Intraoperative endobronchial rupture of pulmonary hydatid cyst: An airway catastrophe
A 20 kg, 7-year-old girl with history of recurrent hemoptysis was scheduled for thoracoscopic excision of a pulmonary hydatid cyst. Chest X-ray revealed a 4 cm homogenous opacity in lower lobe of left lung. Contrast-enhanced computed tomography chest revealed 3-4 cm well-defined hypodense lesion in lower lobe of left lung. ELISA test for a hydatid cyst was positive. All other relevant investigations were within normal limits. The patient had taken multiple courses of albendazole for the same.\nSingle lung ventilation with 3.5 mm ID Uninvent tube (for 6-8 years) was planned.[] A 20 G venous access was taken in the dorsum of left hand. Electrokardiograph, noninvasive blood pressure, peripheral oxygen saturation (SpO2), and capnography monitoring was initiated.\nThe patient was administered fentanyl 40 mcg and hydrocortisone 100 mg intravenously (IV). Pheniramine maleate 34.125 mg was given intramuscularly. After preoxygenation for 3 min, anesthesia was induced with propofol 40 mg and vecuronium 2 mg IV. The trachea was intubated with the 3.5 mm ID Univent tube and lung ventilation was confirmed. The bronchial blocker was guided into the left bronchus under fiberoptic guidance for isolating the two lungs. The patient was positioned in the right lateral position. Tube position and lung isolation were reconfirmed clinically by auscultation and fiberoptically. Anesthesia was maintained with an oxygen–nitrous oxide inhalation mixture (1:1) with isoflurane ≤1% and supplemental IV doses of fentanyl and vecuronium.\nWhile creating pneumothorax there was sudden fall of SpO2 from 98% to 56% with bradycardia (heart rate dropped from 110 to 46/min) and bloody discharges appeared in the Univent tube. Airway pressures increased from 18 cm to 35 cm. Pneumothorax was released, atropine 0.4 mg IV was given, 100% oxygen administered and tube suction done. SpO2 improved to 98-99% and heart rate increased to 130/min. Patient's blood pressure remained stable. Anaphylaxis and contra-lateral pneumothorax was ruled out clinically. On chest auscultation, there was decreased air entry on the right side and air entry was present on the left side.\nAnticipating a displaced bronchial blocker patient's position was made supine and flexible fiberscopy was done which showed fluid with membranes along with a displaced bronchial blocker in the trachea. Suctioning was done through the flexible fiberscope suction channel but membranes could not be removed. The Univent tube was withdrawn and rigid bronchoscopy was performed with 4.5 mm pediatric ventilating bronchoscope. About 20-25 ml of fluid with flakes of membrane was removed by forceps, bronchoalveolar lavage, and suction [Figures and ]. After bronchoscopy, trachea was reintubated with a 6 mm ID uncuffed endotracheal tube.\nPatient¢s vital parameters remained stable. At the end of procedure, the patient was shifted to ICU for elective ventilation. Postoperative chest X-ray was normal. The trachea was extubated the next day and the patient was discharged home on the 7th postoperative day. Histopathological examination of membranes was of suggestive of a hydatid cyst.