Case presentation Present by R1 黃信豪

Brief history (1)  This 62 y/o male patient suffered from cough with sputum and progressive exertional dyspnea for 1.5 years.  Because the symptoms got worse and fever was noted in this November, he went to 彰基 H. for help. Fever subsided after introductions of antibiotics, but CXR revealed a mass lesion at LLL.

Brief history (2)  The patient also went to Dr. 李麗娜 ’ s OPD, and the CXR showed a mass lesion around 3*4 cm at LLL field with pleural effusion.  Under the impression of lung ca., he was admitted on 2002/11/20 for further evaluation.

Past history 1. Hypertension for over 10 years with regular medicine control. 2. BPH under medicine control. 3. Smoked around 1PPD for over 30 years. 4. Denied asthma history. 5. No known drug allergy.

Physical examination on admission  General appearance: ill-looked  Conscious: clear and alert  Vital sign: TPR 37.8 ℃ / 81 per min / 22 per min BP 142/100 mmHg  Chest: expansion symmetrically, breathing sound slight decreased at LLL, no crackles or wheezing, percussion tympanic

Lung cancer work-up  Chest CT (11/21) ： 1) 5.2 cm in diameter mass at LLL associated with lobar consolidation and small pleural effusion. 2) Multiple small right paratracheal lymph nodes.  Cytology of echo-guided lung aspiration and bronchial brushing (11/22) ： poorly differentiated carcinoma  PET (11/26) ： showed no FDG hypermetabolic lesions except LLL nodule lesion.

Pulmonary function test Observ ed Predict ed %predict ed Observ ed Predict ed %predi cted FEV (L) VC FEV1( L) FRC %FEV RV FEF TLC PEFR MVV

Operative plants LLL. lobectomy was suggested if VATS lymph nodes biopsy showed negative for malignant cell on 12/02/2002.

Peri-operation (1)  Induction of anesthesia with Fentanyl 300 μg, Pentothal 250 mg, SCC 80 mg, Tracurium 40 mg., then a 37cm L ’ t side double-lumen was inserted.  Due to cuff ruptured, a new L ’ t side double- lumen tube was replacement by tube exchanger and fixed at 30 cm. The position checked by auscultation with stethoscope and fiberoptic bronchoscope. Wheezing bilaterally was noted (L>R) while auscultation.

Peri-operation (2)  Solu-medrol 400 mg and solu-cortef 100 mg was given for preventing bronchospasm.  Anesthesia was maintained by propofol continuous infusion, and tracurium was given intraoperation.  Right radial a. A-line and 14*14 CVP were setup after intubation.  After induction, the patient ’ s position was change to right side decubitus position.

Peri-operation (3)  High airway pressure (>40 cmH 2 O ) and absent of ETCO 2 were noted while trying one-lung ventilation.  Checking tube position with fiberoptic bronchoscopy performed immediately. Malposition (right bronchus intubation) was noted. Replacement the tube under the fiberoptic bronchoscopy guieded.

Peri-operation (4)  After replacing the tube, the situation did not improve. So two lung ventilation was used.  Checking position with fiberoptic bronch-oscopy performed again. the position was confirmed, and no severe bronchospasm was found over right lung. No foreign body was found, either.

Peri-operation (5)  Sputum was suctioned by fiberoptic bronch- oscope, but the symptom still did not improved.  Aminophylline 1 amp for IV drip was used.  Bronchodilater was used, too.  After bronchodilater was used, the high airway pressure improve (keep around cmH 2 O ) in 2 hours, and ETCO2 showed around 50 during one lung ventilation.

Peri-operation  The operation finished at 20:20. The LDLT was changed to 7.5 single ET-tube smoothly.  Then the patient was transferred to 3A  T-piece was trying in the morning on 12/03. With stable vital sign and smooth respiratory pattern, the ET-tube was removed in the evening. The patient was sent to 14A on 12/04.

Discussion

Differential diagnosis 1. Kinking of the tube 2. Malposition: too deep, not deep enough, entered the right bronchus. 3. Obstruction by sputum 4. Foreign body 5. Tension pneumothorax due to CVP insertion 6. bronchospasm

One-lung bronchospasm  Severe unilateral bronchospasm mimicking inadvertenet endobronchial intubation: a complication of the use of a topical lidocaine laryngojet injector. British Journal of Anaesthesia. 85(6):917-9,2000 Dec.  Unilateral bronchospasm after interpleural analgesia. Anesthesia & Analgesia. 74(2):291-3, 1992,Feb.  Unilateral bronchospasm during pleurodesis in an asthmatic patient. Chest. 98(3): 767-8, 1990 Sep.

Risk factors of bronchospasm A. Patient ’ s underlying 1. Asthma history 2. COPD (smoker) 3. Recurrent pulmonary infections B. The drugs 1.tracurium, rapacuronium, tubocurarine 2.thiopental C. The direct stimulation: intra-tracheal lidocaine injection D. Regional anesthesia

Management of bronchospasm  For intubation: thiopental (1-2 mg/kg), volatile agent, IV or intra-tracheal lidocaine.  Anticholinergic agent: atropine 2mg, glycopyrolate 1mg.  β-adrenergic agonist  Steroid: IV hydrocortisone (1.5-2 mg/kg)  For emergence: deep extubation, libocaine bolus (1.5-2 mg/kg) or continuous infusion (1- 2 mg/min)

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