TRACHEAL bronchus (TB) is an aberrant, accessary, or ectopic bronchus arising almost exclusively from the right side of the tracheal wall above the carina, with the incidence of approximately 0.1% to 5% of the population.1,2  We present an image of a fiberoptic bronchoscopy performed in a patient with known TB for video-assisted thoracoscopic surgery and left lower lobectomy (fig.).

Although the existence of TB has been described as early as 1957, it is not a common differential for intraoperative desaturations.3  In the image, the TB arises a few millimeters above the carina. It is important to recognize a TB by bronchoscopy because when present, a properly placed tracheal tube cuff can obstruct the right upper lobe (RUL) or the tube itself can migrate into a TB, causing pulmonary atelectasis, hypoxemia, or both.4,5 

Preoperative diagnosis of this anomaly is especially important when lung isolation is needed. For left lung isolation, a bronchial blocker can be placed into the left main bronchus. A left-sided double-lumen tube (DLT) can also be used, but care must be taken not to obstruct the RUL by the tracheal cuff. For right-sided lung isolation, a right DLT should not be used, as the opening for the RUL will not correspond to the location of the TB. However, a left-sided DLT can be used. If left DLT cannot be placed for any reason, a Fogarty catheter can be placed in the TB and a bronchial blocker placed into the right main bronchus.6 

Acknowledgments

The authors thank Garrett Sendlewski, B.F.A., Yale Anesthesia Media Lab, Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, for labeling graphics used in this article.

Competing Interests

The authors declare no competing interests.

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