Department of Anaesthetics, St Marys Hospital, Praed Street, London W2 1NY, UK
Corresponding author. E-mail: matt.mackenzie@virgin.net
Accepted for publication: April 2, 2003
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Abstract |
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Br J Anaesth 2003; 91: 2978
Keywords: complications, intubation endobronchial; surgery, laparoscopy
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Introduction |
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Case report |
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Discussion |
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The authors diagnosed endobronchial intubation promptly, but were misled by the results of direct laryngoscopy and fibre-optic examination. The only explanation is that the tube position moved because of flexion and extension of the neck during these examinations. Neck extension can move the tip of the tube up to 5.2 cm away from the carina.3 The tracheal tube was initially tied at 22 cm, which would not usually be associated with endobronchial intubation in a patient of normal stature. At the second laryngoscopy, the tube was only pulled back to 21 cm. The cuff could be seen directly below the vocal cords, but the patients head would still have been extended on the neck. For the radiographic examination, we assume that the head was in a more neutral, slightly flexed position, allowing the tube tip to enter the brochus. During bronchoscopy, the patients pillow was removed to straighten the tracheal tube and aid passage of the instrument. This would increase the oro-carinal distance and thereby withdraw the tip of the tube. When the radiograph was seen, the tube was pulled back 2 cm to 19 cm with the patients head in the neutral position and sitting up. When the tube was repositioned first to 21 cm, the cuff was visible below the cords. By pulling it back by another 2 cm extubation might be expected, but the tube remained satisfactorily placed.
The clinical circumstances could have been caused by other conditions than endobronchial intubation. Because the diagnosis of endobronchial intubation appeared to have been excluded, we considered other diagnoses.
Our differential diagnosis included pneumothorax, bronchial obstruction by mucus plug or cuff herniation, and severe bronchospasm, which can occur with tracheal intubation and positive pressure ventilation. With laparoscopy, carbon dioxide pneumothorax or pneumomediastinum are possible.
Pneumothorax may be caused by a number of mechanisms. First, spontaneous rupture of a pleural bleb or bulla is possible, as in any other operation. Secondly, carbon dioxide may pass from the perioneal to the pleural space,4 5 if there is surgical trauma to the diaphragm or falciform ligament6 or a congenital pleuroperitoneal fistula. Pneumomediastinum may present with hypercapnia and hypoxia alone, without signs of pneumothorax.7 After diagnosing pneumothorax, it may be useful to aspirate and analyse the gas in an analyser to determine if the carbon dioxide concentration is high. The treatment of carbon dioxide pneumothorax is to apply positive end-expiratory pressure and reduce intra-abdominal pressure. Most patients make a good recovery without the need for a pleural drain.
This report shows that radiography may be needed to distinguish between pneumothorax and endobronchial intubation. Direct laryngoscopy and bronchoscopy can mislead if the tube position is changed during the procedures.
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References |
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