H. Patel, R. Mooney, C. Holmes

Children's Health Ireland at Temple Street, Dublin, Ireland


A tracheal (or “pig”) bronchus is a rare congenital anatomical variant where an accessory bronchus originates from the trachea and directs to the upper lobe.

An eight-month-old child presented for elective right upper lung lobectomy to remove a massive congenital lobar emphysema (CLE), which had caused extensive contralateral mediastinal shift as seen on the image below. Following anaesthesia induction, microlaryngobronchoscopy identified a right sided tracheal bronchus supplying the right upper lobe.  It was agreed between anaesthesiologist, ENT surgeon and general surgeon to attempt to isolate this bronchus and emphysematous lobe before positive pressure ventilation.

Using rigid bronchoscopy, with patient breathing spontaneously, an oral uncuffed size 2.5 endotracheal tube was placed directly into the tracheal bronchus and left open to air.  This served as a both a bronchial blocker and ventilation tube - obstructing the emphysematous lobe from positive pressure ventilation (and thus worsening mediastinal shift and instability) and decompressing the right upper lobe. This was followed by an oral size 3.5 cuffed endotracheal tube placed above the carina, which was then used for positive pressure ventilation.  An open thoracotomy was performed in the left lateral position and right upper lobectomy was performed, with the patient remaining stable throughout with optimum surgical conditions.  Following isolation and ligation of the emphysematous lobe, the smaller uncuffed endotracheal tube was removed. The remainder of the peri-operative course was uneventful, with a planned overnight admission to pediatric ICU and extubation the following day.


This case highlights the need for multidisciplinary collaboration within paediatric care when creating and adapting a treatment plan for complex surgical patients. In addition, it highlights the need for flexibility and occasional improvisation when encountering unanticipated and rare clinical conditions.


This case is reported with the permission of the child’s parents.


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