Abstract
We report a case of differential lung ventilation in a patient with tracheobronchial anomaly that was undiagnosed pre-operatively. A 24-year old man was presented for video-assisted thoracic surgery of biopsy and resection of a left posterior mediastinal tumor.
After induction of general anesthesia, we tried left bronchial intubation with a 37 Fr double lumen tube two times without bronchoscopic guidance, but we failed to obtain adequate positioning of the DLT. On the third attempt, we inserted the bronchoscope into the left lumen of the DLT and tried to guide the tip of the left lumen to the left main bronchus. From this procedure, we obtained bronchoscopic views showing three lumens arising at the height of the tracheal carina. With this finding and re-evaluation of thoracic CT images, we diagnosed a tracheal bronchus where the right upper bronchus arises at the tracheal carina level. The left main bronchus was intubated under bronchoscopic guidance and successful one lung ventilation was performed.
The following two points are emphasized in the discussion ; 1) thorough preoperative evaluation of thoracic CT images should have been made to rule out tracheobronchial anomaly. 2) Bronchoscopic guidance should have been utilized for bronchial intubation from the beginning of the procedure.
