Rescue One-Lung Ventilation via Orotracheal Double-Lumen Tube after Failed Fogarty Bronchial Blockade in Long-Term Tracheostomy Patients Undergoing Thoracic Surgery in a Resource-Limited Setting: A Case Series

Abstract

One-lung ventilation (OLV) is a prerequisite for adequate surgical exposure during video-assisted thoracic surgery (VATS) and open thoracotomy. Standard OLV techniques include double-lumen tube (DLT) intubation and endobronchial blockade with dedicated bronchial blockers. In patients with pre-existing tracheostomy, both approaches are technically challenging, and the difficulty is compounded in resource-limited settings where specialized bronchial blocking devices may be unavailable, necessitating improvised solutions. We describe two young adult male patients with long-term tracheostomy (>7 days) who underwent thoracic surgery: one VATS repair of a bronchopleural fistula and one thoracotomy for lung abscess evacuation. In both cases, lung isolation was first attempted using a 5 Fr Fogarty catheter as a surrogate bronchial blocker; this failed in each instance due to a size mismatch between the Fogarty cuff and the bronchial lumen. A rescue strategy was then applied: following general anesthesia induction, the tracheostomy cannula was removed, orotracheal intubation was performed with a left-sided 37 Fr DLT, and the stoma was temporarily sutured and dressed to prevent ventilation leaks. DLT position was confirmed by fiberoptic bronchoscopy in both cases. Effective OLV was achieved throughout each procedure. At closure, the DLT guided tracheostomy recannulation under direct visualization. Both patients were transferred post-operatively without airway complications. In resource-limited settings where dedicated bronchial blockers are unavailable, temporary decannulation with orotracheal DLT insertion and stomal occlusion represents a feasible rescue strategy for OLV in patients with long-term tracheostomy. This approach requires meticulous preoperative planning, fiberoptic bronchoscopy capability, and careful post-procedural stomal management.