Positive pressure ventilation in a patient with a right upper lobar bronchocutaneous fistula: right upper bronchus occlusion using the cuff of a left-sided double lumen endobronchial tube

In patients with a bronchocutaneous fistula, positive pressure ventilation leads to air leakage and potential hypoxemia. A male patient with a right upper bronchocutaneous fistula was scheduled for esophageal reconstruction. His preoperative chest computed tomography image revealed aeration in the right middle and lower lobe, a large bulla in the left upper lobe, and pleural effusion and pneumonia in the left lower lobe. Therefore, left one-lung ventilation was considered to result in hypoxemia. Before anesthesia induction, the bronchocutaneous fistula was covered with gauze and film to prevent air leakage. After anesthesia induction, mask ventilation was performed with a peak positive pressure of 10 cmH₂O. A left-sided double lumen endobronchial tube (DLT) was then inserted into the right main bronchus for occluding only the right superior bronchus, and two-lung ventilation was performed to minimize airway pressure and maintain oxygenation, which did not cause air leakage through the fistula. During anesthesia, no ventilation-related difficulty was faced. The method of inserting a left-sided DLT into the right main bronchus and occluding the right upper bronchus selectively by bronchial cuff is considered to be an option for mechanical ventilation in patients with a right upper bronchial fistula, as demonstrated in the present case.