A Missed Case of Tracheal Bronchus Leading to Difficult Lung Isolation in a Cardiac Patient: A Case Report

Abstract The tracheal bronchus, an unusual tracheobronchial anatomy with an incidence rate between 0.1% and 2%, is almost synonymous with the right upper lobe bronchus, which emerges from the right side of the tracheal wall above the carina. Although it is mostly asymptomatic, some cases may suffer from recurrent chest infection, chronic bronchitis, or even complicated with bronchiectasis. The standard anterolateral chest X-ray is often unable to detect the tracheal bronchus which is usually missed. A tracheal bronchus can significantly affect airway management, especially during lung isolation. Other coexisting respiratory or cardiac congenital anomalies may complicate the situation. We reported a case of a 19-year-old girl scheduled for minimally invasive tricuspid valve replacement who was accidentally discovered to have an ectopic bronchus during establishing lung isolation. Our approach involved the use of a Fogarty embolectomy catheter in conjunction with an endobronchial blocker, following an unsuccessful attempt to separate the right lung using a left-sided double-lumen endotracheal tube. We succeeded in isolating the right lung, and the surgical team successfully replaced the tricuspid valve without hypoxia or any other complication. This case highlights the importance of bronchoscopy examination before lung isolation and reminds anesthesiologists to be flexible in their airway management plans.