Sir,

Tracheostomy is a clinical scenario where a double-lumen tube can be difficult to insert and other methods of lung isolation are preferred. We would like to report a complication with the use of an EZ blocker (Teleflex Medical Incorporated), used for lung isolation in a patient with a tracheostomy. A 46 year old male patient presented to the hospital with complaints of altered sensorium and right-sided weakness. Noncontrast computed tomography of the head revealed left frontal and temporal intracranial haemorrhage with intraventricular extension. The patient was intubated because of a poor Glasgow coma scale and shifted to the intensive care unit (ICU). During the ICU course, he developed pleural effusion, for which an intercostal drain (ICD) was inserted and the patient was tracheostomised because of prolonged intubation. Because of the failure of the lung to expand despite an ICD, contrast enhanced computed tomography thorax was done which showed a left-sided hydropneumothorax with segmental collapse of the left lower lobe and a fistulous communication between left segmental bronchus and pleural cavity. The patient was considered for video-assisted thoracoscopic decortication and wedge resection of the left lower lobe segment. After induction of anesthesia with injection fentanyl, propofol, and rocuronium, an EZ multiport adapter was connected to the tracheostomy tube 15 mm connector, and the tube was pulled out a little to allow for the Y-shaped limbs to open up considering the short distance of the tracheostomy site to the blocker. The EZ bronchial blocker was inserted under the guidance of a fiberoptic bronchoscope and the patient was positioned in the right lateral decubitus position for surgery with isolation of the left lung. Left sided empyema was noted on thoracoscopy, septations were removed and decortication done. Because of difficulty in the dissection of the posterior segments, surgery was converted to open thoracotomy. On the surgeon’s request for two lung ventilation to look for a fistula, the left lung was suctioned through the bronchial blocker port, and the cuff was deflated. The patient developed sudden increased peak airway pressures of 40 cmH₂O, and desaturation up to 80%. On auscultation, there was reduced air entry on the dependent side. Suction with 10 French suction catheter through bronchial blocker port was tried, but no improvement in peak airway pressure and saturation was noticed. A diagnostic fiberoptic guided visualisation of the right bronchus showed a mucus plugging of the right bronchus which could not be suctioned out with the 2.8 mm bronchoscope compatible with the EZ blocker. Bronchial blocker was then removed, a larger fiberoptic bronchoscope (FOB) of 4.6 mm was inserted and the mucus plug was suctioned out. The surgery was continued with two lung ventilation with low tidal volumes and low Positive end-expiratory pressure. A short apnoeic duration of 1 to 5 min was provided for the closure of the Broncho pleural fistula. The patient was shifted to ICU on ventilator support and weaned off the ventilator on the first postoperative day.

EZ blocker has been used successfully in patients with tracheostomy and its ease of positioning with minimal intraoperative displacement has been reported [1]. In a review by Moritz et al. [2] no serious complications were reported in 100 cases with EZ blocker. No reports of lung soiling have been reported with the use of EZ blocker but such complication should also be anticipated while deflation of the bronchial cuff as the secretion distal to the cuff can move into the trachea owing to the position of non-dependent lung. Also, larger size FOBs should be kept handy as smaller FOBs compatible with the EZ blocker do not allow for suction of larger clots and mucus plugs.

We suggest that increased airway pressures and desaturation on deflating cuff of the EZ blocker should raise a suspicion of dependent lung contamination. Also, all sizes of bronchoscope should be kept in the cart while using an EZ blocker for lung isolation.