Esophageal misplacement of a single-lumen tube after its exchange for a double-lumen tube despite the use of an airway-exchange catheter
A 22-year-old male victim of a traffic accident presented with dyspnea, and was diagnosed with right hemothorax and pneumothorax. He was intubated and chest tube drainage (CTD) was performed, after which he was transferred to our emergency room (ER) for further evaluation and management. On arrival, he had decreased mental status, and his initial vital signs were as follows: Blood pressure (BP): 80/50 mmHg, heart rate (HR): 124 beats/minute, respiratory rate (RR): 28 breaths/minute, oxygen saturation: 90%, and arterial blood gas analysis (ABGA) values of pH: 7.28, PaCO2: 31, PaO2: 60 mmHg, HCO3: 14.6 mEq/dL, and Hb: 10.9 g/dL. The patient was placed on mechanical ventilation (continuous mandatory ventilation (CMV) mode, fraction of inspired oxygen (FiO2): 100, tidal volume: 500 mL, respiratory rate: 15/minute, positive end-expiratory pressure (PEEP): 5 mmHg), and a central catheter and arterial catheter were inserted into the right subclavian vein and left femoral artery, respectively. Chest X-ray showed right pulmonary hemorrhage [], and computed tomography (CT) revealed a 9 cm radiopacity in the right upper hemithorax which suggested hematoma (hemothorax) as well as minor pneumothorax.\nSoon after undergoing CT, the patient stopped responding to mechanical ventilation. At that time, ABGA showed pH: 7.03, PaCO2: 42, PaO2: 43 mmHg, HCO3: 10.8 mEq/dL, oxygen saturation: 58%, and Hb: 7 g/dL. The patient was transferred to the angiography room for extracorporeal membrane oxygenation (ECMO), where a 21 Fr venous cannula (DLP®, Medtronic Inc., Minneapolis, MN, USA) was inserted into the right atrium, and a 24 Fr venous cannula (RMI®, Edward's Life Science LLC, Irvine, CA, USA) was inserted into the inferior vena cava via both femoral veins using the Seldinger technique, and venous ECMO was begun at 4 L/minute.\nNext, the patient was transferred to the operating room, where general anesthesia was induced with a bolus of rocuronium 50 mg for muscle relaxation. Then, a 37 Fr left DLT was inserted following removal of the single-lumen tube, and the correct position of the DLT was confirmed by fiberoptic bronchoscopy, both before and after positioning in the lateral decubitus position. A right anterolateral thoracotomy via the fifth intercostal space was performed, which revealed 3 L of blood in the extrapleural space as well as a blood clot due to a right subclavian artery injury. The blood and blood clot were removed and the damaged subclavian artery was repaired. During the surgery, which lasted approximately two hours, five pints of packed red cells were transfused. At the end of the operation, the DLT needed to be exchanged for a single-lumen tube. Using the AEC as a guidewire, a 12 F, 80 cm AEC with a flexible tip (METTI, VBM, Germany) was inserted 25 cm from the lip through the DLT, which we then tried to remove over the AEC. The DLT was removed stiffly, and the AEC remained in situ 25 cm from the lip following its removal. Subsequent intubation was performed through the AEC using a 7.5 Fr single-lumen tube. The tube was inserted smoothly, and fixed at 22 cm. We assumed that the ETT had been placed correctly into the trachea, although its position was not confirmed by auscultation or end-tidal carbon dioxide. Then, the patient was transferred to the intensive care unit (ICU) with Ambu bagging under ECMO. Immediately after arrival in the ICU, portable chest X-ray revealed esophageal misplacement of the ETT []. The patient was successfully reintubated using laryngoscopy, then extubated a week later. The ECMO was stopped 10 days later.