INTRODUCTION: An Arndt Endobronchial Blocker (AEB) is usually utilized during anesthesia for procedures that require single lung ventilation. It's spectrum of use has been extended to include temporary control of massive hemoptysis. Patients with respiratory failure require frequent airway suctioning. However, the multiport airway adapter supplied with AEB does not allow passage of a suction catheter. We describe a technique that allowed us to continue ventilation and pulmonary toileting after placement of an AEB in a patient with recurrent massive hemoptysis.
CASE PRESENTATION: A 44-year-old caucasian female with a history of cryoglobulinemia, transposition of the great vessels, systemic atrioventricular valve replacement and atrial fibrillation requiring anticoagulation presented with an acute onset of massive hemoptysis. In the emergency room she was intubated for airway protection and subsequently admitted to the medical intensive care unit. Initial chest radiograph and chest computed tomography revealed bilateral lower lobe alveolar infiltrates. Despite an extensive investigation the etiology of her hemoptysis remained elusive. She had recurrent episodes on at least eight separate occasions and received a tracheostomy due to chronic respiratory failure. Serial flexible bronchoscopy eventually localized active hemorrhage from the left lower lobe (LLL). Having failed arterial embolization, we decided to explore the option of endobronchial tamponade. Under bronchoscopic guidance an AEB was positioned in the LLL. This was placed through a commercial Bodai suction safe swivel Y connector (BSC) which in turn was attached to her tracheostomy. The hemoptysis was contained. However, due to the 90 degree angle between the BSC ventilation port and the tracheostomy tube, it was impossible to advance the suction catheter after connection to a ventilator circuit. Because of this obstacle we decided to place the AEB through the oral cavity. The tip of an oral endotracheal tube (ETT) was placed through the vocal cords just above the tracheostomy tube cuff. The AEB was then inserted through the ETT. Upon deflation of the tracheostomy cuff the AEB was advanced and correctly positioned in the LLL bronchus. Subsequently the ETT was retracted and then cut in a longitudinal manner. This was necessary to facilitate its removal as we were unable to slide the ETT over the AEB due to the wide nature of the proximal portion of the AEB. The AEB, with the cuff inflated, was left in situ for 72 hours. Thereafter it was removed but unfortunately she started to have hemoptysis after anticoagulation was resumed. Left lower lobectomy was not an option because of her poor respiratory status and multiple co-morbidities. She remains ventilator dependent in a long term acute care facility without any further hemoptysis.
DISCUSSIONS: In massive hemoptysis, isolation of a bleeding segment with a balloon catheter is necessary to maintain airway patency and oxygenation.  To gain temporary control of her hemoptysis, an AEB was required. Placement through the tracheostomy was not feasible as this impaired airway suctioning in a patient with copious secretions. Successful positioning was achieved through the oral cavity with the aid of an ETT. Division of the ETT along its longitudinal axis allowed for its removal. With this technique we were able to continue with adequate mechanical ventilation and frequent pulmonary toileting.
CONCLUSION: AEB can be successfully placed orally after longitudinal section of an ETT to manage massive hemoptysis. This technique permits mechanical ventilation and pulmonary toileting through the tracheostomy tube while achieving adequate hemostasis.
DISCLOSURE: Steven Kadiev, None.