79th PostGraduate Assembly in Anesthesiology 2025

Lung Isolation in a Patient with a Difficult Airway Due toRecurrent Mandibular Osteosarcoma

Emily Walsh M.D.,1 Mitchell Kerfeld, M.D.1
Departments of 1Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN

The Patient

22yF with hx recurrent mandibular osteosarcoma (s/pmultiple resections and radiation)
Known difficult airway: multiple previous awake fiberopticintubations
Here for R thoracoscopic wedge resection (for RLL nodulesuspicious for osteosarcoma metastasis)

Learning Objective

To compare and contrast the risks and benefits of different airway management techniques for proceduresrequiring single-lung isolation in a patient with a known difficult airway.

Lung Isolation Techniques in Difficult Airways

	Double-Lumen Endotracheal Tube	Single Lumen Endotracheal Tube + Bronchial Blocker
Pro	Quick and easy to convert between one- and two-lung ventilation Can use suction catheters, fiberoptic scopes May require less repositioning	Useful when DLT would be difficult to place, such as restricted mouth opening, limited neck extension, distorted anatomy from previous surgeries or radiation
Con	Rigid, large – hard to place, risk of injury such as lacerations/tears of membranous trachea, bronchus rupture, tension pneumothorax.	Cannot easily convert between one- and two-lung ventilation Cannot use suction catheters, fiberoptic scopes May be more difficult to place

What We Did

Plan: awake fiberoptic intubation with single-lumen ETT + bronchial blocker
Premeds: glycopyrrolate, remifentanil infusion, PRN remimazolam bolus, topical lidocaine
Scope: easily passed tongue into oropharynx
Deep inspiration: could see tracheal rings
After entering trachea: anatomy normal
Placed single-lumen size 7.5 ETT on first attempt, then placed bronchial blocker

Discussion

For lung isolation: Double-lumen endotracheal tubes (DLTs)offer many advantages, remain the gold standard
However, DLT's may be impossible to place in patients withdifficult airway and may pose risk of serious injury to theairway
Option of placing single-lumen ETT and then exchanging forDLT poses similar risks to initial DLT placement
Single-lumen ETT + bronchial blocker can work well forpatients with difficult airway

Patient Outcome

Intubated on first attempt as described!
Surgery completed, no issues
Pt extubated in OR to room air
POD1: discharged to home
POD23: doing well at office visit, no complaints, no new lungnodules on exam

References

Collins, S et al. Lung Isolation in the Patient with a Difficult Airway. Anesthesia & Analgesia 126(6):p 1968-1978, June 2018.
McLean, S et al. Airway Exchange Failure and Complications with the Use of the Cook Airway Exchange Catheter. Anesthesia & Analgesia 117(6):p 1325-1327, December 2013.
Thomas, V et al. Tracheal Laceration After the Use of an Airway Exchange Catheter for Double-Lumen Tube Placement. Journal of Cardiothoracic and Vascular Anesthesia 21(5):p 718-719, October 2007.
Bussieres, J et al. Bronchial blocker versus left double-lumen endotracheal tube in video-assisted thoracoscopic surgery: a randomized-controlled trial examining time and quality of lung deflation. Canadian Journal of Anesthesia 63(7):p 818-827, July 2016.
Clayton-Smith, A et al. A Comparison of the Efficacy and Adverse Effects of Double-Lumen Endobronchial Tubes and Bronchial Blockers in Thoracic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Journal of Cardiothoracic and Vascular Anesthesia 29(4):p 955-966, August 2015.
Campos, J et al. Lung isolation in the morbidly obese patient: a comparison of a left-sided double-lumen tracheal tube with the Arndt® wire-guided blocker. British Journal of Anaesthesia 109(4):p 630-635, October 2012.

79th PostGraduate Assembly in Anesthesiology 2025

Lung Isolation in a Patient with a Difficult Airway Due to Recurrent Mandibular Osteosarcoma

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