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.