A New Method for Selective Left Main Bronchus Intubation in Premature Infants By Zalman Weintraub,
Anita Oliven, Danny Weissman,
and Zeev Sonis
Haifa, Israel 0 Unilateral massive pulmonary atelectasis, and pulmonary interstitial emphysema (PIE) are problems that frequently occur in ventilated premature infants. Selective main bronchus intubation (SBI) of the atelectatic lung. or the contralateral lung in unilateral PIE, is an accepted procedure. However, whereas right SBI is usually easily performed, left SBI is frequently difficult. We have developed a method for left SBI using a regular portex endotracheal tube in which an elliptical hole 1 cm in length has been cut through half the circumference 0.5 cm above the tip of the oblique distal end. With the elliptical side hole directed to the left lung, left SBI can easily, and repeatedly be accomplished. This method may prove life saving in certain cases of unilateral atelectasis or PIE. @ 1990 by W.B. Saunders Company. INDEX WORDS: sema, infants.
Atelectasis,
infants;
pulmonary
introduce an endotracheal tube to the left bronchus were unsuccessful. The endotracheal tube (Portex no. 2.5) was then adapted as follows. An elliptical hole, 2 cm in length, was cut through half the circumference 0.5 cm above the tip of the oblique distal end (Fig 2).
emphy-
ELECTIVE SUCTIONING of the bronchus of the involved lung has been recommended in massive unilateral atelectasis.1*2 However, this is not always successful and in such cases selective main bronchus intubation (SBI), ventilation, and repeated suctioning through the endotracheal tube may reexpand the collapsed lung. SBI may also be helpful in resolving unilateral pulmonary interstitial emphysema (PIE) by selective intubation and ventilation of the contralateral lung.3 The right bronchus is easily intubated without the need of fluoroscopy. However, left SBI is more problematic. We have developed an effective method by which left SBI can easily be accomplished without the aid of Ruoroscopy.
S
CASE
REPORT
A 1,000-g 28 weeks’ gestation girl was intubated and mechani-
cally ventilated for RDS. She developed massive left lung collapse due to thick bronchial secretions (Fig lA), accompanied by marked deterioration of her physical condition. Positioning the infant on her right side, vigorous physiotherapy, and suctioning, including selective left bronchial suctioning with a curved pediatric arterial line, failed to reopen the collapsed left lung. Multiple attempts to
From the Neonatal Intensive Care Unit, Lady Davis Carmel Hospital, Haifa, Israel. Date accepted: August 2. 1989. Address reprint requests to Z. Weintraub, MD. Neonatal Intensive Care Unit, Lady Davis Carmel Hospital, 7 Michal St. Haifa 34362, Israel. 0 1990 by W.B. Saunders Company. 0022-3468/90/2506-0005$03.00/0
Fig 1. W Massive left lung stelectasis. (6) The adapted endotrscheal tube positioned in the left main bronchus.
604
Journal of Pediatric Surgery, Vol 25, No 6 (June),
1990:
pp 604-606
SELECTIVEMAIN BRONCHUS INTUBATION
605
SBI were abandoned. Later, the infant developed severe progressive bilateral PIE, suffered a cardiac arrest, and died at the age of 1 month. DISCUSSION
Fig 2. The adapted endotracheal tube. Note the elliptical hole (1 cm in length) through half the circumference of the tube, % cm above the tip of the oblique distal end along the longer edge. The infant’s head was positioned in the midline and the endotracheal tube was introduced into the trachea with the elliptical hole directed towards the infant’s left side. The tube was easily inserted into the left main bronchus, and this was confirmed roentgenographically (Fig 1B). In order to confirm the reliability of this method, the infant was extubated and the procedure easily repeated, again with roentgenographic confirmation. After 3 hours of selective left lung ventilation and repeated bronchial suctioning, the collapsed left lung completely reexpanded (Fig 3) with the disappearance of the compensatory hyperinflation of the right lung. The tube was then replaced by a regular intratracheal tube. The entire procedure was well tolerated by the baby. Left lung collapse reoccurred on two occasions. In both instances, the left lung was reexpanded by left SBI, accomplished promptly and easily by the method described previously. At 3 weeks of age, the infant’s condition further deteriorated due to severe right PIE (Fig 4A). SBI, by the previously described method, was again easily performed, followed several hours later by virtual resolution of PIE (Fig 4B). Subsequently, due to reoccurrence of right PIE, left SBI, by the specially prepared tube, was successfully repeated on two occasions with a significant resolution of right PIE. As right PIE persisted, after changing the left main bronchus tube with a regular intratracheal tube, further attempts at treatment by
Massive lung atelectasis occurs frequently in preterm infants receiving assisted ventilation4 The condition is related to thickened bronchial secretions, ciliary dysfunction, and damaged tracheal mucosa. If the atelectasis is recalcitrant to chest physiotherapy and suctioning, selective lavage and suctioning of the bronchus may be achieved by passing a curved catheter through the endotracheal tube and advancing it into the occluded bronchus. L* Due to difficulties of the procedure, selective suctioning of the left main bronchus frequently has to be carried out under direct fluoroscopic control. Bronchoscopy is an alternative method of management,5 although this procedure may endanger the already compromised infant, and is not always successful. Some cases require frequent selective left lung suctioning and continuous ventilation for several hours in order to fully expand the involved lung. In such instances, SBI may be the only solution. The right main bronchus is easily intubated but it is difficult or even impossible to intubate the left bronchus without fluoroscopic control. Therefore, an easy and reliable method for left SBI is of importance. We found that by adapting an endotracheal tube as described previously and introducing it into the bronchus with the pointed tip and the elliptical side hole directed to the left lung, the tube can easily and repeatedly be placed in the left main bronchus. The success of the method may be explained as follows. As the distal end of the tube
Fig 3. Complete expansion of the collapsed left lung, after 3 hours of selective left bronchial intubation suctioning and ventilation.
WEINTRAUB ET AL
Fig 4. (A) Right interstitial emphysema with the adapted endotracheal tube positioned in the left main bronchus. (B) Disappearance of interstitial emphysema of the right lung after several hours of left main bronchus intubation and ventilation.
reaches the carina, the pointed tip of the oblique end that is directed toward the left lung naturally slips over the carina to the left side toward the entrance of the left main bronchus. The elliptical side-hole gives the distal segment of the tube the necessary flexibility in order to bend towards the left bronchus. The left lung can then be repeatedly suctioned and ventilated until it fully expands. This method provides an easy and reliable form of left main bronchus intubation and can
be used as the initial procedure of choice for massive left lung atelectasis. Bilateral, or unilateral PIE is another frequent, life endangering sequela in ventilated premature infants.6 Occasionally, contralateral SBI may be needed in order to resolve unilateral PIE.3 Therefore, left SBI may also prove life saving in some cases of massive isolated right PIE.
REFERENCES 1. Placzek M, Silverman M: Selective placement of bronchial suction chatheters in intubated neonates. Arch Dis Child 58:829, 1983 2. Wesenberg RL, &ruble R: Selective bronchial catheterization and lavage in the newborn. Pediatr Radio1 195:397,1972 _ 3. Brooks JG, Bustamante SA, Koops BL, et al: Selective bronchial intubation for the treatment of severe localized pulmonary interstitial emphysema in newborn infants. J Pediatr 91:648,1977 4. Whitfilcd NM, Douglas Jones M: Atelectasis associated with
mechanical ventilation for hyaline membrane disease. Crit Care Med 8:729,1980 5. Wood RE: The flexible fiberoptic bronchoscope as a diagnostic and therapeutic tool in infants, in Milner AD, Marvin RY (eds): Neonatal and Pediatric Respiratory Medicine. London, England, Butterworths, 1985, pp 101-l 10 6. Thibeault DW, Lachman RS, Laul VR, et al: Pulmonary interstitial emphysema, pneumomediastinum and pneumothorax. Am J Dis Child 126:611, 1973
Anita Oliven, Danny Weissman,
and Zeev Sonis
Haifa, Israel 0 Unilateral massive pulmonary atelectasis, and pulmonary interstitial emphysema (PIE) are problems that frequently occur in ventilated premature infants. Selective main bronchus intubation (SBI) of the atelectatic lung. or the contralateral lung in unilateral PIE, is an accepted procedure. However, whereas right SBI is usually easily performed, left SBI is frequently difficult. We have developed a method for left SBI using a regular portex endotracheal tube in which an elliptical hole 1 cm in length has been cut through half the circumference 0.5 cm above the tip of the oblique distal end. With the elliptical side hole directed to the left lung, left SBI can easily, and repeatedly be accomplished. This method may prove life saving in certain cases of unilateral atelectasis or PIE. @ 1990 by W.B. Saunders Company. INDEX WORDS: sema, infants.
Atelectasis,
infants;
pulmonary
introduce an endotracheal tube to the left bronchus were unsuccessful. The endotracheal tube (Portex no. 2.5) was then adapted as follows. An elliptical hole, 2 cm in length, was cut through half the circumference 0.5 cm above the tip of the oblique distal end (Fig 2).
emphy-
ELECTIVE SUCTIONING of the bronchus of the involved lung has been recommended in massive unilateral atelectasis.1*2 However, this is not always successful and in such cases selective main bronchus intubation (SBI), ventilation, and repeated suctioning through the endotracheal tube may reexpand the collapsed lung. SBI may also be helpful in resolving unilateral pulmonary interstitial emphysema (PIE) by selective intubation and ventilation of the contralateral lung.3 The right bronchus is easily intubated without the need of fluoroscopy. However, left SBI is more problematic. We have developed an effective method by which left SBI can easily be accomplished without the aid of Ruoroscopy.
S
CASE
REPORT
A 1,000-g 28 weeks’ gestation girl was intubated and mechani-
cally ventilated for RDS. She developed massive left lung collapse due to thick bronchial secretions (Fig lA), accompanied by marked deterioration of her physical condition. Positioning the infant on her right side, vigorous physiotherapy, and suctioning, including selective left bronchial suctioning with a curved pediatric arterial line, failed to reopen the collapsed left lung. Multiple attempts to
From the Neonatal Intensive Care Unit, Lady Davis Carmel Hospital, Haifa, Israel. Date accepted: August 2. 1989. Address reprint requests to Z. Weintraub, MD. Neonatal Intensive Care Unit, Lady Davis Carmel Hospital, 7 Michal St. Haifa 34362, Israel. 0 1990 by W.B. Saunders Company. 0022-3468/90/2506-0005$03.00/0
Fig 1. W Massive left lung stelectasis. (6) The adapted endotrscheal tube positioned in the left main bronchus.
604
Journal of Pediatric Surgery, Vol 25, No 6 (June),
1990:
pp 604-606
SELECTIVEMAIN BRONCHUS INTUBATION
605
SBI were abandoned. Later, the infant developed severe progressive bilateral PIE, suffered a cardiac arrest, and died at the age of 1 month. DISCUSSION
Fig 2. The adapted endotracheal tube. Note the elliptical hole (1 cm in length) through half the circumference of the tube, % cm above the tip of the oblique distal end along the longer edge. The infant’s head was positioned in the midline and the endotracheal tube was introduced into the trachea with the elliptical hole directed towards the infant’s left side. The tube was easily inserted into the left main bronchus, and this was confirmed roentgenographically (Fig 1B). In order to confirm the reliability of this method, the infant was extubated and the procedure easily repeated, again with roentgenographic confirmation. After 3 hours of selective left lung ventilation and repeated bronchial suctioning, the collapsed left lung completely reexpanded (Fig 3) with the disappearance of the compensatory hyperinflation of the right lung. The tube was then replaced by a regular intratracheal tube. The entire procedure was well tolerated by the baby. Left lung collapse reoccurred on two occasions. In both instances, the left lung was reexpanded by left SBI, accomplished promptly and easily by the method described previously. At 3 weeks of age, the infant’s condition further deteriorated due to severe right PIE (Fig 4A). SBI, by the previously described method, was again easily performed, followed several hours later by virtual resolution of PIE (Fig 4B). Subsequently, due to reoccurrence of right PIE, left SBI, by the specially prepared tube, was successfully repeated on two occasions with a significant resolution of right PIE. As right PIE persisted, after changing the left main bronchus tube with a regular intratracheal tube, further attempts at treatment by
Massive lung atelectasis occurs frequently in preterm infants receiving assisted ventilation4 The condition is related to thickened bronchial secretions, ciliary dysfunction, and damaged tracheal mucosa. If the atelectasis is recalcitrant to chest physiotherapy and suctioning, selective lavage and suctioning of the bronchus may be achieved by passing a curved catheter through the endotracheal tube and advancing it into the occluded bronchus. L* Due to difficulties of the procedure, selective suctioning of the left main bronchus frequently has to be carried out under direct fluoroscopic control. Bronchoscopy is an alternative method of management,5 although this procedure may endanger the already compromised infant, and is not always successful. Some cases require frequent selective left lung suctioning and continuous ventilation for several hours in order to fully expand the involved lung. In such instances, SBI may be the only solution. The right main bronchus is easily intubated but it is difficult or even impossible to intubate the left bronchus without fluoroscopic control. Therefore, an easy and reliable method for left SBI is of importance. We found that by adapting an endotracheal tube as described previously and introducing it into the bronchus with the pointed tip and the elliptical side hole directed to the left lung, the tube can easily and repeatedly be placed in the left main bronchus. The success of the method may be explained as follows. As the distal end of the tube
Fig 3. Complete expansion of the collapsed left lung, after 3 hours of selective left bronchial intubation suctioning and ventilation.
WEINTRAUB ET AL
Fig 4. (A) Right interstitial emphysema with the adapted endotracheal tube positioned in the left main bronchus. (B) Disappearance of interstitial emphysema of the right lung after several hours of left main bronchus intubation and ventilation.
reaches the carina, the pointed tip of the oblique end that is directed toward the left lung naturally slips over the carina to the left side toward the entrance of the left main bronchus. The elliptical side-hole gives the distal segment of the tube the necessary flexibility in order to bend towards the left bronchus. The left lung can then be repeatedly suctioned and ventilated until it fully expands. This method provides an easy and reliable form of left main bronchus intubation and can
be used as the initial procedure of choice for massive left lung atelectasis. Bilateral, or unilateral PIE is another frequent, life endangering sequela in ventilated premature infants.6 Occasionally, contralateral SBI may be needed in order to resolve unilateral PIE.3 Therefore, left SBI may also prove life saving in some cases of massive isolated right PIE.
REFERENCES 1. Placzek M, Silverman M: Selective placement of bronchial suction chatheters in intubated neonates. Arch Dis Child 58:829, 1983 2. Wesenberg RL, &ruble R: Selective bronchial catheterization and lavage in the newborn. Pediatr Radio1 195:397,1972 _ 3. Brooks JG, Bustamante SA, Koops BL, et al: Selective bronchial intubation for the treatment of severe localized pulmonary interstitial emphysema in newborn infants. J Pediatr 91:648,1977 4. Whitfilcd NM, Douglas Jones M: Atelectasis associated with
mechanical ventilation for hyaline membrane disease. Crit Care Med 8:729,1980 5. Wood RE: The flexible fiberoptic bronchoscope as a diagnostic and therapeutic tool in infants, in Milner AD, Marvin RY (eds): Neonatal and Pediatric Respiratory Medicine. London, England, Butterworths, 1985, pp 101-l 10 6. Thibeault DW, Lachman RS, Laul VR, et al: Pulmonary interstitial emphysema, pneumomediastinum and pneumothorax. Am J Dis Child 126:611, 1973
