Case presentation
A 74-year-old man presented with a cough persisting for 2 months and weight loss. A chest computed tomography scan displayed a 45-mm-long mass lesion in the right lung at the end of S9–S10, enlarged lymph nodes (35 mm) below the tracheal bifurcation, and infiltration in the right middle bronchus. The right main bronchus was stenotic (Fig. 1), which could lead to atelectasis, hence the patient was admitted to our hospital for emergency endobronchial stenting.
After entering the operating theater, the patient’s vital signs were recorded as follows: oxygen saturation, 99% under room air; blood pressure, 176/82 mmHg; and heart rate, 62 bpm. In the supine position, the patient had no respiratory distress. Oxygenation (6 L/min) was started using an oxygen mask. Anesthesia was induced by TIVA combined with propofol and dexmedetomidine. Propofol was administered by target-controlled infusion (TCI) with a Terufusion®Syringe Pump (Terumo Co., Tokyo, Japan). Dexmedetomidine administration was started at 0.6 μg/kg/h. After intravenous infusion of 50 μg of fentanyl, 5 mL, and 2.5 mL of 4% lidocaine were sprayed into the space between the pharyngeal wall and the glottis and into the trachea, respectively, using a McGrath MAC® video laryngoscope (Medtronic Co., Minneapolis, MN, USA). A pillow was placed under the patient’s shoulder to maintain neck extension, and the linear probe (13–6 MHz) Sonosite SII (Fujifilm Sonosite, Inc., Bothell, WA, USA) was placed in the parasagittal plane of larynx to identify the thyroid cartilage, thyrohyoid muscle, thyrohyoid membrane, and hyoid bone (Fig. 2). Next, a hockey stick-type probe (13–6 MHz) was used to identify the greater horn of the hyoid bone, and then SLNB was performed using a 23-gauge, 60-mm needle and a 5-mL syringe in the sagittal approach under real-time ultrasound guidance (Fig. 3 A, B). Lidocaine (2 mL of a 2% solution) was injected to each side of larynx, and no bleeding was confirmed after compression for 5 minutes after the SLNB. After confirming the anesthetic procedure, the bispectral value remained about 60 and spontaneous breathing was maintained, a rigid bronchoscope was inserted by a respiratory surgeon. There was almost no bucking during insertion. Spontaneous breathing was maintained throughout the procedure, and pure oxygen was supplied through the side port of the rigid bronchoscope. The stenosis was balloon dilated and a 9-mm silicone stent was inserted. There was little body movement during insertion of the rigid speculum alone, but when endotracheal manipulation was performed, bucking was observed, so a total of 3 mL of 2% lidocaine was intermittently administered into the trachea. Intraoperative hemodynamics remained stable throughout the operation, even though no additional fentanyl was administered. The endoscopic procedure was completed without any adverse events, and the rigid bronchoscope was removed. SpO2 was maintained at 97% to 100% during the anesthesia. The operation time was 1 hour 55 minutes. There were no complications such as tracheal bleeding or vocal cord paralysis after the surgery.