Airway obstruction due to endobronchial hemorrhage after insertion of a double-lumen endobronchial tube.

 Authors: Fengoudaki M^1a, Fyntanidou B^2b*, Foroulis Ch^3c, Tsagkaropoulos S^4c, Kyparissa M^5a,  Sarridou D^6a, Argiriadou H^5a, Kotzampassi K^7d, Grosomanidis V^5a

¹ MD, MSc, Anesthesiology
² MD, MSc, PhD, Emergency Medicine
³ MD, PhD, Cardiothoracic Surgery
⁴ MD, MSc, PhD, Cardiothoracic Surgery
⁵ MD, PhD, Anesthesiology
⁶ MD, MSc, PhD, Anesthesiology
⁷ MD, PhD, General Surgery

^a Clinic of Anesthesiology and Intensive Care, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
^b Emergency Medicine Clinic, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
 ^c Department of Cardiothoracic Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece
^d Department of Surgery, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece

*Corresondence: Kautatzoglou 14A, 54639, Thessaloniki, Greece, Tel: 0030 6977427336, e-mail:

ABSTRACT

Double Lumen endobronchial Tubes (DLTs) are the default choice for achieving lung isolation when One Lung Ventilation (OLV) is indicated. DLTs are the preferred choice since their insertion is quicker, they are less prone to displacement, lung deflation is accomplished faster and secretions suctioning from both lungs is feasible. Inappropriate size selection, increased number of insertion attempts, forceful and too distal advancement of the DLT and any movements with inflated cuffs are associated with risk of airway injury. Although minor airway trauma is common, major complications such as severe airway bleeding are rare.This report describes a 65-year-old patient (BMI 31, ASA II) who was scheduled for left thoracotomy, due to lung cancer. Patient was an old smoker without any other comorbidities. After anesthesia induction and standard endotracheal intubation, bronchoscopy was performed to obtain tumor samples for staging. During bronchoscopy endobronchial projection of the tumor was revealed. Thereafter, the endotracheal tube was removed and a left DLT (39F) was placed. However, ventilation through the DLT was not possible, and therefore it was removed and a new normal endotracheal tube (8.5F) was inserted. Immediately thereafter major bleeding through the tube and hypoxemia occurred. Blood was initially suctioned with a standard catheter and then via the bronchoscope. Moreover, intrabronchial administration of adrenaline was decided. During the bleeding, PaO₂ levels dropped and PaCO₂ levels increased and surgery was cancelled. Patient gradually improved and finally he was transferred to the ICU, where he was extubated 3hrs later. Patient was rescheduled to 8 days later for left pneumonectomy. A right DLT was selected and placed for the operation. Surgery was uneventful. This case highlights a rare but potentially life-threatening complication of DLT placement in a patient with endobronchial projection of the tumor, which caused an almost total airway obstruction, recognized by bronchoscopy. The distance between the tumor and the carina was not evaluated correctly and the associated high bleeding risk was not taken into careful consideration. Bleeding could have been avoided by initial selection of a larger right DLT or by bronchoscopic DLT insertion. Airway obstruction due to acute endotracheal bleeding is an emergency and should be managed immediately by the anesthesiologist since it could

 

INTRODUCTION

Lung separation and one-lung ventilation (OLV) are employed in a wide variety of surgical procedures and are essential in thoracic surgery, particularly during thoracoscopic operations where they are considered mandatory. OLV can be achieved using several techniques, and there is ongoing debate regarding the optimal approach^1,2.

The double-lumen tube (DLT) is the most commonly used device for achieving OLV. Its placement is generally faster, provides superior ventilation conditions, allows suctioning of secretions from both lungs, and facilitates bronchoscopic examination^3,7. DLTs are available in both right-sided and left-sided configurations and in a range of sizes. Left-sided DLTs are more frequently used because of the potential complications associated with right-sided tubes^8,9.  Selection of the appropriate DLT size remains a major challenge, as no clear guidelines exist and clinical practice often relies on the anesthesiologist’s experience¹⁰. Recommendations are mainly based on patient height; however, situations are not uncommon in which the theoretically appropriate tube cannot pass through the glottis, whereas in other cases it proves too short for the individual patient. In addition, DLTs from different manufacturers may vary in dimensions despite having the same nominal size.

An appropriately sized DLT should pass easily through the glottis and, when the bronchial lumen is positioned within the mainstem bronchus, the tracheal lumen should remain correctly located within the trachea. Chest radiography, computed tomography (CT), and ultrasonography have all been used to estimate tracheal dimensions for DLT size selection⁴.

Intraoperative hypoxemia and many DLT-related complications are largely attributable to tube malposition^3,11-13. Traditionally, correct DLT positioning has been assessed clinically; however, clinical evaluation alone frequently fails to detect malposition¹⁴.

Bronchoscopic confirmation of DLT position has been shown to significantly reduce the incidence of malposition^15,16. Introduction of flexible fiberoptic bronchoscopy into routine clinical practice for DLT position verification represents one of the most important advances in thoracic anesthesia in recent decades. In contemporary thoracic anesthesia, flexible bronchoscopy is considered the gold standard for confirming correct DLT placement¹⁷.

Minor airway injuries are common and usually manifest as postoperative sore throat and hoarseness, whereas major airway injuries are rare. Inappropriate DLT size selection, repeated intubation attempts, forceful or excessively deep advancement of the tube, and manipulation while the cuffs remain inflated are recognized risk factors for airway trauma. ¹⁸⁻²²

Aspiration of blood-stained secretions through a DLT, particularly in patients with coagulation disorders, is a relatively common finding; however, severe hemorrhage resulting in interruption of surgery is uncommon²³. Airway obstruction secondary to sudden endotracheal bleeding represents an emergency and potentially life-threatening condition that requires immediate management by the anesthesiologist²⁴.

CASE PRESENTATION

A 65-year-old male patient with a body mass index (BMI) of 31 kg/m², classified as ASA Physical Status II, a former smoker, and without significant comorbidities, was scheduled for left thoracotomy because of lung cancer (Figure 1). Preoperative spirometry demonstrated FVC and FEV₁ values of 54% and 55% of predicted, respectively, while laboratory investigations were within normal limits. Imaging studies, including computed tomography and positron emission tomography (PET), revealed no evidence of distant metastases. Apart from bronchodilator therapy, the patient was not receiving any other medication. Despite near-complete atelectasis of the left lung (Figure 1), he reported no dyspnea.

 

Anesthesia was induced with intravenous propofol 2 mg/kg and fentanyl 0.1 mg/kg. Neuromuscular blockade was achieved with rocuronium 0.8 mg/kg. In addition to standard monitoring, invasive arterial blood pressure monitoring, central venous pressure measurement, and noninvasive assessment of cardiac output, stroke volume, stroke volume variation (SVV), and pulse pressure variation (PPV) using the ClearSight system were employed.

Following induction of general anesthesia, an 8.5-mm single-lumen endotracheal tube was inserted, and diagnostic bronchoscopy was performed to obtain tumor samples for staging. Bronchoscopy revealed endobronchial extension of the tumor into the left main bronchus.

The single-lumen tube was subsequently removed, and placement of a 39-Fr left-sided DLT was attempted. Tube size selection was based on the patient’s anthropometric characteristics.

During verification of tube position, effective ventilation could not be achieved. The DLT was therefore immediately removed and replaced with an 8.5-mm single-lumen endotracheal tube.

Immediately after reintubation, sudden massive airway bleeding was observed through the endotracheal tube, accompanied by an inability to ventilate the patient and occurrence of severe hypoxemia (Figure 2). Initial management included suctioning of blood using a standard suction catheter. Flexible bronchoscopy was then performed, allowing airway clearance and endobronchial administration of epinephrine to achieve hemostasis.

 

During the bleeding episode, a significant decrease in arterial oxygen tension (PaO₂) and an increase in arterial carbon dioxide tension (PaCO₂) were documented, as shown in Table 1. Following gradual clinical and blood-gas improvement, the surgical procedure was postponed. The patient was transferred to the cardiothoracic intensive care unit (ICU), where he was successfully extubated three hours later without further complications (Table 1).

 

 

Eight days later, after detailed discussion with the patient and his family regarding the previ-ous complication and associated risks, surgery was rescheduled. A right-sided DLT was selected for lung isolation, and correct tube position was confirmed using flexible fiberoptic bronchoscopy. OLV was maintained for 95 minutes, and a left pneumonectomy was successfully performed (Figures 3 and 4).

 

 

The intraoperative and postoperative courses were uneventful. Patient was discharged from the ICU on postoperative day 1 and from the hospital 6 days after surgery without the need for supplemental oxygen.

 

DISCUSSION

DLTs are the most frequently used devices for lung separation and OLV. Although their primary indication is thoracic surgery, they are also employed in selected non-thoracic procedures, such as esophageal and spinal surgery, and, less commonly, for isolated lung ventilation in patients with unilateral pulmonary pathology^21,22.

Despite their advantages over bronchial blockers (BBs), DLTs have been associated with a higher incidence of airway trauma^25,26. Nevertheless, most injuries are minor and typically manifest as postoperative hoarseness and sore throat, whereas major airway injuries remain uncommon. Factors associated with airway trauma include repeated intubation attempts, patient-specific anatomical characteristics, and the experience of the anesthesiologist. The incidence of injury is increased in patients with difficult airways²⁷. The use of video laryngoscopy and long flexible introducers (bougies) during difficult intubation has been shown to reduce the risk of airway trauma^3,28,29.

At our institution, DLT placement is routinely performed without direct visual guidance, while correct positioning is subsequently confirmed both clinically and with flexible fiberoptic bronchoscopy.

In the present case, a left-sided DLT was selected, as this represents the most commonly used device for thoracic surgical procedures^4,18,30. Indications for the use of a right-sided DLT include procedures involving the left main bronchus (such as left lung transplantation or left pneumonectomy), distortion of the anatomy of the left main bronchus (e.g., descending thoracic aortic aneurysm or extrinsic tumor compression), endobronchial tumors, and penetrating injuries of the left main bronchus^18,31.  Nevertheless, some centers routinely use right-sided DLTs even for procedures involving the left lung³².

Following DLT placement, effective ventilation could not be achieved. Failure to ventilate after intubation may result from a variety of causes, including esophageal intubation, endotracheal tube obstruction, bronchospasm, or pneumothorax. Prompt identification and correction of the underlying cause are among the most critical responsibilities of the anesthesiologist³³.   In the present case, the DLT was immediately removed and replaced with a single-lumen endotracheal tube, as the inability to ventilate was initially attributed to DLT malposition. The severity of the respiratory compromise did not permit bronchoscopic confirmation or repositioning of the DLT.

The occurrence of massive airway bleeding immediately after reintubation with a single-lumen tube fundamentally altered the clinical assessment, as it strongly suggested airway injury related to the intubation procedure. Such bleeding may result from trauma or rupture of the trachea or bronchi. The reported incidence of tracheobronchial rupture associated with DLT placement is approximately 0.2%. Tracheal ruptures most commonly involve the membranous portion of the trachea, whereas DLT-related injuries more frequently affect the left main bronchus^34,35.  Diagnosis is not always straightforward and typically presents with subcutaneous emphysema, pneumomediastinum, and hypoxemia. Although blood may be observed within the endotracheal tube, this finding is not consistently present³⁶.

Lower airway hemorrhage resulting in airway obstruction is a potentially fatal condition and a major cause of airway-related mortality³⁷. Unlike upper airway bleeding, which is more common and generally easier to manage, hemorrhage originating from the lower airways requires immediate and effective intervention because ventilation may become impossible or severely impaired, resulting in profound hypoxemia and an increased risk of cardiac arrest.

In the present case, the bleeding was ultimately attributed to mechanical injury of the endobronchial tumor projection by the bronchial tip of the left-sided DLT. Although endobronchial tumor extension causing near-complete obstruction of the left main bronchus had been identified during preoperative bronchoscopy, the distance between the lesion and the carina was not adequately assessed, and the increased risk of bleeding due to mechanical trauma was not fully appreciated.

This complication might have been avoided through the initial selection of a right-sided DLT, the use of a larger-sized tube, or advancement of the DLT under continuous bronchoscopic guidance.

CONCLUSIONS

Although placement of a double-lumen tube is generally considered a technically straightforward procedure, it may be associated with serious airway injuries that can, in certain circumstances, have catastrophic consequences. Lower airway hemorrhage constitutes an emergency and potentially life-threatening condition requiring immediate, targeted, and effective management. In the present case, prompt recognition of the complication and rapid implementation of an appropriate management strategy were crucial for patient’s survival.

Careful preoperative evaluation, appropriate selection of the type and size of the DLT, and meticulous tube placement are essential measures that may substantially reduce the risk of airway injury and related complications.

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Addittional materials: No

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Acknowledgements: Not applicable

Authors’ contributions: FM drafted the paper and is the lead author. FB contributed to planning and the critical revision of the paper. FCh contributed to planning and the critical revision of the paper. TS contributed to planning and the critical revision of the paper. KM contributed to planning and the critical revision of the paper. SD contributed to planning and the critical revision of the paper. AH contributed to planning and the critical revision of the paper. KK contributed to planning and the critical revision of the paper. GV contributed to planning and the critical revision of the paper.  All authors read and approved the final manuscript.

Funding: Not applicable.

Availability of supporting data: The datasets analyzed during the current article are available from the corresponding author on reasonable request.

Ethical approval and consent to participate: Ethics committee approval required. Patient’s consent was obtained

Competing interests: The authors declare that they have no competing interests.

Received: June 2026, Accepted: September 2026, Published: September 2026

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REFERENCES

1. Neustein S. Pro. Βronchial blockers should be used routinely for providing one-lung ventilation. J Cardiothorac Vasc Anesth 2015;29:234-6. DOI: 10.1053/ j.jvca.2014.07.028.
2. Brodsky J. Con. Α bronchial blocker is not a substitute for a double-lumen endobronchial tube. J Cardiothorac Vasc Anesth 2015;29 :237-9. DOI: 10.1053/ j.jvca.2014.07.027.
3. Patel M, Wilson A, Ong C. Double lumen tubes and bronchial blockers. BJA Educ 2023;23:416-424. DOI: 10.1016/j.bjae. 2023.07.001.
4. Shoni M, Rodriguez G. Intraoperative Anesthetic Management of the Thoracic Patient. Thorac Surg Clin. 2020 ;30:279-291. DOI: 10.1016/j.thorsurg.2020. 04.011.
5. Bernasconi F, Piccioni F. One-lung ventilation for thoracic surgery: current perspectives. Tumori 2017;103:495-503. DOI: 10.5301/tj.5000638.
6. Zong Z, Shen Q, LuY, et al. A simple blind placement of the left-sided double-lumen tubes. Medicine 2016 ;95:5376. DOI: 10.1097/MD.0000000000005376.
7. Bahk J, Oh Y. A new and simple maneuver to position the left-sided double-lumen tube without the aid of fiberoptic bronchoscopy. Anesth Analg 1998;86:1271-5. DOI: 10.1097/ 00000539-199806000-00026.
8. Falzon D, Alston R, Coley E, et al. Lung Isolation for Thoracic Surgery: From Inception to Evidence-Based. J Cardiothorac Vasc Anesth 2017;31:678-693.DOI: 10.1053/j.jvca.2016.05.032.
9. Shelley B, Macfie A, Kinsella J. Anesthesia for thoracic surgery: A Survey of uk practice. Cardiothorac Vasc Anesth 2011;25:1014-7. DOI: 10.1053/J.JVCA. 2011.06.018.
10. Clayton-Smith A, Bennett K, Alston R, et al. A Comparison of the Efficacy and Adverse Effects of Double-Lumen Endobronchial Tubes and Bronchial Blockers in Thoracic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2015;29 :955-66. DOI: 10.1053/j.jvca.2014.11.017.
11. Brodsky J, Shulman M, Mark J. Malposition of left-sided double-lumen endobronchial tubes. Anesthesiology 1985;62:667-9. DOI: 10.1097/00000542-198505000-00028.
12. Inoue S, Nishimine N, Kitaguchi K, et al. Double lumen tube location predicts tube malposition and hypoxaemia during one lung ventilation. Br J Anaesth 2004; 92:195e201.
13. Zhang X, Wang D, Wei J, et al. Recent advances in double-lumen tube malposition in thoracic surgery: A bibliometric analysis and narrative literature review. Front Med 2022;9:1071254. DOI: 10.3389/fmed.2022.1071254.
14. Park J, Jo J, Park J, et al . Comparison of conventional and fibreoptic-guided advance of left-sided double-lumen tube during endobronchial intubation: A randomised controlled trial. Eur J Anaesthesiol 2020;37:466-473. DOI: 10.1097/ EJA. 0000000000001216.
15. Slinger PD. Fiberoptic bronchoscopic positioning of double-lumen tubes. J Cardiothorac Anesth 1989;3:486-96. DOI: 10.1016/s0888-6296(89)97987-8.
16. Liang C, Jiang L, Liu Y, et al. The anatomical landmarks for positioning of double lumen endotracheal tube using flexible bronchoscopy: A prospective observational study. Heliyon 2022;8 :e11779. DOI: 10.1016/j.heliyon. 2022.e11779.
17. Cohen E. Double-lumen tube position should be confirmed by fiberoptic bronchoscopy. Curr Opin Anaesthesiol 2004; 17:1–6. DOI: 10.1097/01.aco. 0000114682.04870.6a
18. Ashok V, Francis J. A practical approach to adult one-lung ventilation. BJA Educ 2018;18:69-74. DOI: 10.1016/j.bjae. 2017.11.007.
19. Gilbert T, Goodsell C, Krasna MJ. Bronchial rupture by a double-lumen endobronchial tube during staging thoracoscopy. Anesth Analg 1999;88:1252-3. DOI: 10.1097/00000539-199906000-00012.
20. Liu H, Jahr J, Sullivan E, et al. Tracheobronchial rupture after double-lumen endotracheal intubation. J Cardiothorac Vasc Anesth 2004;18:228-33. DOI: 10.1053/j.jvca.2004.01.003.
21. Campos J. Lung isolation techniques. Anesthesiol Clin North Am 2001;19:455-74. DOI: 10.1016/s0889-8537(05)70243-1.
22. Berg S, Bittner E, Berra L, et al. Independent lung ventilation: Implementation strategies and review of literature. World J Crit Care Med 2019; 31:49-58. DOI: 10.5492/wjccm.v8.i4.49.
23. Kim H, Baek S, Kim K, et al. Endobronchial hemorrhage after intubation with double-lumen endotracheal tube in a patient with idiopathic thrombocytopenic purpura for minimally invasive cardiac surgery: a case report. Korean J Anesthesiol 2014;66:59-63. DOI: 10.4097/kjae. 2014.66.1.59.
24. Usman M, Yamamoto Τ, Yamamoto S. Intraoperative Airway Obstruction: A Case Report. Cureus 2025;17.8. DOI:10.7759/cureus.91089
25. Brodsky J, Lemmens H. The history of anesthesia for thoracic surgery. Minerva Anestesiol 2007;73:513-24. PMID: 17380101.
26. Knoll H, Ziegeler S, Schreiber J, et al. Airway injuries after one-lung ventilation: a comparison between double-lumen tube and endobronchial blocker: a randomized, prospective, controlled trial. Anesthesiology 2006;105:471-7. DOI: 10.1097/00000542-200609000-00009.
27. Brodsky J. Lung separation and the difficult airway. Br J Anaesth 2009;103 :i66-75. DOI: 10.1093/bja/aep262.
28. Apfelbaum J, Hagberg C, Connis R et al. 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiol 2022;136:31-81. DOI: 10.1097/ALN. 0000000000004002.
29. Luther D, Robertson H, Suchett-Kaye I, et al. Double-lumen tracheal tubes and bougies: a bench study to investigate factors that influence the risk of shearing. Anaesthesia 2019;74:891-895. DOI: 10.1111/anae.14672.
30. Brodsky J, Lemmens H. Left double-lumen tubes: clinical experience with 1,170 patients. J Cardiothorac Vasc Anesth 2003;17:289-98. DOI: 10.1016/s1053-0770(03)00046-6.
31. Pedoto A. How to choose the double-lumen tube size and side: the eternal debate. Anesthesiol Clin 2012;30:671-81. DOI: 10.1016/j.anclin.2012.08.001.
32. Ehrenfeld J, Walsh J, Sandberg W. Right- and left-sided Mallinckrodt double-lumen tubes have identical clinical performance. Anesth Analg 2008;106:1847-52. DOI: 10.1213/ane.0b013e31816f24d5.
33. Fosse K, Salomonsen M, Gisvold SE, et al. Can intubate, cannot ventilate: A proposed algorithm to handle problems with ventilation and oxygenation after intubation. Acta Anaesthesiol Scand. 2025;69(3):e70007. DOI: 10.1111/ aas.70007.
34. Liu S, Mao Y, Qiu P, et al. Airway Rupture Caused by Double-Lumen Tubes: A Review of 187 Cases. Anesth Analg. 2020;131(5):1485-1490. doi: 10.1213/ ANE.0000000000004669. PMID: 33079871.
35. Miñambres E, Burón J, Ballesteros M, et al. Tracheal rupture after endotracheal intubation: a literature systematic review, Eur Jof Cardio-Thoracic Surgery 2009;35:1056–1062. https://doi.org/1016/ j.ejcts.2009.01.053
36. Evans D, McGlashan J, Norris A. Ιatrogenic airway injury. BJA Education 2015;15: 184–89 DOI: 10.1093/ bjaceaccp/mku026
37. Kristensen M, McGuire B. Managing and securing the bleeding upper airway: a narrative review. Can J Anaesth. 2020;67:128-140. DOI: 10.1007/s12630-019-01479-5.

 

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Citation: Fengoudaki M, Fyntanidou B, Foroulis Ch, Tsagkaropoulos S, Kyparissa M, Sarridou D, Argiriadou H, Kotzampassi K, Grosomanidis V: Airway obstruction due to endobronchial hemorrhage after insertion of a double-lumen endobronchial tube. Greek e j Perioper Med. 2026;25(b): 28-39.

 

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