An Unforeseen Complication of EZ Blocker in a Case of Difficult Airway: A Case Report

INTRODUCTION

The management of lung isolation in a difficult airway scenario has always intrigued thoracic anesthesiologists and airway experts in the past. We were also fortunate in our setup to manage such a case of an ankylosing spondylitis patient who had a difficult airway and also required lung isolation. This particular case helped us learning a new unforeseen complication associated with EZ blocker.

CASE REPORT

A 61-year-old male patient (wt.-54 kg, Ht.-160 cm) suffering from non-small cell lung carcinoma was scheduled for thoracoscopic left upper lobectomy. The pre-operative anesthesia concerns were –

1. Lung isolation required for one lung ventilation

2. Difficult airway (extreme restriction of neck extension [Grade 4], upper lip bite test -grade 3, and thyromental distance 4 cm due to ankylosing spondylitis [human leukocyte antigen B27 positive, receiving indomethacin for 8 years])

3. Difficult epidural placement (extensive calcification due to ankylosing spondylitis)

4. Hypertension (since past 8 years, taking telmisartan, amlodipine, and metoprolol, and controlled with medication)

5. Previous history of coronary artery disease (percutaneous transluminal coronary angioplasty with stent in situ in the left anterior descending branch 4 years ago)

6. Neoadjuvant chemotherapy concerns (three cycles of paclitaxel and carboplatin)

7. Smoker.

The plan for airway management was to insert a double-lumen tube (DLT) (Mallinckrodt) for lung isolation after induction of anesthesia. However, after induction, the best laryngoscopic view (Cormack-Lehane grade) (with McCoy blade and laryngeal manipulation [Backward, Upward, Rightward Pressure]) was II B. The DLT insertion was attempted, but intubation was not possible because the secondary curvature of the DLT was abutting the lower incisor during laryngoscopy. The other methods of inserting a DLT in a difficult airway (videolaryngoscopy-guided and over airway exchange catheter) also failed. Hence, as a backup plan, EZ blocker (Rüsch^® EZ-Blocker^® Endobronchial Blocker, Teleflex, USA) was used for lung isolation after intubating with no. 8 mm internal diameter polyvinyl chloride endotracheal single lumen tube (SLT). After securing the airway, the SLT was fixed at 21 cm at the right angle of mouth with Dynaplast and EZ blocker was fixed with the SLT by the multiport adapter at 58 cm. Both fiber optic and clinical confirmation were done for the correct placement of the EZ blocker.

Subsequently, a nasogastric tube (Ryle’s tube) was inserted to deflate the stomach and facilitate port placement. The initial blind attempt failed, so insertion was attempted under laryngoscopic guidance using Magill forceps. After multiple attempts, the tube was successfully advanced into the stomach; however, the process resulted in the SLT being displaced outward by approximately 3 cm. Hence, after deflating the cuff, the SLT was repositioned inside and fixed at 21 cm again. After tube fixation, flexible bronchoscopy was done, and it was found that the bifurcated end of the EZ blocker had folded on itself [Figure 1]. The probable cause of this unforeseen event was that we did not unscrew the attachment of EZ blocker and SLT before the renegotiation of tube and did not use bronchoscopy-guided advancement of the SLT.

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Figure 1:

EZ blocker inside the single lumen tube (Please note: bent tip of the EZ blocker).

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When we attempted to gently withdraw the EZ blocker, it became stuck at the distal end of the SLT. We then retracted the SLT by 2 cm and tried to unfold the EZ blocker, but this was also unsuccessful, so after a few attempts, we stopped maneuvering the EZ blocker to prevent injury to the tracheal mucosa and the chances of possible foreign body aspiration in case the EZ blocker sheared at the distal end.

As a rescue plan, both the SLT and EZ blocker were taken out over the airway exchange catheter and new SLT was railroaded over it. After successful SLT placement, new EZ blocker was inserted and confirmed fiber optically. The rest of the surgery was uneventful. In view of repeated airway manipulation and documented airway edema seen on flexible fiber optic bronchoscopy, we administered dexamethasone 8 mg and planned to extubate the patient after overnight elective ventilation.

DISCUSSION

Moritz et al., in a case series of 100 patients, in whom an EZ blocker was used, found only one complication where the FOB got stuck inside the SLT with the EZ blocker.^[1] Fortunately, we did not face this issue. In another case report by Honikman et al., it was mentioned that failure of balloon deflation can be one another complication of EZ blockers.^[2] We did not face any such issue with balloon deflation in EZ blocker. Templeton et al. presented one case report in a 7-month-old infant undergoing thoracotomy and left lower lobe lobectomy.^[3] They experienced a significant complication related to lung isolation with a bronchial blocker due to entrapment of the blocker within the staple line at the bronchial stump. Since we were using EZ blocker in a 61-year-old male, the “margin of safety” was higher. Kosarek et al. tried to assess complications specifically associated with the Cohen BB (CBB) (Cook Medical, Bloomington, IN) in a retrospective review and found that airway injury occurred in 2 patients with a CBB but none with DLT.^[4] Literature search revealed that both airway injuries were due to surgical technique. Two cases of post-operative hoarseness occurred in the CBB group, one of which was due to vagus nerve transection, and the other was vocal cord paralysis of unknown etiology. Despite these small hitches, this study demonstrated the usefulness of CBB in different types of thoracic operations. Ruetzler et al. compared the efficiency of DLT and different types of BB and noticed that though the time of intubation was longer in BB, there was no significant difference in perioperative surgical outcome or complication in both the groups.^[5] In two different case reports by Soto and Oleszak and Murphy, both have found that the loop of the Arndt blocker getting hitched in the surgical stapler line and failed to come out at the end of the surgery.^[6,7] This complication was not possible in our case since EZ blocker is non-wired. A retrospective review of 302 cases by Ueda et al. studied the Arndt Wire-guided, Univent, Cohen Flexi-tip, Fogarty catheter, and Fuji BB, but there were no complications reported due to them, and that’s why we consider our case to be a valuable addition to the existing literature.^[8]

CONCLUSION

From this undesired complication, we have learned that whenever the EZ blocker is being used for lung isolation, any movement of the primary tube should be done after due consideration of EZ blocker fixation at the multiport adapter or under bronchoscopic guidance to avoid unwanted incidents like this.