Iatrogenic Left Main Bronchus Injury following Atraumatic Double Lumen Endotracheal Tube Placement

Tracheobronchial disruption is an uncommon but severe complication of double lumen endotracheal tube placement. The physical properties of a double lumen tube (large external diameter and length) make tracheobronchial injury more common than that associated with smaller single lumen endotracheal tubes. Here we present the case of an iatrogenic left main bronchus injury caused by placement of a double lumen tube in an otherwise unremarkable airway. 1. Introduction Thoracic surgery procedures requiring lung isolation are often performed with the assistance of a double lumen endotracheal tube (DLT). While placement of DLTs is routine and safe in experienced hands, it is not without risk. A rare complication is airway rupture, perhaps due to DLTs having a larger external diameter compared to a single lumen tube and a stiff stylette used for ease of proper endotracheal tube placement [1, 2]. Early recognition of airway rupture, evaluation of the defect, and repair of the airway are critical to optimal patient outcome [3]. Here we present the case of a 52-year-old woman who presented to the operating room for removal of a right upper lobe mass via right thoracotomy. Despite a seemingly atraumatic intubation with a 35-French left double lumen endotracheal tube, a significant tear in her left main bronchus was identified intraoperatively. 2. Case Report A 158？cm, 93？kg (BMI 37.4), 52-year-old woman presented to a tertiary care center for evaluation of a Merkel cell tumor in her right forearm. Wide resection of this forearm tumor and an axillary lymph node dissection were successfully performed. During the course of her evaluation, however, a suspicious mass in her right upper lobe was identified on chest X-ray, and a 2.7 × 2.2 × 2.9？cm hypermetabolic solid nodule in the right apex was confirmed with CT imaging. The patient was asymptomatic. Preoperative pulmonary function tests were normal. Patient was deemed to be optimized for a thoracic surgical procedure and was brought to the operating room. After routine intravenous sedation with Midazolam and Fentanyl, an epidural was placed at the T6-7 vertebral interspace. Patient was returned to the supine position where general anesthesia was induced intravenously with fentanyl, lidocaine, propofol, and succinylcholine. Her airway was secured via direct laryngoscopy (grade one view) and placement of a styleted 35-French left double lumen endotracheal tube without difficulty. Once the tracheal cuff had passed through the cords, the stylette was removed and bilateral breath sounds were confirmed. Proper placement of