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

  Observed

Predicted

%predicted

  Observed

Predicted

%predicted

FEV (L)

2.19 2.85 76.92 VC 2.26 2.85 79.38

FEV1(L)

1.49 2.28 65.41 FRC 2.83 2.58 109.65

%FEV1

68.04 79.08   RV 2.36 1.49 157.97

FEF25-75

0.92 2.07 44.38 TLC 4.62 4.34 106.45

PEFR 2.60 6.42 40.47 MVV 51.70 97.49 53.03

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 300μg,

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 cmH2O) and

absent of ETCO2 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-o

scope, 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 airwa

y pressure improve (keep around 35-40 cmH2

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 3A2-05-

01. 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-13-02 on 12/04.

Discussion

Differential diagnosis

1. Kinking of the tube2. Malposition: too deep, not deep enough, entere

d the right bronchus.

3. Obstruction by sputum4. Foreign body5. Tension pneumothorax due to CVP ins

ertion6. bronchospasm

One-lung bronchospasm Severe unilateral bronchospasm mimicking inadv

ertenet 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 bronchospasmA. 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, glycopyr

olate 1mg. β-adrenergic agonist Steroid: IV hydrocortisone (1.5-2 mg/kg) For emergence: deep extubation, libocaine bo

lus (1.5-2 mg/kg) or continuous infusion (1-2 mg/min)

Thanks for your attention!