(12):e943\u0026ndash;e55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZHENG Y, DONG J, YANG X, et al. Benign-malignant classification of pulmonary nodules by low-dose spiral computerized tomography and clinical data with machine learning in opportunistic screening [J]. Cancer Med. 2023;12(11):12050\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLIM E, HARRIS R, MCKEON H et al. Impact of video-assisted thoracoscopic lobectomy versus open lobectomy for lung cancer on recovery assessed using self-reported physical function: VIOLET RCT [J]. Health technology assessment (Winchester, England), 2022, 26(48): 1\u0026ndash;162.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMART\u0026iacute;N-RUIZ S, GUTI\u0026eacute;RREZ-COLLAR C, FORC\u0026eacute;N VICENTE DE VERA, E, et al. The bronchial segmentation and its anatomical variations. A clinical-anatomic and bronchoscopy study [J]. Annals of anatomy = Anatomischer Anzeiger: official organ of the Anatomische Gesellschaft. 2021;235:151677.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWOOTEN C, PATEL S. CASSIDY L, et al. Variations of the tracheobronchial tree: anatomical and clinical significance [J]. Volume 27. Clinical anatomy (New York, NY); 2014. pp. 1223\u0026ndash;33. 8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCHO H, KIM H, GONG H, et al. Incidental left main bronchus obstruction during left-sided double-lumen tube intubation of a patient with an unrecognized tracheal bronchus: A case report [J]. Medicine. 2016;95(52):e5674.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYOSHIMURA T, UEDA K, KAKINUMA A, et al. Difficulty in placement of a left-sided double-lumen tube due to aberrant tracheobronchial anatomy [J]. J Clin Anesth. 2013;25(5):413\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWISER S, HARTIGAN P. Challenging lung isolation secondary to aberrant tracheobronchial anatomy [J]. Anesth Analg. 2011;112(3):688\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHO A, KARMAKAR M, LAM W, et al. Does the presence of a tracheal bronchus affect the margin of safety of double-lumen tube placement? [J]. Anesth Analg. 2004;99(1):293\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKARZAI W. Hypoxemia during one-lung ventilation: prediction, prevention, and treatment [J]. Anesthesiology. 2009;110(6):1402\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCHEN Y, GUO Y, MI W, et al. Anatomy of the right upper lobe revisited and clinical considerations in Chinese population [J]. PLoS ONE. 2020;15(11):e0242178.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Bronchial anatomy, lobectomy, anaesthesia","lastPublishedDoi":"10.21203/rs.3.rs-3724591/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3724591/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe accessory bronchus is a physiological congenital malformation suggestive of abnormal bronchial growth that is present in 0.1%-2% of the general population. Providing adequate perioperative single-lung ventilation and airway management to affected patients remains a persistent challenge facing anesthesiologists.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eIn the present report, we describe a rare case of abnormal airway anatomy in a patient with lung cancer who exhibited a bronchial opening entering the right upper lobe and who had a history of right lower lobectomy for lung cancer. In addition to the normal opening, this patient exhibited a distinct tracheobronchial opening in the upper right lobe of the lung originating directly from the trachea and above the protuberans. However, the patient had two side tracheal bronchi that he could see above the bronchus. Using left single lumen endotracheal intubation and right lung single lung ventilation, the patient underwent left lower lung lobectomy, and no anesthetic complications were observed during recovery.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eIn this case, timely tracheobronchial identification and successful single-lung ventilation of the right lung while avoiding hypoxemia were central to appropriate anesthesia management.\u003c/p\u003e","manuscriptTitle":"Second thoracoscopic left lobectomy in a case of difficult single lung ventilation during left tracheobronchial intubation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-12-19 20:59:12","doi":"10.21203/rs.3.rs-3724591/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b07629d5-1189-4f7e-a9a3-05bf63aa03f7","owner":[],"postedDate":"December 19th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-04-16T13:27:25+00:00","versionOfRecord":[],"versionCreatedAt":"2023-12-19 20:59:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3724591","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3724591","identity":"rs-3724591","version":["v1"]},"buildId":"J0_U0BvcaRcwD8yVFaRlm","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}