DOPS: bronchial blocker in a difficult airway, and a blocker that slipsDOPS: 58-year-old woman, previous neck radiotherapy, limited mouth opening
DOPS: bronchial blocker placement in a difficult airway, and dislodgement
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Know this first
- Blockers suit difficult airways: keep the single-lumen tube, no tube exchange.
- Types: Arndt, Cohen, Fuji Uniblocker, EZ-Blocker; usually passed coaxially through the tube.
- Blockers dislodge more often than double-lumen tubes.
- Keep peak airway pressure below 30 cmH2O to stop gas leaking past the cuff.
- A cuff that slips into the trachea blocks ventilation and loses lung separation.
The patient
The examiner asks
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Prepare
How do you prepare?
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- Difficult airway, so I keep her single-lumen tube and add a blocker instead of exchanging tubes. (Procedure step)
- Options: Arndt, Cohen, Fuji Uniblocker or EZ-Blocker; I'll pass an Arndt through the tube.
- Multiport adapter, lubricated fibreoptic scope, blocker cuff tested, suction ready.
Perform
Talk me through placement.
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- Blocker through the adapter, with its wire loop around the fibreoptic scope. (Procedure step)
- Scope into the left main bronchus; slide the blocker along it, then retract the loop.
- Inflate the cuff under direct vision until it seals the left main bronchus.
- Lock the blocker at the adapter and secure the tube firmly.
Perform
How do you confirm isolation and keep it?
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- Scope check: the inflated cuff sits in the left main bronchus, clear of the carina. (Procedure step)
- Suction through the blocker lumen helps the left lung deflate.
- Recheck with the scope after turning her lateral, since blockers shift easily.
- Keep peak airway pressure under 30 cmH2O so gas doesn't leak past the cuff.
Crisis
During surgical handling, ventilation suddenly fails: peak pressure 45 cmH2O, capnography trace flattening, SpO2 92% and falling. What do you do?
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- The blocker cuff has probably slipped into the trachea and is obstructing both lungs. (Crisis)
- Deflate the blocker cuff at once and ventilate with 100% oxygen.
- Tell the surgeon to pause lung retraction.
- When saturation recovers, scope down the tube and reposition the blocker into the left bronchus.
- Reinflate under vision, lock it again, and recheck after any further movement.
Scan · Bronchoscopy: right upper lobe
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Fibreoptic bronchoscope via the tracheal lumen, then through the right DLT's upper-lobe slot.
Inside the right upper lobe bronchus (per caption); scope rotation not stated
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, open the image full sizeThis image carries no labels of its own; the structures are named below.
Labels Right upper lobe (from the source caption)
- On the right side wall, this opening is the right upper lobe.
- Going in shows three holes, which only this lobe has.
- It starts about two centimetres below the carina, sometimes higher, even off the trachea.
- A right tube's slot must line up here, or the lobe is cut off.
- Right-sided blockers have the same small margin for error.
- Right upper lobe orifice Lateral wall, about 3–4 o'clock, roughly 2 cm below carina
- Three segmental openings Apical, anterior, posterior: unique trifurcation that identifies it
- Anomalous take-off May be under 2.5 cm away or arise from trachea
- Right DLT ventilation slot Must sit over the orifice; margin only 1–8 mm
- Bronchus intermedius Seen beyond the slot through the bronchial lumen
Checked against: Miller 10e · Barash 9e
Image: Knight SE et al., Pigtail catheter found in the Lingula of a pediatric patient on VV-ECMO while performing flexible bronchoscopy: a case report on an unexpected finding (Front Med (Lausanne) 2026; doi:10.3389/fmed.2026.1912185), Figure 2 (image 3, cropped), CC BY 4.0. Changes: Trimmed the frame edge. Question image: panel number '3' covered
Scan · Bronchoscopy: bronchial blocker
Here is your image. Point to and name each structure, then say why it matters.
Fibreoptic bronchoscope through the single-lumen tube, viewing from just above the carina.
From above the carina: blocker (yellow shaft) with inflated balloon in the left main bronchus at upper left, open right main bronchus below
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, open the image full sizeLabels Arrow: the blocker with its balloon inflated
- From just above the carina, the blocker goes into the chosen main bronchus.
- I inflate the balloon while watching, using only enough to seal.
- The balloon stays below the carina, not bulging into the trachea.
- On the right there is less room because the upper lobe comes off early.
- If it slips into the trachea we cannot ventilate, so I deflate it immediately.
- Main carina Viewed from just above it in the trachea
- Blocker balloon in main bronchus Inflate under vision with least volume that seals
- Balloon edge clear of carina Must not ride up over the carina
- Right-sided placement Upper lobe close by: smaller margin for error
- Dislodged balloon in trachea Blocks both lungs: hypoxia, arrest; deflate at once
Checked against: Miller 10e · Barash 9e
Image: Gupta S et al., Anesthetic Management for the Retrieval of Retained Intrathoracic Foreign Bodies Adjacent to Critical Mediastinal Structures Using One-Lung Ventilation With a Bronchial Blocker: A Report of Two Cases (Cureus 2026; doi:10.7759/cureus.110538), Figure 7, CC BY 4.0. Changes: Cropped to the round scope image. Question image: black arrow covered with a box on the bronchial wall
Fatal mistakes
- Placing the blocker blind.
- Leaving the cuff inflated when ventilation fails.
Checked against: Miller 10e · Barash 9e
Report a problem with this case
Mark Got it only if you said every point. Again brings the case back tomorrow; Got it brings it back in 3, then 7, 14 and 30 days.