Pierre Conne
Jon Andri Lutz
Corinne Grandjean1- 1Anesthesiology Department, Hospital of Fribourg, Fribourg, Switzerland
- 2Thoracic Surgery Unit, Department of Surgery, HFR Fribourg Cantonal Hospital, Fribourg, Switzerland
One-lung ventilation (OLV) is the standard treatment during thoracic surgery; however, maintaining adequate oxygenation can be particularly challenging in patients with a history of contralateral lobectomy. We report the case of a 44-year-old woman who underwent uniportal video-assisted thoracic surgery for a right upper lobectomy after a previous left upper lobectomy. The patient developed severe hypoxemia during OLV despite maximal ventilatory adjustments and the application of conventional continuous positive airway pressure (CPAP) to the operative lung, which impaired surgical exposure. As a rescue strategy, a bronchial blocker was advanced through a left-sided double-lumen tube (DLT) into the right bronchus intermedius, enabling selective delivery of CPAP to the right middle and lower lobes while maintaining collapse of the right upper lobe. This approach successfully restored oxygenation without interfering with the surgical field. This case illustrates that the combined use of a DLT and bronchial blocker can provide an effective and safe solution for refractory hypoxemia and can be considered as a rescue technique in complex thoracic procedures in patients with prior contralateral resections.
Introduction
Lung cancer is a leading cause of death worldwide (1), responsible for an estimated 1.8 million deaths in 2020 (2). However, post-diagnosis survival rates have been improving, likely due to advances in screening and treatment strategies (3). The use of high-resolution computed tomography (CT) scans has increased opportunities for detecting multifocal lung cancer (4).
Uniportal video-assisted thoracic surgery (uVATS) lobectomy in patients with a history of contralateral lobectomy remains challenging, as maintaining stable oxygenation during one-lung ventilation (OLV) is often difficult. Hypoxemia is the most common and clinically significant complication during OLV, occurring in approximately 4%–6% of cases (5).
Selective lobar collapse can be an effective strategy for patients who have previously undergone contralateral lobectomy (6). A bronchial blocker enables selective lobar blockade (SLB) by occluding a specific bronchial branch. The combined use of a double-lumen endotracheal tube (DLT) and a bronchial blocker has been described in several studies (7–9).
In this case report, we present the use of a DLT in combination with a bronchial blocker, through which continuous positive airway pressure (CPAP) was applied as a rescue strategy for persistent hypoxemia during selective pulmonary ventilation. Verbal and written informed consent for this publication, including images, was obtained from the patient.
Case
We present the case of a 44-year-old woman, classified as American Society of Anesthesiologists (ASA) Physical Status 3, who was an active smoker with a 40-pack-year history. She was diagnosed with two synchronous non-small cell lung carcinomas (NSCLCs), one of which was associated with a solitary brain metastasis. After cerebellar resection and a uVATS left upper lobectomy, a right upper lobectomy was subsequently scheduled via uVATS.
Preoperative evaluation before the first lobectomy revealed the following pulmonary function parameters: functional vital capacity (FVC) of 3.93 L, forced expiratory volume in 1 second (FEV1) of 89%, and an FEV1/FVC ratio of 89%. The diffusing capacity for carbon monoxide (DLCO) was not recorded. Vital signs included a blood pressure (BP) of 113/45 mmHg, heart rate (HR) of 87 bpm, and oxygen saturation (SpO₂) of 97% on room air. Lung function testing was not repeated between the two surgeries.
After a multidisciplinary discussion, we determined that isolating the right upper lobe using a bronchial blocker placed in the upper right main bronchus would interfere with the surgeon's access to the superior lobe. Therefore, we planned to ventilate the patient using a left-sided DLT.
On the day of surgery, a thoracic epidural catheter was inserted at the T4–T5 level. General anesthesia was induced with fentanyl, propofol, and rocuronium. A 37-Fr left-sided Rusch® Bronchopart™ DLT (Teleflex Medical, Wayne, PA, USA) was inserted, and correct placement was confirmed via fiberoptic bronchoscopy. Invasive monitoring was established via a right radial arterial line.
The patient was then positioned in the left lateral decubitus position, and tube placement was reconfirmed using a fiberoptic bronchoscope [Ambu® aScope™ 4 Broncho Slim, 3.8/1.2 (Ambu A/S, Ballerup, Denmark)].
Figure 1 shows the template of intraoperative vital sign monitoring. OLV was initiated using a lung-protective ventilation strategy with a tidal volume of 5 mL/kg and a positive end-expiratory pressure (PEEP) of 7 cmH₂O. However, shortly after lung isolation, oxygenation became difficult. The SpO₂ decreased from 99% to 83%, and the ETCO2 increased from 5.4 to 5.9 kPa, despite increasing the fraction of inspired oxygen (FiO₂) to 100% and raising the PEEP on the ventilated lung to 9 cmH₂O (individualized PEEP titration for optimal compliance was not performed; instead, a fixed PEEP of 9 cmH₂O was used based on the attending anesthesiologist's experience). Peak pressure increased from 23 cmH2O to 29 cmH2O, and plateau pressure increased from 17 cmH2O to 20 cmH2O. Static and dynamic compliance were not recorded intraoperatively.
Figure 1. Intraoperative monitoring. (1) Start of left one-lung ventilation, (2) initiation of the rescue maneuver (detailed in Figure 2), and (3) placement of the bronchial blocker.
Fiberoptic bronchoscopy was used to confirm the absence of macroscopic airway obstruction and to simultaneously verify the correct placement of the left-sided DLT. A single-step recruitment maneuver was performed for 1 min at 30 cmH2O on the ventilated lung; however, no improvement in SpO2 was observed. Neuromuscular blockade was corrected until a train-of-four (TOF) count of 0 was achieved. Applicationof CPAP at 5 cmH2O to the right operative lung (using a Shiley™ CPAP system with an external O2 flow of 5 L/min) impaired surgical visibility.
No adjustments were made to the inspiratory-to-expiratory ratio, and the tidal volume was maintained at 5 mL/kg. Intraoperative hemoglobin levels were not checked, as preoperative values were within normal limits and no significant bleeding occurred. Hemodynamic parameters remained stable, and no optimization was required. Figure 2 shows the sequence of interventions undertaken to improve oxygenation during one-lung ventilation.
Figure 2. Rescue maneuver timeline.
We then decided to place a 7-Fr Arndt bronchial blocker (Cook Medical, Bloomington, IN, USA) into the right bronchus intermedius under fiberoptic bronchoscopy (Ambu® aScope™ 4 Broncho Slim, 3.8/1.2) guidance. CPAP at 5 cmH2O was applied via the suction channel of the bronchial blocker (using the Shiley™ CPAP system with an external O2 flow of 5 L/min) to the right middle and lower lobes while maintaining collapse of the upper lobe. As shown in Figure 3, correct positioning of the blocker within the bronchus intermedius was repeatedly verified using fiberoptic bronchoscopy throughout the procedure (image not published due to suboptimal quality). Unfortunately, measurement of airway pressure distal to the bronchial blocker was not possible.
Figure 3. Setup for CPAP application through the bronchial blocker's suction channel using the Shiley™ CPAP system. The bronchial lumen is ventilated normally, and the Shiley CPAP system is connected to the suction channel of the bronchial blocker, which passes through the tracheal lumen. (1) Tracheal lumen of the 37-Fr left-sided Rusch Bronchopart™ DLT, (2) bronchial lumen, (3) Arndt multiport airway adapter, (4) fiberoptic bronchoscopy port, (5) 7-Fr Arndt bronchial blocker, (6) inflating balloon port, and (7) Shiley™ CPAP system connected to the suction port of the bronchial blocker.
Oxygenation improved promptly and was maintained, with SpO2 consistently above 90%, without affecting the surgeon's visual field. As shown in Figure 4, Thoracoscopic surgery could therefore proceed.
Figure 4. Thoracoscopic view of the operative field. Left: ventilated middle and lower lobes (black arrow); Right: collapsed upper lobe (red arrow).
At the end of the surgery, fiberoptic bronchoscopy confirmed the absence of trauma, ulceration, or petechiae in the intermediate bronchus (no image available).
Before extubation, the patient demonstrated adequate oxygenation, with both lungs ventilated. After 2 h in the recovery room, she remained stable and comfortable and was subsequently transferred to the general ward. She was discharged on postoperative day 3.
Discussion
Hypoxemia during OLV remains a significant challenge. Several factors contribute to low intraoperative arterial oxygen saturation, including impaired preoperative pulmonary function, low PaO2 during two-lung ventilation, ventilation–perfusion mismatch, morbid obesity, and supine positioning (10).
Although CPAP is an effective strategy for managing hypoxemia, it may compromise surgical visualization, especially during uVATS procedures (11).
While the use of bronchial blockers with single-lumen tubes is well described, the combined use of a DLT with a bronchial blocker is less common in clinical practice. However, this technique has been reported in the literature. For example, Muelleck et al. (7) demonstrated that the combination of a DLT and a bronchial blocker can allow selective lobar isolation of one or two lobes in cases of refractory hypoxemia during OLV. Similarly, Tang et al. (9) used this combination as a rescue strategy for inadequate oxygenation during OLV.
In contrast to the case reported by Tang et al. (9), lung isolation itself was not the challenge in our patient. Compared with Muelleck et al. (7), we successfully isolated the right upper lobe for resection by applying PEEP to the middle and lower lobes through the lumen of the bronchial blocker rather than through the tracheal lumen. This approach avoids positioning the bronchial blocker within the bronchus of the resected lobe, facilitating surgical access while maintaining clear operative field visibility. This approach proved to be an effective late rescue maneuver for refractory hypoxemia during right upper lobectomy in a patient with a history of left upper lobectomy.
Another aspect that influenced the sequence of surgical interventions was oncological priority rather than pulmonary function considerations. The left upper lobectomy was performed first because it addressed the more advanced tumor, which had already caused a brain metastasis. Therefore, the decision to operate on the left side first was guided by oncological considerations rather than functional or oxygenation concerns.
Bronchial blockers are more technically challenging to position and manipulate than DLTs and are therefore used less frequently. Their combined use with a DLT is even less common; however, this approach offers advantages, such as selective lobar collapse and reduced airway trauma due to the smaller size of the blocker (12). In addition, this strategy enables the targeted application of CPAP to the ipsilateral non-operated lobes when oxygenation becomes compromised.
Limitations
This report describes a single case, which inherently limits the generalizability of our observations. No serial measurements of gas exchange (e.g., repeated arterial blood gas analyses) were performed, restricting our ability to quantitatively assess the physiological impact of the combined use of a DLT and a bronchial blocker. Furthermore, measurements of lung or respiratory system compliance were not obtained, preventing a detailed evaluation of mechanical changes or potential benefits in ventilation efficiency.
Additional limitations include the technical challenges in positioning the bronchial blocker in the right lobes, the potential for small movements to dislodge the blocker and compromise lobar isolation, and the need for very close airway pressure monitoring when applying CPAP through the bronchial blocker, which could increase the risk of barotrauma distal to the blocker (13). For these reasons, this technique should be considered a late rescue maneuver.
The feasibility of this approach depends on the brand of the DLT, its internal diameter, and airway anatomy. An accompanying video illustrates the technical feasibility of the procedure and highlights the limitations imposed by the various devices and their diameters.
These limitations should be taken into account when interpreting the applicability of this approach to other clinical settings.
Conclusion
Selective lobar isolation with CPAP applied to non-operated lobes is a useful technique for optimizing oxygenation in patients with a history of contralateral lobectomy undergoing additional lung resection. While the combined use of a bronchial blocker and a DLT is not routinely employed, it can serve as a valuable late rescue strategy in complex thoracic surgeries that are complicated by difficult oxygenation.
Data availability statement
The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.
Ethics statement
Ethical approval was not required for the studies involving humans because it was not applicable to this case report. Written informed consent for publication was obtained from the patient. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.
Author contributions
PC: Writing – original draft, Writing – review & editing. JL: Writing – review & editing. CG: Conceptualization, Writing – review & editing. RM: Writing – review & editing. MA: Writing – original draft, Writing – review & editing.
Funding
The author(s) declared that financial support was not received for this work and/or its publication.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fanes.2026.1700476/full#supplementary-material
Supplementary Video S1 | Video demonstrating the simultaneous passage of a 7-Fr Arndt bronchial blocker and an Ambu® 4 aScope regular flexible bronchoscope through the tracheal lumen of a 37-Fr left-sided Well Lead™ double-lumen tube. Notably, the internal diameter of this tube is 0.1 mm larger than that used in the present case report; therefore, the demonstration was performed using a bronchoscope with a larger outer diameter than the one used in the reported case.
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Keywords: bronchial blocker, case report, double lumen tube, hypoxemia, one-lung ventilation
Citation: Conne P, Lutz JA, Grandjean C, Maarbess R and Al Chammas M (2026) Management of refractory hypoxemia during one-lung ventilation applying CPAP through a bronchial blocker to non-operated lobes on the operative side in combination with a double lumen tube: a case report. Front. Anesthesiol. 5:1700476. doi: 10.3389/fanes.2026.1700476
Received: 6 September 2025; Revised: 9 January 2026;
Accepted: 12 January 2026;
Published: 29 January 2026.
Edited by:
Mohamed R. El Tahan, Mansoura University, EgyptReviewed by:
Alessandro Russo, Integrated University Hospital Verona, ItalyJonathan Tang, The Ohio State University Wexner Medical Center, United States
Copyright: © 2026 Conne, Lutz, Grandjean, Maarbess and Al Chammas. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Pierre Conne, cGllcnJlLmNvbm5lQGluc2VsLmNo