【Background】In patients after left upper lobectomy (LUL), U- or V-shaped angulation of the left main bronchus (LMB) develops with expansion of the left lower lobe. We reported that a standard left-sided double-lumen tube (LDLT) cannot be used to achieve successful one-lung ventilation (OLV) for right lung surgery in post-LUL patients with remarkable LMB angulation, characterized by a combination of a wide angle (> 140°) between the trachea and LMB and a narrow angle (< 100°) between the LMB and left lower bronchus, whereas it can be used safely in patients with unremarkable angulation (J Cardiothorac Vasc Anesth. 2016;30:961-6). Herein, we present a female after left upper division segmentectomy (LUDS) with unremarkable LMB angulation scheduled for robot-assisted thoracic surgery (RATS), in whom ventilation failure occurred with a standard LDLT immediately after she was placed in a lateral jack-knife position required for RATS.  
【Case Report】A 73-year-old female was scheduled to undergo RATS for right lung cancer. She had undergone LUDS for adenocarcinoma 5 years before. A chest X-ray revealed that she had LMB angulation, albeit unremarkable. After induction of general anesthesia, a standard LDLT (35Fr Portex blue line®) was placed correctly with video laryngoscopy and bronchoscopy. Pressure-controlled ventilation was used for OLV. Adequate OLV could be achieved during test OLV while she was placed in the supine position, and also in the left lateral position. However, ventilation failure occurred as soon as she was placed in the lateral jack-knife position with the waist raised. Fiberoptic examinations revealed that the tip of the bronchial lumen was completely obstructed by the LMB wall despite correct LDLT placement. The LDLT was exchanged to another type of LDLT with a soft, flexible, wire-reinforced tip (Silbroncho®, 37Fr) using a tube exchanger and video laryngoscopy while she remained in the lateral position. Thereafter, adequate OLV could be achieved even after she was replaced in the lateral jack-knife position. The scheduled RATS could be completed uneventfully. 
【Discussion and learning points】 Our experience suggests that ventilation failure with a standard LDLT can occur more easily when a patient with LMB angulation is placed in a lateral jack-knife position than simple lateral position probably due to more significant posture-induced exacerbation of bronchial angulation, and that Silbroncho® tube is useful to overcome this problem. 


06 / Sudden ventilation failure during left one lung ventilation for robot-assisted right upper lobectomy in a patient after left upper division segmentectomy.