Case Presentation:
The pediatric anesthesiology service at a rural tertiary care center was
emergently consulted for the management of a five-week-old, one kg
hypoxic male with known persistent pneumatocele in the right lung base.
The patient was born at 29 weeks and two days via Cesarean section;
antenatal steroids were reportedly given. On initial assessment, the
neonate had two 8.5 F pigtail thoracostomy tubes in place which were
placed by the surgical team for possible management of hypoxia - one in
the anterior pleural space with a small one-chamber leak, and one in the
posterior pleural space with a continuous five-chamber leak (see Figure
1). The patient was intubated with a 3.0 uncuffed endotracheal tube
(ETT). The patient was experiencing desaturation events to 50-60% with
associated hypotension due to high-volume air loss from the posterior
chest tube. Clamping of the tube resulted in short-term improvement in
the patient’s oxygen saturation; within minutes of clamping the
patient’s saturation would begin to again dip into the 50-60% range.
This cycle was ongoing as the anesthesia team assessed the patient.
Upon initial evaluation, it was determined the ETT was too large to
advance and mainstem for one-lung ventilation. The anesthesia team
emergently decided to utilize a Syntel® silicone embolectomy catheter
with a 3 Fr Fogarty balloon at the end to selectively isolate the distal
portion of the patient’s lung affected by the pneumatocele and allow for
subsequent unclamping of the posterior chest tube for decompression.
After time-out was called, the 3 Fr catheter was passed into the
patient’s trachea next to the in-place ETT. Due to the limited space
available between the patient’s vocal cords, the inter-cord space
between the ETT and tubercle of the epiglottitis was utilized. Downward
pressure on the ETT via the clinician’s thumb was used to increase the
distance between the vocal cords and the ETT, allowing the catheter to
slide past the superior surface of the ETT. The catheter was advanced
until resistance was felt. Portable radiography was utilized to guide
the catheter into the patient’s right lung, and catheter placement in
the pneumatocele was confirmed via chest radiograph (see Figure 2).
Fluoroscopy was not available due to the emergent nature of this
situation.
The catheter was then pulled back slightly, and the patient’s head was
turned to the side of the unaffected lung. The catheter was then
advanced further, past the ETT, in the hope it would preferentially
occlude the desired primary bronchus, proximal to the portion of the
patient’s lung affected by the pneumatocele. Multiple attempts resulted
in the catheter advancing into the patient’s unaffected lung; success
was ultimately achieved by withdrawing the ETT one to two cm to allow
more room for the catheter to maneuver. The catheter was again advanced
until resistance was felt, and subsequent portable radiography confirmed
the catheter was in the patient’s pneumatocele. After placement was
confirmed, the balloon was inflated with one mL of air and the catheter
was placed under tension with gentle superior force. While the leak from
the posterior chest tube was still present, the air leak decreased from
five to two chambers. The patient’s oxygen saturation resolved to 98%
and remained so on continued mechanical ventilation. The anterior chest
tube was left on -20 mm Hg and the posterior chest tube was put to water
seal. In conjunction with the neonatal intensive care unit team, it was
decided to leave the catheter in place for the time being.
The next day the patient remained stable, with oxygen saturation between
92 and 98%. Two days after the Fogarty catheter was placed the patient
began experiencing repeated desaturation events. The catheter’s position
was seen still in place under fluoroscopy. At this time, the cause of
the repeated desaturations was believed to be the result of a secondary
and more proximal pneumatocele. It was decided that the best way to
temporize the situation was to pull the catheter back into the right
bronchus, proximal to the affected lung areas. This was accomplished by
putting radiology contrast dye into the catheter balloon and taking a
portable chest radiograph. The measurement feature was used on the
machine to determine the distance to withdraw the catheter, the balloon
was deflated, and the catheter was moved superiorly and placed proximal
to the patient’s pneumatocele, with immediate improvement in
oxygenation. The balloon was subsequently reinflated slowly until
bubbling occurred in the patient’s chest tubes, and a minimal amount of
contrast was re-injected to stop the bubbling and ensure a seal had been
obtained; positioning was confirmed via repeat chest radiograph (see
Figure 3). Unfortunately, the patient continued to require increasing
vasopressor support and had worsening acidosis. Two days after the
Fogarty catheter was placed the patient ultimately expired due to
cardiorespiratory arrest due to pulmonary hypertension and metabolic
acidosis. Informed consent was obtained from the patient’s mother for
publication of this case report.