Effect of pre-use of Dexmedetomidine on the effective inhibitory dose of remimazolam tosilate on positive cardiovascular response in double-lumen endobronchial intubation: a clinical study.

BACKGROUND: Herein, the effect of pre-use of Dexmedetomidine(Dex) on the half-effective dose (ED50) and 95%-effective dose (ED95) of Remimazolam tosilate(RT) in inhibiting the positive cardiovascular response(CR) which means blood pressure or heart rate rises above a critical threshold induced by double-lumen bronchial intubation was evaluated. METHODS: Patients who underwent video-assisted thoracic surgery were divided into groups A (0), B (0.5 µg/kg), and C (1 µg/kg) based on different Dex doses. Group A included subgroups comprising young (A-Y) and elderly (A-O) patients. Neither groups B nor C included elderly patients due of the sedative effect of Dex. Based on the previous subject's CR, the dose of RT was increased or decreased in the next patient using the sequential method. This trial would be terminated when the seventh crossover occurred, at which point the sample size met the stable estimate of the target dose. Heart rate (HR) and mean arterial pressure (MAP) were monitored throughout the trial, and sedation was assessed using the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale. HR and MAP were recorded at baseline (T1), the end of Dex (T2), and the end of RT (T3), the maximum HR and MAP were recorded within 3 min of intubation from beginning to end (T4). There was a positive CR when the T4 levels rose above 15% of the baseline. The ED50/ED95 and corresponding confidence interval were calculated using probability regression. RESULTS: In total, 114 patients completed the trial. Without the use of Dex, the ED50/ED95 of TR inhibiting the positive CR caused by double-lumen bronchial intubation was 0.198/0.227 and 0.155/0.181 mg/kg in groups A-Y and A-O, respectively. The changes in vital signs from T1 to T3 were similar in the subgroups, indicating that the elderly patients were more sensitive to the dose of RT. The ED50/ED95 of RT inhibiting the positive CR caused by double-lumen endobronchial intubation was 0.122/0.150 and 0.068/0.084 mg/kg in groups B and C, respectively. And, the fluctuation of blood pressure from T3 to T4 was reduced by using Dex. RT was 100% effective in sedation with no significant inhibition of circulation. Apart from one case of hypotension occurred in group A-Y, two cases of low HR in group B, and one case of low HR in group C, no other adverse events were noted. CONCLUSIONS: The optimal dose of RT to inhibit positive CR induced by double-lumen bronchial intubation in elderly patients was 0.18 mg/kg and 0.23 mg/kg in younger patients. When the pre-use dose of Dex was 0.5 µg/kg, the optimal dose to inhibit positive CR of RT was 0.15 mg/kg. And, when the pre-use dose of Dex was 1 µg/kg, the optimal dose of RT was 0.9 mg/kg. CLINICAL TRIAL REGISTRATION: NCT05631028.

Research and development of the sOLVe Tube™ dual lumen endobronchial tube: from concept to construct.

Introduction: Dual lumen endobronchial tubes (DLTs) are frequently used for lung isolation and one lung ventilation in thoracic surgery and other specialized clinical scenarios. Modern DLTs are large and rigid, and account for half of all tracheobronchial injuries. Their 70 year old design has numerous flaws which limit their safety and clinical utility. Our research team set out to design a new and improved DLT to mitigate these shortcomings, and then test the proposed device to ensure proper function. Methods: Using published airway anatomy data and computed tomography imaging from 195 thoracic surgery patients, we designed a new DLT with a single size/configuration that would fit into adult surgery patients. This single "Universal design" was intended to replace both left and right sided 35Fr-41Fr DLTs (8 total products), while remaining small in diameter (35Fr). Other design goals included: 1) making intubation easier and safer, 2) allowing full sized therapeutic bronchoscopes to fit into this tube, 3) making the DLT more resistant to dislodgement. After design process completion the proposed dimensions were tested against 195 patients' left and right mainstem bronchi for radiographic fit. Once production prototypes were manufactured, they were tested in large adult Yorkshire pigs and fresh human cadavers for anatomic fit and performance. Results: The proposed design passed the radiographic fit test in all 195 patients for both left and right mainstem endobronchial placement. Intubation was successful and deemed atraumatic in all pigs and cadavers, and the device appropriately fit in both the right and left mainstem bronchi. Lung isolation was successfully achieved and the device proved resistant to axial force dislodgement. Conclusion: We propose a new design for a novel DLT meant to replace 8 currently supplied adult configurations with a single, one size/configuration fits all product that allows for large bore bronchoscopy and resists axial force dislodgement.

Depth of double-lumen endobronchial tube: a comparison between real practice and clinical recommendations using height-based formulae.

BACKGROUND: The depth of double-lumen endobronchial tube (DLT) is reportedly known tobe directly proportional to height and several height-based recommendations have beensuggested. This retrospective study was designed to find out the difference between calculated depths using height-based formulae and realistic depths in clinical practice of DLTplacement by analyzing pooled data from patients intubated with left-sided DLT. METHODS: The electronic medical records of adults, intubated with DLT from February 2018to December 2020, were reviewed. Data retrieved included age, sex, height, weight, andsize and depth of DLT. The finally documented DLT depth (depth final, DF) was comparedwith the calculated depths, and the relationship between height and DF was also evaluated.A questionnaire on endobronchial intubation method was sent to anesthesiologists. RESULTS: A total of 503 out of 575 electronic records of consecutive patients were analyzed.Although the relationship between height and DF was shown to have significant correlation(Spearman's rho = 0.63, P < 0.001), DF was shown to be significantly greater than calculated depths (P < 0.001). Despite 57.1% of anesthesiologists have knowledge of clinical recommendations to anticipate size and depth of DLT, no one routinely utilizes those recommendations. CONCLUSIONS: Anesthesiologists tend to place DLTs in a deeper position than expected whendepths are calculated using height-based recommendations. Although such discrepanciesmay not be clinically meaningful, efforts are needed to standardize the methods of endobronchial intubation to prevent potential complications associated with malposition.

Airway Management of a Patient With Tracheoesophageal Fistula and Tracheal Stent.

A 69-year-old male patient, a known case of squamous cell carcinoma of the esophagus on palliative care and Do Not Attempt Resuscitation (DNAR) status, presented for urgent laparoscopic gastrostomy tube insertion under general anesthesia. The patient had developed an iatrogenic tracheoesophageal fistula (TEF) because of the tracheal stent, which was placed for tracheal stenosis. A preoperative assessment was done, and a plan of airway management via one-lung ventilation (OLV) through an endobronchial tube was devised by the anesthesia team and discussed with the surgery team. The airway was secured via asleep fiberoptic right endobronchial intubation using a microlaryngeal tube (MLT) size 6 since there was uncertainty regarding adequate patency of the airway due to the invasion by the tumor and the presence of the stent. The patient remained hemodynamically stable. After surgical incision and insufflation of CO2 in the abdominal cavity, the patient's airway pressures were increased and we were unable to deliver adequate tidal volumes. Surgery was stopped; the presence of a kink in the circuit or endotracheal tube (ETT), the possibility of laryngospasm/bronchospasm, and pneumothorax were ruled out. Fiberoptic bronchoscopy (FOB) revealed that the endobronchial tube was abutting the secondary carina. We pulled the MLT by 2 cm. The rest of the procedure was uneventful and we extubated the patient at the end of the procedure under vision using a fiber optic bronchoscope. The patient was discharged after two days of stay in the hospital. Our patient with TEF and tracheal stent posed a significant challenge for airway management. A thorough plan was drawn up and a team briefing was done. Perioperatively, the difficulty in ventilation was identified, and various other etiologies were ruled out with the successful identification and management of the problem.

Comparison of Endobronchial Intubation Versus Bronchial Blockade for Elective Pulmonary Lobectomy of Congenital Lung Anomalies in Small Children.

Purpose: Resection of many congenital lung lesions is commonly performed under single-lung ventilation, which helps collapse the lung being manipulated and enables a thoracoscopic approach in most cases. We set out to determine whether lung isolation achieved by either main stem intubation or usage of a bronchial blocker was associated with superior clinical outcomes. Materials and Methods: A retrospective review of all patients aged <2 years undergoing elective pulmonary lobectomy for congenital lung malformations at a tertiary-care pediatric hospital from 2011 through 2020 was performed. Demographic data, diagnosis type, type of lung isolation method employed, and perioperative outcomes were recorded. Continuous variables were analyzed with Student's t-tests, whereas categorical variables were analyzed with Fisher's exact tests and chi-square tests. Results: Thirty-two patients were analyzed-17 were managed with a bronchial blocker while 15 underwent main stem intubation. The most common diagnoses were congenital pulmonary airway malformations (53.1%) and intralobar bronchopulmonary sequestrations (34.4%). Patients managed with main stem intubation were slightly younger (P = .06) than those for which a bronchial blocker was used. Thirty-one (96.9%) resections were initiated thoracoscopically. Main stem intubation was associated with shorter operative times (P = .01), shorter anesthetic times (P = .02), and less blood loss (P = .04). No differences in length of stay (P = .64), conversation to thoracotomy (P = .35), intraoperative complications (P = .23), or postoperative complications (P = .49) were observed. Conclusion: Lung isolation through main stem intubation, when compared with bronchial blockers, is associated with shorter operative time, shorter anesthetic exposure, and diminished blood loss in pediatric patients undergoing lobectomy for congenital lung anomalies.

Error traps in pediatric one-lung ventilation.

With the advent of thoracoscopic surgery, the benefits of lung isolation in children have been increasingly recognized. However, because of the small airway dimensions, equipment limitations in size and maneuverability, and limited respiratory reserve, one-lung ventilation in children remains challenging. This article highlights some of the most common error traps in the management of pediatric lung isolation and focuses on practical solutions for their management. The error traps discussed are as follows: (1) the failure to take into consideration relevant aspects of tracheobronchial anatomy when selecting the size of the lung isolation device, (2) failure to execute correct placement of the device chosen for lung isolation, (3) failure to maintain lung isolation related to surgical manipulation and isolation device movement, (4) failure to select appropriate ventilator strategies during one-lung ventilation, and (5) failure to appropriately manage and treat hypoxemia in the setting of one-lung ventilation.

Optimising endotracheal length in adult cats: a retrospective CT study.

OBJECTIVES: The aim of this study was to determine the maximal endotracheal insertion length by measuring the larynx to carina (L-C) distance by means of CT. An additional objective was to establish certain anatomical landmarks to optimise the process of endotracheal intubation (ETI). METHODS: Head, neck and thoracic CT images from adult cats at a single referral hospital between 2013 and 2020 were retrospectively evaluated. After standardising and identifying key markers (larynx, carina and first rib) the L-C, larynx to first rib (L-1R) and first rib to carina (1R-C) distances were measured. RESULTS: Forty-five adult cats were enrolled in the study, from which a total of nine different breeds were identified. The L-C distance was 14.3 ± 1.1 cm. This was longer in male (14.7 ± 1.1 cm) than in female cats (13.5 ± 0.7 cm). The first rib (1R) was 8.8 ± 0.7 cm from the larynx and the mean 1R-C distance was 5.4 ± 0.7 cm. The carina was found within the fifth intercostal space in 93.3% (n = 42) of the cats. CONCLUSIONS AND RELEVANCE: The process of ETI in adult cats may be guided by using the L-C and L-1R distance for a maximal and optimal endotracheal tube introduction, respectively. In addition, the maximal insertion length may be guided by estimating the position of the carina parallel to the fifth intercostal space.

Comparison of clinical methods to diagnose pediatric endobronchial intubation-A randomized controlled trial.

BACKGROUND AND AIMS: Diagnosing accurate placement of the tip of the endotracheal tube is crucial in pediatric practice. This study was conducted to find out the efficacy of five clinical methods to ascertain the tube position by a resident anesthesiologist. MATERIAL AND METHODS: This was a randomized crossover study conducted in a research institute. Fifty pediatric patients were enrolled. All patients were randomly allocated to tracheal (group T) or bronchial group (group B). The five clinical methods which were evaluated include the auscultation, observation of chest movements, bag compliance, tube depth, and capnography. In group T, the tube was placed in the trachea and later positioned in bronchus (assisted by fiberoptic bronchoscopy). The vice versa was done in group B. In each position, a single test followed by all tests was performed and after the change of position, the same single test followed by all tests was performed. Correct and incorrect diagnoses by tests in detecting tube positions were made and their sensitivity and odds ratio were estimated. RESULTS: The tube depth and combination of all tests detected endobronchial intubation with a sensitivity of 88% and 97%, respectively, which is more than that of auscultation (70%) and observation (55%). Evaluation of the difference in agreement level of tube depth to detect tube-position showed the odds ratio of 2.28 (0.17-30.95) for detecting endobronchial intubation. CONCLUSION: We observed that the tube-depth was better than the other individual tests in diagnosing endobronchial intubation in pediatric patients. However, its efficacy is lesser than that of performing all clinical tests together.

Unmasking the Lung Pulse for Detection of Endobronchial Intubation.

The ultrasound lung pulse for detecting endobronchial intubation was first described in 2003 in the only study to date assessing its accuracy. It refers to rhythmic movement of the visceral pleura along the stationary parietal pleura as cardiac vibrations transmit through a motionless, airless lung. Compared to delayed visualization on chest radiography, this artifact immediately detects physiologic atelectasis. There is a scarcity of studies assessing the lung pulse, while several others that encountered this artifact did not even identify it. The lung pulse is useful for immediate detection of endobronchial intubation, but it remains unrecognized and underused by physicians.

A controlled trial to investigate whether the orientation of the bevel and angle of approach determine the side of endobronchial intubation in an adult manikin.

One of the commonest complications of endotracheal intubation occurs when the tip of the endotracheal tube passes distal to the carina and enters one of the main bronchi. The perioperative practitioner may observe high airway pressures, hypoxia or even pneumothorax. The most common reason given for the high incidence of right endobronchial intubation is that the right main bronchus comes off the trachea at a more acute angle from the midline. We sought, however, to explore two other factors which may explain this phenomenon ­ the angle of the tube's bevel and its trajectory of approach. We conducted a prospective controlled trial in which doctors from our department intubated the trachea of an adult manikin in three distinct sets using standard tube, reversed tubes and reversed laryngoscope blades. We found that the angle of the bevel and trajectory of approach determines the side of endobronchial intubation in an adult manikin.

Double-lumen tracheal tubes and bougies: a bench study to investigate factors that influence the risk of shearing.

Tracheal intubation with a double-lumen tube can be more challenging than with a single-lumen tube. A bougie can be used to facilitate intubation. Case reports have described fragment shearing from bougies when they are removed from the tube after intubation. These fragments have the potential to cause harm. It has even been suggested that bougies and double-lumen tubes should not be used together. We conducted a benchtop trial to investigate factors that influence the risk of shearing. We investigated three brands of double-lumen tube (each in three sizes and both lateralities) and four brands of bougie. We simulated one intubation and 29 further insertions/removals of bougie with every bougie-double-lumen tube combination. We inspected the inside of the tube for evidence of shearing after first, tenth and thirtieth removals. We found that brand of bougie, brand of double-lumen tube and size of double-lumen tube (but not its laterality) all influenced the degree of shearing. Certain bougie-double-lumen tube combinations produced a particularly high degree of shearing, so these should be avoided.

Selective left mainstem bronchial intubation in the neonatal intensive care unit / Intubação seletiva do brônquio principal esquerdo em unidade de terapia intensiva neonatal

Abstract Background: Selective neonatal left mainstem bronchial intubation to treat right lung disease is typically achieved with elaborate maneuvers, instrumentation and devices. This is often attributed to bronchial geometry which favors right mainstem entry of an endotracheal tube deliberately advanced beyond the carina. Case summary: A neonate with severe bullous emphysema affecting the right lung required urgent non-ventilation of that lung. We achieved left mainstem bronchial intubation by turning the endotracheal tube 180° such that the Murphy's eye faced the left instead of the right, and simulated a left-handed intubation by slightly orientating the endotracheal tube such that its concavity faced the left instead of the right as in a conventional right-handed intubation. Conclusion: Urgent intubation of the left mainstem bronchus with an endotracheal tube can be easily achieved by recognizing that it is the position of the endotracheal tube tip and the direction of its concavity that are the chief determinants of which bronchus an endotracheal tube goes when advanced. This is important in critically ill neonates as the margin of safety and time window are small, and the absence of double-lumen tubes. Use of fiberoptic bronchoscope and blockers should be reserved as backup plans.

Resumo Justificativa: A intubação seletiva neonatal do brônquio principal esquerdo para tratar a doença pulmonar direita é tipicamente feita com elaboradas manobras, instrumentação e dispositivos. Isso é frequentemente atribuído à geometria brônquica que favorece a entrada principal direita de um tubo endotraqueal (TET) deliberadamente avançado para além da carina. Resumo do caso: Recém-nascido com enfisema bolhoso grave que afetava o pulmão direito e precisou com urgência da não ventilação desse pulmão. Para conseguir a intubação brônquica esquerda fizemos uma rotação de 180° do TET, de forma que o olho de Murphy ficasse voltado para a esquerda, e não para a direita, e para simular uma intubação à esquerda orientamos ligeiramente o TET, de modo que sua concavidade virasse para a esquerda em vez de para a direita, como em uma intubação convencional à direita. Conclusão: A intubação urgente do brônquio principal esquerdo com um TET pode ser facilmente obtida se reconhecermos que é a posição da ponta do TET e a direção de sua concavidade que determinam para qual brônquio o TET irá quando avançado. Isso é importante em neonatos criticamente doentes diante da margem de segurança e janela de tempo pequenas e na ausência de tubos de duplo lúmen. O uso de broncofibroscópio e bloqueadores deve ser considerado como planos de segurança.

Needle wash solution cultures following EBUS-TBNA with or without endobronchial intubation.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure with a high diagnostic yield in lesions adjacent to the airways. However, complications associated with EBUS-TBNA, such as mediastinitis, have recently been reported. Oral bacteria contamination in punctured lymph nodes can cause severe infections. In the current study, we investigated whether endobronchial intubation using EBUS-TBNA can prevent oral bacterial contamination of punctured lymph nodes. METHODS: We retrospectively evaluated 80 patients (102 lymph nodes) who had undergone EBUS-TBNA and divided them two groups: Group A comprised 60 patients who had undergone EBUS-TBNA with endobronchial intubation and Group B consisted of 20 patients who had undergone EBUS-TBNA without endobronchial intubation. The patients' medical records were examined and the two groups were compared using the unpaired Student's t-test. RESULTS: EBUS-TBNA needle wash cultures were positive in only two Group A cases (3.3%), but in all 20 Group B cases (100%) (P < 0.05). Except for one case of Mycobacterium tuberculosis, all bacterial isolates yielded typical oropharyngeal commensal flora. Fever (≥ 38.0 °C) was observed in six Group A cases (10%) and two Group B cases (10%; P = 0.526). This was treated by cooling, a single administration of non-steroidal anti-inflammatory drugs, and/or antibiotic therapy. Fever was not associated with any clinical features, including malignancy in punctured lesions, number of punctures, echo features, simultaneous peripheral biopsy, additional oral prophylactic antibiotics, or positive needle wash cultures. CONCLUSIONS: Endobronchial intubation may prevent contamination by oropharyngeal commensal bacteria.

[Selective left mainstem bronchial intubation in the neonatal intensive care unit]. / Intubação seletiva do brônquio principal esquerdo em unidade de terapia intensiva neonatal.

BACKGROUND: Selective neonatal left mainstem bronchial intubation to treat right lung disease is typically achieved with elaborate maneuvers, instrumentation and devices. This is often attributed to bronchial geometry which favors right mainstem entry of an endotracheal tube deliberately advanced beyond the carina. CASE SUMMARY: A neonate with severe bullous emphysema affecting the right lung required urgent non-ventilation of that lung. We achieved left mainstem bronchial intubation by turning the endotracheal tube 180° such that the Murphy's eye faced the left instead of the right, and simulated a left-handed intubation by slightly orientating the endotracheal tube such that its concavity faced the left instead of the right as in a conventional right-handed intubation. CONCLUSION: Urgent intubation of the left mainstem bronchus with an endotracheal tube can be easily achieved by recognizing that it is the position of the endotracheal tube tip and the direction of its concavity that are the chief determinants of which bronchus an endotracheal tube goes when advanced. This is important in critically ill neonates as the margin of safety and time window are small, and the absence of double-lumen tubes. Use of fiberoptic bronchoscope and blockers should be reserved as backup plans.

Microlaryngeal endotracheal tube for lung isolation in pediatric patient with significant tracheal narrowing.

A 15-year-old boy, weighing 45 kg, 160 cm height with large anterior mediastinal mass and significant tracheal narrowing was scheduled for thoracotomy and excision of the mass. He had a history of progressive dyspnea, inability to lie supine, and a right upper hemithorax mass 13 cm × 13 cm × 11 cm as evident on a computerized tomography with significant compression of the trachea and right main stem bronchus. Inhalational induction was carried out using sevoflurane with 100% oxygen. After achieving adequate depth of anesthesia with the maintenance of spontaneous respiration with oxygen and sevoflurane (minimum alveolar concentration 1.7), left principal bronchus was intubated under fiber-optic bronchoscopy, with 5 mm cuffed microlaryngeal surgery tube. Excellent lung isolation was achieved. Selection of endotracheal tube for lung isolation and endobronchial intubation in the presence of significant tracheal narrowing are discussed.

The tracheal accordion and the position of the endotracheal tube.

The purpose of this review is to, first, determine the static factors that affect the length of the human trachea across different populations and, second, to investigate whether or not there are dynamic factors that cause the length of the human trachea to vary within the same individual. We also investigated whether these changes in tracheal length within the same individual are significant enough to increase the risk of endobronchial intubation or accidental extubation. A PubMed/MEDLINE and a Web of Science database English-language literature search was conducted in May 2016 with relevant keywords and MeSH terms when available. We found that gender, extremes of age, patient height, postsurgical changes and co-existing disease are static patient factors that affect the length of the human trachea. Dynamic clinical changes that occur under anaesthesia, including Trendelenburg position, head and neck flexion and extension, paralysis of the diaphragm and pneumoperitoneum, cause the trachea to act as an accordion, decreasing and increasing its length. The length of the human trachea in both awake and anaesthetised and paralysed patients is a critical consideration in preventing both endobronchial intubation and tracheal extubation. It is clear from the literature that tracheal length varies widely across populations and, additionally, with the dynamic clinical changes that occur under anaesthesia, the trachea acts as an accordion decreasing and increasing its length within the same individual. Knowledge of the magnitude of the change in tracheal dimensions in response to these factors is an important clinical consideration.

Discomfort during bronchoscopy performed after endobronchial intubation with fentanyl and midazolam: a prospective study.

OBJECTIVE: Although endobronchial intubation during a bronchoscopic examination is useful for invasive procedures, it is not routine practice in Japan. The present study evaluated discomfort due to endobronchial intubation using fentanyl and midazolam sedation during bronchoscopy. METHODS: Thirty-nine patients were enrolled prospectively from November 2014 to September 2015 at Okayama University Hospital. Fentanyl (20 µg) was administered to the patients just before endobronchial intubation, and fentanyl (10 µg) and midazolam (1 mg) were added as needed during the procedure. A questionnaire survey was administered 2 h after the examination. In the questionnaire, patient satisfaction was scored using a visual analog scale as follows: excellent (1 point), good (2 points), normal (3 points), uncomfortable (4 points) and very uncomfortable (5 points). An additional question ('Do you remember the bronchoscopic examination?') was also asked. Predefined parameters (blood pressure, heart rate, oxygen saturation and complications) were recorded. RESULTS: The enrolled patients included 22 males and 17 females; their median age was 70 (range: 28-88) years. The patients received a mean dose of 47.9 µg of fentanyl (range: 30-90 µg) and 2.79 mg of midazolam (range: 1-7 mg). In total, 28 patients (71.7%) agreed to undergo a second bronchoscopic examination; the mean levels of discomfort and for the re-examination were 2.07 points each. About 41% of the patients remembered the bronchoscopic examination. No severe complications were reported. CONCLUSION: Endobronchial intubation using fentanyl and midazolam sedation during an invasive bronchoscopic procedure might be recommended. CLINICAL TRIAL REGISTRATION: UMIN000015578 in the UMIN Clinical Trials Registry.

Severe Respiratory Event Initially Thought to be Inadvertent Endobronchial Intubation: Possible Complications From Using of a Topical Metered-Dose of 8% Lidocaine Pump Spray.

INTRODUCTION: Pulmonary collapse after intubation is common, and it is caused by a variety of factors. CASE PRESENTATION: A 21-year-old man presented at our operation room to undergo an appendectomy. Except for a history of cigarette smoking, his history was negative. Anesthesia was induced with 100% oxygen and sevoflurane, remifentanil infusion, and propofol. Neuromuscular block was obtained with rocuronium. The tip and cuff of a tracheal tube were lubricated with a topical metered-dose of 8% Lidocaine pump spray. After intubation, SPO2 suddenly decreased. The chest x-ray revealed right upper lobe atelectasis. Fiber optic bronchoscopy showed that a large amount of yellow sticky mucus had been secreted into the right main bronchus. CONCLUSIONS: In Japan, 8% Lidocaine pump spray contains menthol and ethanol as additives. These additives, particularly menthol, might have led to excessive mucus production, although we did not analyze the mucus secretion.