Surprise evidence of a bronchial rent in a case of pulmonary Koch’s posted for lung decortication using the one-lung ventilation protocol

Tracheobronchial injury is a potentially life-threatening clinical scenario. In the case of surprise evidence of bronchial wall tear while doing lung surgery, tracheal tube extubation and post-operative management pose a challenge to the anaesthesiologist. We present a case of a 16-year-old girl, a known case of pulmonary Koch’s taking anti-Koch’s treatment, admitted with hydropneumothorax, who was posted for left lung decortication. She presented with complaints of left-sided chest pain and cough since 3 months and a weight loss of 13 kg in 3 months. An inter-costal drain was inserted on the left side. Her high-resolution computed tomography thorax showed multiple cavitatory lesions with ground glass opacities in right lung parenchyma, Hydropneumothorax from the upper lobe to lower lobe of the left lung; consolidation, calcification in the left lower lobe; mediastinal shift toward the right. In the Operation theatre, the patient was pre-oxygenated, induced with Inj Propofol + Inj Fentanyl + Inj Suxamethonium according to the patient’s weight, and intubated with a 28 Fr’ left-sided double lumen tube (DLT). Left-sided decortication was performed uneventfully. On conclusion of surgery, while checking for leaks, it was noted that the exhaled tidal volume was unacceptably low and a rent on the left main bronchus of around 2 x 2 cm with scarred borders was detected, which was repaired with tissue patch suturing by the surgeons. After closure, the DLT was removed and re-intubation was performed with endotracheal tube no. 6. The patient was shifted to the intensive care unit, electively ventilated, and gradually weaned off in 2 days. Then, the patient was discharged in a week. To conclude, meticulous planning, vigilant monitoring of vital parameters, and close communication between the surgeons and the anaesthesiologists are essential to timely manage a life-threatening complication.