A 55-year-old man underwent left single lung transplantation for end-stage emphysema from alpha 1-antitrypsin deficiency. After induction of anesthesia, a 37-Fr left-sided double-lumen endotracheal tube was placed for selective lung isolation during the procedure. After the patient was positioned for a left thoracotomy approach, higher-than-expected airway pressures were encountered, prompting multiple repositioning attempts of the endotracheal tube. The patient then proceeded to undergo an uncomplicated left-sided orthotopic lung transplant. At the end of the procedure, the double-lumen endotracheal tube was changed to an 8-Fr single-lumen endotracheal tube over an exchange catheter. Routine intraopera-tive bronchoscopy to assess the anastomosis demonstrated a .3-cm posterior laceration extending from carina to the midpor-tion of the left main stem bronchus (Fig. 1). The adventitia at the site of injury appeared intact. There was dynamic collapse of the airway at the injury site as a result of prolapse of the posterior wall during the respiratory cycle. Because a portable chest x-ray demonstrated no evidence of pneumothorax or pneurnomediastinum, no specific intervention was performed. After 1 week of observation, fiberoptic bronchoscopy demonstrated early healing with deposition of fibrin over the injured airway. The patient was discharged without any sequela of the airway injury, and follow-up bronchoscopy 3 months later revealed a well-healed left mainstem bronchus.
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