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.