Successful One-Lung Ventilation in a Patient with Aberrant
Tracheal Bronchus
Hui-Ling Lee, MD, Angie C.Y. Ho, MD, Robin K.S. Cheng, MD,
and Ming-Hwang Shyr, MD, PhD
Department of Anaesthesia, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
been tied together with the fiberoptic bronchoscope with a
retractable knot. We successfully blocked the right upper
lobe bronchus by inflation of the Fogarty catheter. The air-
way pressure under one-lung ventilation was up to 31 cm
H2O, and no desaturation was noted through the procedure.
The surgical procedure proceeded uneventfully with good
visualization of the operative field.
ne-lung ventilation is widely practiced in major
thoracic and mediastinal surgery. In some cir-
cumstances, lung isolation is mandatory. We
O
report the case of an incidentally found aberrant tra-
cheal bronchus (right upper lobe bronchus originating
in the trachea). This atypical origin of the right upper
lobe bronchus complicated one-lung ventilation. In
addition to a Univent tube, we used a Fogarty catheter
to block the tracheal bronchus and successfully estab-
lish isolation of the right lung.
Discussion
Selective ventilation of one lung has been accom-
plished by several methods (1,2). The Univent tube
might be advantageous for this purpose and easier to
place, especially in patients with difficult airways (3).
We described a patient with anticipated anatomical
constraint of mouth opening, which disallowed the
passage of the double-lumen tube. Using a flexible
bronchoscope was a sure way to accomplish selective
bronchial block by a Univent tube.
The tracheal bronchus is an aberrant, accessory, or
ectopic bronchial branch arising directly from the lat-
eral wall of the trachea above the carina, with an
incidence ranging from 0.1% to 2% (4). It occurs al-
most exclusively on the right side, involves the right
upper lobe, and usually represents a displaced origin
of the right main bronchus or apical segmental bron-
chus (5). Most cases of tracheal bronchus are asymp-
tomatic, like our patient, but some patients may expe-
rience recurrent pneumonia, chronic bronchitis, or
bronchiectasis (4). Although it is usually of little clin-
ical significance, this atypical origin of the right upper
lobe bronchus may complicate one-lung ventilation
during thoracic surgery (6).
Case Report
A 47-yr-old man was scheduled for esophagectomy and
reconstruction with gastric tube substitution because of
esophageal cancer (T4N1M0). Six years ago, he suffered
from right buccal cancer and received radical neck dissec-
tion, marginal mandibulectomy, and left forearm-free flap
for inner and outer defects. Postoperative radiotherapy was
completed. At this admission, preoperative laboratory
workups, including biochemical tests, chest radiograph, and
electrocardiogram, were unremarkable. Trismus was noted
after the radiotherapy. The mouth opening was up to 2 cm.
In the operating room, after routine monitors were placed,
the patient received general anesthesia with IV atropine,
fentanyl, thiopental, and vecuronium. A flexible fiberoptic
bronchoscope was used as a guide to pass a Univent tube
(inner diameter, 6.0 mm) through the right mouth angle into
the trachea. The right mainstem bronchus was identified
and blocked with a Univent bronchial blocker. A right tho-
racotomy was performed. Unfortunately, the right upper
lobe was still inflated during mechanical ventilation, al-
though the right middle and lower lobes were successfully
collapsed. The position of the bronchial blocker was recon-
firmed by bronchoscopy. Accidentally, we found an ectopic
opening from the tracheal wall. Aberrant tracheal bronchus
was suspected (Fig. 1). The surgeon requested complete lung
collapse. We inserted a 6F Fogarty catheter through the left
nostril to the opening of the tracheal bronchus, which had
The combination of a Fogarty catheter with a
double-lumen endotracheal tube may be practically
used to provide excellent lung separation and obviate
the need to re-intubate the patient’s trachea (7). In this
case, we used a Univent tube instead of a double-
lumen endotracheal tube with a Fogarty catheter and
provided excellent lung separation. Advantages of
placing a Fogarty catheter within a Univent tube may
include the ability to deflate/inflate a lung on the
Accepted for publication April 23, 2002.
Address correspondence and reprint requests to Ming-Hwang Shyr,
MD, PhD, Department of Anaesthesia, Chang Gung Memorial Hospital,
Taoyuan 333-33, Taiwan. Address e-mail to an001@adm.cgmh.org.tw.
DOI: 10.1213/01.ANE.0000021364.42109.AA
©2002 by the International Anesthesia Research Society
0003-2999/02
492 Anesth Analg 2002;95:492–3
Hodgson
