An unusual airway problem.

ON WE~Y ~A~E OCCASIONS it may be necessary to ventilate each lung separately in association with major injuries to the trachea. A double lumen tube (e.g. Carlens tube) may be unsatisfactory ff the defect in the trachea is of such a location and magnitude as to allow an air leak when the tracheal cuff is inflated. The following is a ease report describing the management of the airway of a patient with a large tracheal defect about one centimeter above the carina, who required artificial ventilation. Mr. W., a previously healthy man of 42, sustained a severe chest injury on April 5, 1969. He required tracheostomy and artificial ventilation. On April 20, 1969, as his James tube was being removed, he sustained a massive haemorrhage from his tracheostomy stoma. 1 This was partially controlled by digital pressure on the bleeding artery and the patient was taken to the operating room immediately, where the bleeding was controlled with great difficulty. Severe bleeding recurred on four further occasions and each time was controlled by digital pressure and suturing of the bleeding vessel. However, associated with the diflqculty of controlling the haemorrhage, the tracheal stoma progressively increased in size. By May 5 the patient had a large defect in the anterior wall of the trachea ending about one centimeter above the carina. On May 6th, it was decided to attempt an aortic arch angioplasty under extracorporeal circulation. Controlled respiration, which would be required for a full sternal split thoracotomy, could not be achieved by using a cuffed tracheotomy or endotracheal tube, since the tracheal defect had extended too close to the carina. It was felt that the only way to solve this problem was to intubate each main bronchus separately with cuffed endobronchial tubes. After adequate topical anaesthesia of the larynx, a #8 single lumen Gordon Greene tube was introduced with ease in the right main stem bronchus. Our intention was then to pass a long cuffed nasotracheal tube through the mouth and into the left main stem bronchus, but the patient's larynx would not allow even the smallest available cuffed tube (6 mm) to go through. Intubation of the left main stem bronchus directly through the tracheal stoma was ruled out as the surgeons felt that it would be incompatible with adequate surgical conditions. The bronchial cuff of the Gordon Greene tube was then inflated, the left lung allowed to collapse, and general anaesthesia with controlled ventilation of the right lung was conducted with clinically adequate oxygenation of the patient. Under eardiopulmonary bypass an aortic arch angioplasty and innominate artery ]igation were then performed. At the end of the procedure an 8 mm endotraeheal tube was introduced *Deparlanent of Anaesthesia, University of Western Ontario, London, Ontario.